2022 MIPS Quality Measures List

Centers for Medicare & Medicaid Services (CMS) logo.
2022 Merit-based Incentive Payment System (MIPS)
Quality Measures List

12/1/2021
Version 6.0
End of worksheet
Step-by-Step Instructions to Search for Quality Measures Using This Excel File
This spreadsheet is a tool that eligible clinicians can use to search for current 2022 quality measures. The third tab of this file,
titled "2022 MIPS Quality Measures List" includes the full set of current measures reportable through any collection type, as o
2022. Eligible clinicians can use this resource to find measures in any number of ways and then then use the measure
specification manuals to dive deeper into any given measure.
For guidance on how to search for measures, please see step by step instructions on how to execute the following basic
functions:
1. Search by measure number

2 Search by NQS domain
3. Search by collection type
4. Search using keywords
1. Search by measure number
Step 1: Identify the type of measure number you are searching by (CMS, NQF, Quality) and click on the arrow below that
program.
Measure Number
Quality
CMS eCQM eCQM
NQF Number
This isID
a picture ofNQF
the categories of the measure number. This includes columns for the CMS eCQM ID, eCQM NQF, NQF, and Quality Num
(Q#)
Measure Number
Quality
CMS eCQM eCQM
Step-by-Step
ID NQFInstructions to Search for Quality Measures Using This Excel File
NQF Number
(Q#)
Step 2: Once the arrow is selected, a drop down menu will appear. Input the measure number you are searching for and selec
"OK."
Screen shot showing drop down menu allowing to search for a measure number.
Step 3: This excel function will filter out all other measures, leaving you with just the measure with the number you are
searching for.
This is a picture of the categories of the measure title and measure number. Under the measure number row are columns for the CMS eCQ
Step 4: To undo your search (so that you might search for something else), reclick the arrow that is filtered and select "Clear
Filter From '…'."
This is a picture of the categories of the measure number. Under the measure number row are columns for the CMS eCQM ID, eCQM NQF
2. Search by NQS Domain

Step 1: Select the arrow below the NQS Domain header (in Column G).
This is an image of the NQS Domain header

Step 2: Once the arrow is selected, a drop down menu will appear. Select all NQS Domains you are searching for (e.g.,
Effective Clinical Care)and select "OK."
This is an image of the drop down list of possible NQS domains and the "Effective Clinical Care" option is selected
Step 3: This will filter out all other measures, leaving you only with measures in the NQS Domain you are searching for.
Measure Number
Quality
CMS eCQM eCQM
Measure Title NQF Number Measure Description NQS Domain
ID NQF
(Q#)
Percentage of patients 18-75 years of age with diabetes who had
hemoglobin A1c > 9.0% during the measurement period
Diabetes: Hemoglobin A1c (HbA1c) Poor Control

CMS122v7 N/A 0059 001 Effective Clinical Care
(>9%)
Percentage of patients aged 18 years and older with a diagnosis

Heart Failure (HF): Angiotensin-Converting of heart failure (HF) with a current or prior left ventricular
Enzyme (ACE) Inhibitor or Angiotensin Receptor ejection fraction (LVEF) < 40% who were prescribed ACE
CMS135v7 2907 0081 005 inhibitor or ARB therapy either within a 12-month period when Effective Clinical Care
Blocker (ARB) Therapy for Left Ventricular
Systolic Dysfunction (LVSD) seen in the outpatient setting OR at each hospital discharge

Coronary Artery Disease (CAD): Antiplatelet of coronary artery disease (CAD) seen within a 12 month
N/A N/A 0067 006 period who were prescribed aspirin or clopidogrel Effective Clinical Care
Therapy
This is an image of the remaining measure titles filtered by the NQS Domain "Effective Clinical Care"
Filter From 'NQS Domain' ".
This image shows a selection of clearing a filter for the NQS Domain
3. Search by Collection Type

Step 1: Select the arrow below the collection type you are searching for
Collection Type(s)
Medicare CMS
Administrative MIPS
Part B CSV eCQM Web
Claims CQM
Claims Interface
This image shows the columns under the Collection Type(s) header. This includes Medicare Part B Claims, CSV, eCQM, CMS Web Interface,
Step 2: Once the arrow is selected, a drop down menu will appear. Unselect the "-" so that only the "X" is marked. Then selec
"OK."
This image shows the selection of an X under the CMS Web Interface column
Step 3: This excel function will filter out all other measures, leaving you only with measures reportable via the chosen
collection type.
Collection Type(s)
Medicare CMS
Administrative MIPS
Part B CSV eCQM Web
Claims CQM
Claims Interface
X - X X - X
- - X - - X
- - - - - X
Screen shot showing results from the filter selection.

Filter From 'MIPS CQM' ".
This is an image of the selection of "X" and "Blanks" under the Registry header
4. Search using Keywords

Step 1: Select the arrow below the Measure Title column.
Measure Title
This is an image of the Measure Title header

Step 2: Once the arrow is selected, a drop down menu will appear. Input a key word you are searching for (e.g., "Diabetes")
and select "OK."
This is an image of the filter of the Measure Title header with the selection of "Parkinson" in the text filter.
Step 3: This excel function will filter out all other measures, leaving you only with measures with the word "Diabetes" in the
measure title.
This is an image of two measure titles that show after the filtering of the measure title. It includes the measure title, measure number
Step 4: To undo your search (so that you might search for something else), reclick the arrow that is filtered and select
"Measure Title' ".
This is an image of selecting the Clear Filter From "Measure Title" selection in the dropdown of the Measure Tile header
Note: This same function can be conducted in the measure description column as well.
Measure Number Measure Developer/Steward NQF Endorsement Status
Comprehensive
Annual Update Due Review Additional information (e.g., Testing Results, Revisions), including Synopsis of NQF Endorsement Activity and/or NQF Communications since
PQRS Number Measure Title Measure Description NQS Domain Measure Type NQF Project Committee NQF Cycle Date Month/Year Completed or Anticipated the most Recent Quarterly Update
Q2 Q1 Q2 Q3 Q4 Due Date
CMS NQF PQRS #1 #2 #3 2013 2014 2014 2014 2014
- AAD
Percentage of new patients whose biopsy results have been reviewed and Non-Endorsed/
communicated to the primary care/referring physician and patient by the Communication and Care Lost
265 Biopsy Follow-Up - - 0265 Coordination Process AAD - - - - - - - - - - - -
performing physician Endorsement
Percentage of patients whose providers are ensuring active tuberculosis

Tuberculosis Prevention for Psoriasis and Psoriatic prevention either through yearly negative standard tuberculosis screening Non-Endorsed/ Q1 - Measure Testing planned for beginning Summer 2104, and then to be
337 Arthritis Patients on a Biological Immune Response - - 0337 Effective Clinical Care Process AAD - - - - - Planned - - - - - -
tests or are reviewing the patient’s history to determine if they have had submitted for NQF endorsement
Modifier appropriate management for a recent or prior positive test Submission
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 Full Q1 Measure Testing for endorsement/maintenance planned for Summer/Fall
137 Melanoma: Continuity of Care - 0650 137 date for the next complete physical skin exam, & - A process to follow up with Effective Clinical Care Process AAD - - - - - Endorsement - - - - 2015 2014 -
patients who either did not make an appointment within the specified time
frame or who missed a scheduled appointment
224 Melanoma: Overutilization of Imaging Studies - 0562 224 Percentage of patients with melanoma, without signs or symptoms, for whom Efficient Use of Healthcare Process AAD - - - - - Full - - - - 2015 Q1 Measure Testing for endorsement/maintenance planned for Summer/Fall -
no diagnostic imaging studies were ordered. Resources/Affordable Care Endorsement 2014
Percentage of patient visits, regardless of patient age, with a new occurrence Non-Endorsed/
of melanoma. They must have a treatment plan documented in the chart that
138 Melanoma: Coordination of Care - - 138 Care Coordination Process AAD - - - - - Lost - - - - - - -
was communicated to the physician(s) providing continuing care within one Endorsement
month of diagnosis.
- ACG
The percentage of patients age 50 years or older with at least one adenoma or Non-
Screening Colonoscopy Adenoma Detection Rate Endorsed/
343 - - 343 other colorectal cancer precursor or colorectal cancer detected during Effective Clinical Care Outcome ACG ASGE ASGE ACG AGA Gastroenterology - N/A - - - - Year or exact date TBD Q2-submitting to NQF measure inventory pipeline Q1-awaiting determination by NQF when measure can be scheduled for review
Measure screening colonoscopy Planned
Submission
- AAHKS
AAHKS is a small specialty society

Percentage of patients regardless of age or gender undergoing a total knee
replacement who are evaluated for the presence or absence of venous with limited staff and resources. Non-Endorsed/
Total Knee Replacement: Venous Thromboembolic and Due to the burdensome process of
351 - - 0351 thromboembolic and cardiovascular risk factors within 30 days prior to the Patient Safety Process AAHKS - - - - No Plan to - - - - - - -
Cardiovascular Risk Evaluation procedure including history of Deep Vein Thrombosis, Pulmonary Embolism, NQF measure endorsement, AAHKS Submit
is not currently capable of seeking
Myocardial Infarction, Arrhythmia and Stroke
NQF endorsement. (04/07/14)
Percentage of patients regardless of age undergoing a total knee replacement Non-Endorsed/

Total Knee Replacement: Preoperative Antibiotic
352 Infusion with Proximal Tourniquet - - 0352 who had the prophylactic antibiotic completely infused prior to the inflation of Patient Safety Process AAHKS - - - - - No Plan to - - - - - - -
the proximal tourniquet Submit
Percentage of patients regardless of age or gender undergoing total knee

Total Knee Replacement: Identification of Implanted replacement whose operative report identifies the prosthetic implant Non-Endorsed/
353 - - 353 Patient Safety Process AAHKS - - - - - No Plan to - - - - - - -
Prosthesis in Operative Report specifications including the prosthetic implant manufacturer, the brand name
of the prosthetic implant and the size of prosthetic implant Submit
Total Knee Replacement: Shared Decision- Making: Percentange of patients regardless of age or gender undergoing a total knee
350 Trial of Conservative (Non-surgical) Therapy - - 350 replacement with documented shared decision-making with discussion of - - - - - - - - - - - - - - - -
(04/07/14) conservative (non-surgical) therapy prior to the procedure
- AAN
Non-Endorsed/
Parkinson’s Disease: Annual Parkinson’s Disease
289 - - 0289 - - - - - - Neurology - Non-endorsed No Plan to - - - - - 4/3: Q2 2014 Update/revision to be initiated -
Diagnosis Review Submit
Non-Endorsed/
Parkinson’s Disease: Psychiatric Disorders or No Plan to
290 Disturbances Assessment - - 0290 - - - - - - Neurology - Non-endorsed - - - - - 4/3: Q2 2014 Update/revision to be initiated -
Submit
Non-Endorsed/
Parkinson’s Disease: Cognitive Impairment or
291 - - 291 - - - - - - Neurology - Non-endorsed No Plan to - - - - - 4/3: Q2 2014 Update/revision to be initiated -
Dysfunction Assessment
Submit
Non-Endorsed/
Parkinson’s Disease: Querying about Sleep
292 Disturbances - - 292 - - - - - - Neurology - Non-endorsed No Plan to - - - - - 4/3: Q2 2014 Update/revision to be initiated -
Submit
Non-Endorsed/
293 Parkinson’s Disease: Rehabilitative Therapy Options - - 293 - - - - - - Neurology - Non-endorsed No Plan to - - - - - 4/3: Q2 2014 Update/revision to be initiated -
Submit
Non-Endorsed/
Parkinson’s Disease: Parkinson’s Disease Medical and
294 - - 294 - - - - - - Neurology - Non-endorsed No Plan to - - - - - 4/3: Q2 '2014 Update/revision to be initiated -
Surgical Treatment Options Reviewed Submit
Non-Endorsed/
Epilepsy: Seizure Type(s) and Current Seizure
266 Frequency(ies) - - 266 - - - - - - Neurology - Non-endorsed No Plan to - - - - - 4/3: 'Q4 2014 Update complete -
Submit
Epilepsy: Documentation of Etiology of Epilepsy or Non-Endorsed/

267 - - 267 - - - - - - Neurology - Non-endorsed No Plan to - - - - - 4/3: 'Q4 2014 Update complete -
Epilepsy Syndrome
Submit
Epilepsy: Counseling for Women of Childbearing Time limited Full

268 - - 268 - - - - - - Neurology - - - - - - 4/3: 'Q4 2014 Update complete 4/3: Testing submitted to NQF on 2/27/2014
Potential with Epilepsy endorsement Endorsement
- AAO
Percentage of patients aged 18 years and older in sample who had cataract
Cataracts: Improvement in Patient’s Visual Function surgery and had improvement in visual function achieved within 90 days Full
303 - 1536 0303 Effective Clinical Care Outcome AAO - - Surgery Endorsement Maintenance C - 2015 - - - - Q2 Unknown None None
within 90 Days Following Cataract Surgery following the cataract surgery, based on completing a pre-operative and post- Endorsement
operative visual function survey
Percentage of patients aged 18 years and older in sample who had cataract
Non-Endorsed/
Cataracts: Patient Satisfaction within 90 Days surgery and were satisfied with their care within 90 days following the Patient and Caregiver-Centered No Plan to
304 Following Cataract Surgery - - 0304 cataract surgery, based on completion of the Consumer Assessment of Experience and Outcomes Patient Engagement/Experience AAO - - N/A - - - - - - N/A - -
Submit
Healthcare Providers and Systems Surgical Care Survey
- AGA
Page 12 of 119
Comprehensive
CMS NQF PQRS #1 #2 #3 2013 2014 2014 2014 2014
Inflammatory Bowel Disease (IBD): Type, Anatomic Percentage of patients aged 18 years and older with a diagnosis of Non-Endorsed/ Non-Endorsed/
269 - - 0269 inflammatory bowel disease who have documented the disease type, anatomic Effective Clinical Care Process AGA - - TBD - Planned Planned - - - - - Q1 - AGA Measurment Committee Review -
Location and Activity All Documented
location and activity, at least once during the reporting period Submission Submission
Percentage of patients aged 18 years and older with a diagnosis of

Non-Endorsed/ Non-Endorsed/
Inflammatory Bowel Disease (IBD): Preventive Care: inflammatory bowel disease who have been managed by corticosteroids
270 - - 0270 Effective Clinical Care Process AGA - - TBD - Planned Planned - - - - - Q1 - AGA Measurment Committee Review -
Corticosteroid Sparing Therapy greater than or equal to 10 mg/day for 60 or greater consecutive days that Submission Submission
have been prescribed corticosteroid sparing therapy in the last reporting year

Inflammatory Bowel Disease (IBD): Preventive Care: Non-Endorsed/ Non-Endorsed/
271 Corticosteroid Related Iatrogenic Injury – Bone Loss - - 271 inflammatory bowel disease who have received dose of corticosteroids Effective Clinical Care Process AGA - - TBD - Planned Planned - - - - - Q1 - AGA Measurment Committee Review -
greater than or equal to 10 mg/day for 60 or greater consecutive days and
Assessment Submission Submission
were assessed for risk of bone loss once per the reporting year
Percentage of patients aged 18 years and older with inflammatory bowel Non-Endorsed/ Non-Endorsed/
Inflammatory Bowel Disease (IBD): Preventive Care:
272 - - 272 disease for whom influenza immunization was recommended, administered Effective Clinical Care Process AGA - - TBD - Planned Planned - - - - - Q1 - AGA Measurment Committee Review -
Influenza Immunization
or previously received during the reporting year Submission Submission
Percentage of patients aged 18 years and older with a diagnosis of Non-Endorsed/ Non-Endorsed/
Inflammatory Bowel Disease (IBD): Preventive Care:
273 Pneumococcal Immunization - - 273 inflammatory bowel disease that had pneumococcal vaccination administered Effective Clinical Care Process AGA - - TBD - Planned Planned - - - - - Q1 - AGA Measurment Committee Review -
or previously received Submission Submission

Inflammatory Bowel Disease (IBD): Testing for Latent Non-Endorsed/ Non-Endorsed/
274 Tuberculosis (TB) Before Initiating Anti-TNF (Tumor - - 274 inflammatory bowel disease for whom a tuberculosis (TB) screening was Effective Clinical Care Process AGA - - TBD - Planned Planned - - - - - Q1 - AGA Measurment Committee Review -
performed and results interpreted within six months prior to receiving a first
Necrosis Factor) Therapy Submission Submission
course of anti-TNF (tumor necrosis factor) therapy
Inflammatory Bowel Disease (IBD): Assessment of Percentage of patients aged 18 years and older with a diagnosis of Non-Endorsed/ Non-Endorsed/
inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status
275 Hepatitis B Virus (HBV) Status Before Initiating Anti- - - 275 Effective Clinical Care Process AGA - - TBD - Planned Planned - - - - - Q1 - AGA Measurment Committee Review -
TNF (Tumor Necrosis Factor) Therapy assessed and results interpreted within one year prior to receiving a first Submission Submission
course of anti-TNF (tumor necrosis factor) therapy
- AMA- PCPI
Percentage of patients 18 years and older who were screened for tobacco use
Preventive Care and Screening: Tobacco Use: Screening AMA- Full
226 138v2 0028 0226 one or more times within 24 months AND who received cessation counseling Community/Population Health Process - - Behavioral Health A -2016 - - - - Q2 TBD by NQF - -
and Cessation Intervention intervention if identified as a tobacco user PCPI Endorsement
Percentage of patients aged 18 years and older with a diagnosis of heart

Heart Failure (HF): Beta-Blocker Therapy for Left failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < Full
008 Ventricular Systolic Dysfunction (LVSD) 144v2 0083 0008 40% who were prescribed beta-blocker therapy either within a 12 month Effective Clinical Care Process AMA- PCPI ACCF AHA Cardiovascular A -2016 - Endorsement - - - Q2 TBD by NQF - -
period when seen in the outpatient setting OR at each hospital discharge
Percentage of patients aged 65 years and older discharged from any inpatient
facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) and seen
within 30 days following discharge in the office by the physician, prescribing Full
046 Medication Reconciliation - 0097 046 Patient Safety Process AMA- PCPI NCQA - Care Coordination B - 2014 - - - - - - - NCQA is the steward for this measure
practitioner, registered nurse, or clinical pharmacist providing on-going care Endorsement
who had a reconciliation of the discharge medications with the current
medication list in the outpatient medical record documented
Percentage of patients aged 6 months and older seen for a visit between
Preventive Care and Screening: Influenza Full
110 147v2 0041 110 October 1 and March 31 who received an influenza immunization OR who Community/Population Health Process AMA- PCPI - - Population Health: Prevention - - - - - Q2 TBD by NQF - -
Immunization reported previous receipt of an influenza immunization Endorsement
Coronary Artery Disease (CAD): Angiotensin- Percentage of patients aged 18 years and older with a diagnosis of coronary
Converting Enzyme (ACE) Inhibitor or Angiotensin artery disease seen within a 12 month period who also have diabetes OR a Full
118 Receptor Blocker (ARB) Therapy -- Diabetes or Left - 0066 118 current or prior Left Ventricular Ejection Fraction (LVEF) < 40% who were Effective Clinical Care Process AMA- PCPI AACF AHA Cardiovascular A -2016 - Endorsement - - - Q2 TBD by NQF - -
Ventricular Systolic Dysfunction (LVEF < 40%) prescribed ACE inhibitor or ARB therapy
Percentage of patients aged 12 years and older screened for clinical
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
Full
197 Coronary Artery Disease (CAD): Lipid Control - 0074 197 Correct measure description: Percentage of patients aged 18 years and older Effective Clinical Care Process AMA- PCPI ACCF AHA Cardiovascular A -2016 - - - - TBD by NQF TBD by NQF - -
Endorsement
with a diagnosis of coronary artery disease seen within a 12 month period
who have a LDL-C result <100 mg/dL OR patients who have a LDL-C result
>=100 mg/dL and have a documented plan of care to achieve LDL-C
<100mg/dL, including at a minimum the prescription of a statin
Percentage of patients aged 18 years and older with a diagnosis of chronic
Adult Kidney Disease: Laboratory Testing (Lipid kidney disease (CKD) (stage 3, 4, or 5, not receiving Renal Replacement Full
121 Profile) - 1668 121 Therapy [RRT]) who had a fasting lipid profile performed at least once within Effective Clinical Care Process AMA- PCPI - - Renal B - 2014 - Endorsement - - - Q2 TBD by NQF - -
a 12-month period
Percentage of patient visits for those patients aged 18 years and older with a
Non-Endorsed/
122 Adult Kidney Disease: Blood Pressure Management - - 122 diagnosis of chronic kidney disease (CKD) (stage 3, 4, or 5, not receiving Renal Effective Clinical Care Outcome AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
Replacement Therapy [RRT]) and proteinuria with a blood pressure < 130/80
Submission
mmHg OR ≥ 130/80 mmHg with a documented plan of care
Percentage of calendar months within a 12-month period during which a

hemoglobin level is measured for patients aged 18 years and older with a
Adult Kidney Disease: Patients On Erythropoiesis- diagnosis of advanced chronic kidney disease (CKD) (stage 4 or 5, not
Full
123 Stimulating Agent (ESA) - Hemoglobin Level > 12.0 - 1666 123 receiving Renal Replacement Therapy [RRT]) or End Stage Renal Disease Effective Clinical Care Outcome AMA- PCPI - - Renal B - 2014 - - - - Q2 TBD by NQF - -
g/dL (ESRD) (who are on hemodialysis or peritoneal dialysis) who are also Endorsement
receiving erythropoiesis-stimulating agent (ESA) therapy have a hemoglobin
level > 12.0 g/dL
Percentage of female patients aged 65 years and older who have a central
Screening or Therapy for Osteoporosis for Women dual-energy X- ray absorptiometry (DXA) measurement ordered or Full
039 Aged 65 Years and Older - 0046 039 performed at least once since age 60 or pharmacologic therapy prescribed Effective Clinical Care Process AMA- PCPI NCQA - Endocrine A -2016 - Endorsement - - - - - - NCQA is the steward for this measure
within 12 months
Urinary Incontinence: Assessment of Presence or Non-Endorsed/

048 Absence of Urinary Incontinence in Women Aged 65 - 0098 048 Percentage of female patients aged 65 years and older who were assessed for Effective Clinical Care Process AMA- PCPI NCQA - GI/GU - - Lost - - - - - - NCQA is the steward for this measure
the presence or absence of urinary incontinence within 12 months
Years and Older Endorsement
Measure replaced by measure NQF #2152: Preventive Care and Screening:

Preventive Care and Screening: Unhealthy Alcohol Use Percentage of patients aged 18 years and older who were screened for
173 - - 173 Community/Population Health Process AMA- PCPI - - Behavioral Health - - - - - - - - - Unhealthy Alcohol Use: Screening and Brief Counseling. Measure 2152 endorsed
– Screening unhealthy alcohol use using a systematic screening method within 24 months via NQF Behavioral Health project in March 2014
Percentage of patients aged 18 years and older with a diagnosis of rheumatoid

arthritis (RA) who have documentation of a tuberculosis (TB) screening Non-Endorsed/
176 Rheumatoid Arthritis (RA): Tuberculosis Screening - - 176 performed and results interpreted within 6 months prior to receiving a first Effective Clinical Care Process AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
course of therapy using a biologic disease-modifying anti-rheumatic drug Submission
(DMARD)
Rheumatoid Arthritis (RA): Periodic Assessment of Percentage of patients aged 18 years and older with a diagnosis of rheumatoid Non-Endorsed/
177 - - 177 arthritis (RA) who have an assessment and classification of disease activity Effective Clinical Care Process AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
Disease Activity
within 12 months Submission
Percentage of patients aged 18 years and older with a diagnosis of rheumatoid Non-Endorsed/
Rheumatoid Arthritis (RA): Functional Status
178 - - 178 arthritis (RA) for whom a functional status assessment was performed at least Effective Clinical Care Process AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
Assessment once within 12 months Submission
Rheumatoid Arthritis (RA): Assessment and arthritis (RA) who have an assessment and classification of disease prognosis Planned
179 Classification of Disease Prognosis - - 179 Effective Clinical Care Process AMA- PCPI - - - - - - - - - TBD by NQF - -
at least once within 12 months Submission
Page 13 of 119
Comprehensive
CMS NQF PQRS #1 #2 #3 2013 2014 2014 2014 2014

Rheumatoid Arthritis (RA): Glucocorticoid arthritis (RA) who have been assessed for glucocorticoid use and, for those on Communication and Care Non-Endorsed/
180 - - 180 prolonged doses of prednisone ≥ 10 mg daily (or equivalent) with Process AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
Management Coordination
improvement or no change in disease activity, documentation of Submission
glucocorticoid management plan within 12 months
Percentage of surgical patients aged 18 years and older undergoing

procedures with the indications for prophylactic parenteral antibiotics, who
Perioperative Care: Timing of Prophylactic Parenteral Full
020 - 0270 020 have an order for prophylactic parenteral antibiotic to be given within one Patient Safety Process AMA- PCPI NCQA - Surgery A -2016 - - - - - - - The plan is to retire this measure
Antibiotic – Ordering Physician hour (if fluoroquinolone or vancomycin, two hours), prior to the surgical Endorsement
incision (or start of procedure when no incision is required)

021 Perioperative Care: Selection of Prophylactic Antibiotic - 0268 021 procedures with the indications for a first OR second generation Patient Safety Process AMA- PCPI NCQA - Surgery A -2016 - Full - - - TBD by NQF '- - Measure submitted and currently under review for maintenance of endorsement
– First OR Second Generation Cephalosporin cephalosporin prophylactic antibiotic, who had an order for a first OR second Endorsement by NQF's Surgery Committee
generation cephalosporin for antimicrobial prophylaxis
Percentage of non-cardiac surgical patients aged 18 years and older

undergoing procedures with the indications for prophylactic parenteral
Perioperative Care: Discontinuation of Prophylactic Full Measure submitted and currently under review for maintenance of endorsement
022 - 0271 022 antibiotics AND who received a prophylactic parenteral antibiotic, who have Patient Safety Process AMA- PCPI NCQA - Surgery A -2016 - - - - TBD by NQF - -
Parenteral Antibiotics (Non-Cardiac Procedures) Endorsement by NQF's Surgery Committee
an order for discontinuation of prophylactic parenteral antibiotics within 24
hours of surgical end time

procedures for which VTE prophylaxis is indicated in all patients, who had an
Perioperative Care: Venous Thromboembolism (VTE) order for Low Molecular Weight Heparin (LMWH), Low-Dose Unfractionated Full
023 Prophylaxis (When Indicated in ALL Patients) - 0239 023 Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical Patient Safety Process AMA- PCPI NCQA - Safety B - 2014 - Endorsement - - - TBD by NQF TBD by NQF - -
prophylaxis to be given within 24 hours prior to incision time or within 24
hours after surgery end time

084 Hepatitis C: Ribonucleic Acid (RNA) Testing Before - 0395 084 hepatitis C who started antiviral treatment within the 12 month reporting Effective Clinical Care Process AMA- PCPI - - Infectious disease C - 2015 - Full - - - Q3 TBD by NQF - -
Initiating Treatment period for whom quantitative hepatitis C virus (HCV) RNA testing was Endorsement
performed within 12 months prior to initiation of antiviral treatment

hepatitis C who started antiviral treatment within the 12 month reporting Full
085 Hepatitis C: HCV Genotype Testing Prior to Treatment - 0396 085 Effective Clinical Care Process AMA- PCPI - - Infectious disease C - 2015 - - - - TBD by NQF TBD by NQF - -
period for whom hepatitis C virus (HCV) genotype testing was performed Endorsement
within 12 months prior to initiation of antiviral treatment

Hepatitis C: Hepatitis C Virus (HCV) Ribonucleic Acid
hepatitis C who are receiving antiviral treatment for whom quantitative Full
087 (RNA) Testing Between 4-12 Weeks After Initiation of - 0398 087 hepatitis C virus (HCV) RNA testing was performed between 4-12 weeks after Effective Clinical Care Process AMA- PCPI - - Infectious disease C - 2015 - Endorsement - - - Q3 TBD by NQF - -
Treatment
the initiation of antiviral treatment
Hepatitis C: Hepatitis A Vaccination in Patients with Percentage of patients aged 18 years and older with a diagnosis of chronic Full
183 - 0399 183 hepatitis C who have received at least one injection of hepatitis A vaccine, or Community/Population Health Process AMA- PCPI - - Infectious disease C - 2015 - - - - Q3 TBD by NQF - -
Hepatitis C Virus (HCV) Endorsement
who have documented immunity to hepatitis A

Heart Failure (HF): Angiotensin-Converting Enzyme failure (HF) with a current or prior left ventricular ejection fraction (LVEF) <
(ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Full
005 135v2 0081 005 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 Effective Clinical Care Process AMA- PCPI ACCF AHA Cardiovascular A -2016 - - - - Q2 TBD by NQF - -
Therapy for Left Ventricular Systolic Dysfunction month period when seen in the outpatient setting OR at each hospital Endorsement
(LVSD)
discharge

Heart Failure: Left Ventricular Ejection Fraction (LVEF) failure for whom the quantitative or qualitative results of a recent or prior Full
198 Assessment - 0079 198 [any time in the past] LVEF assessment is documented within a 12 month Effective Clinical Care Process AMA- PCPI ACCF AHA Cardiovascular A -2016 - Endorsement - - - Q2 TBD by NQF - -
period
Percentage of patients aged 18 years and older with a diagnosis of coronary Full
006 Coronary Artery Disease (CAD): Antiplatelet Therapy - 0067 006 artery disease seen within a 12 month period who were prescribed aspirin or Effective Clinical Care Process AMA- PCPI ACCF AHA Cardiovascular A -2016 - - - - Q2 TBD by NQF - -
Endorsement
clopidogrel
Percentage of patients aged 18 years and older with a diagnosis of coronary

artery disease seen within a 12 month period who have a LDL-C result < 100
Full
197 Coronary Artery Disease (CAD): Lipid Control - 0074 197 mg/dL OR patients who have a LDL-C result ≥ 100 mg/dL and have a Effective Clinical Care Process AMA- PCPI ACCF AHA Cardiovascular A -2016 - - - - Q2 TBD by NQF - -
documented plan of care to achieve LDL-C < 100 mg/dL, including at a Endorsement
minimum the prescription of a statin

artery disease seen within a 12 month period with results of an evaluation of Non-Endorsed/
242 Coronary Artery Disease (CAD): Symptom Management - - 242 level of activity and an assessment of whether anginal symptoms are present Effective Clinical Care Process AMA- PCPI ACCF AHA - - - Planned - - - - TBD by NQF - -
or absent with appropriate management of anginal symptoms within a 12 Submission
month period
Percentage of patients aged 6 months and older with a diagnosis of HIV/AIDS

HIV/AIDS: CD4+ Cell Count or CD4+ Percentage Full
159 - 0404 159 for whom a CD4+ cell count or CD4+ cell percentage was performed at least Effective Clinical Care Process AMA- PCPI NCQA - Infectious disease C - 2015 - - - - - - - NCQA is the steward for this measure
Performed Endorsement
once every 6 months
Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS

HIV/AIDS: Sexually Transmitted Disease Screening for Full
205 Chlamydia, Gonorrhea, and Syphilis - 0409 205 for whom chlamydia, gonorrhea and syphilis screenings were performed at Effective Clinical Care Process AMA- PCPI NCQA - Infectious disease C - 2015 - Endorsement - - - - - - NCQA is the steward for this measure
least once since the diagnosis of HIV infection
053 Asthma: Pharmacologic Therapy for Persistent Asthma - 0047 053 Percentage of patients aged 5 through 64 years with a diagnosis of persistent Effective Clinical Care Process AMA- PCPI NCQA - Pulmonary B - 2014 - Full - - - TBD by NQF TBD by NQF - -
- Ambulatory Care Setting asthma who were prescribed long-term control medication Endorsement
Percentage of patients aged 5 through 64 years with a diagnosis of asthma Non-Endorsed/

Asthma: Assessment of Asthma Control – Ambulatory
064 - 0001 064 who were evaluated at least once during the measurement period for asthma Effective Clinical Care Process AMA- PCPI NCQA - - - - Planned - - - - TBD by NQF - -
Care Setting control (comprising asthma impairment and asthma risk) Submission
Percentage of patients aged 5 through 64 years with a diagnosis of asthma (or

Non-Endorsed/
Asthma: Tobacco Use: Screening - Ambulatory Care their primary caregiver) who were queried about tobacco use and exposure to
231 Setting - - 231 second hand smoke within their home environment at least once during the Effective Clinical Care Process AMA- PCPI NCQA - - - - Planned - - - - TBD by NQF - -
Submission
one-year measurement period
Percentage of patients aged 5 through 64 years with a diagnosis of asthma

Asthma: Tobacco Use: Intervention - Ambulatory Care who were identified as tobacco users (or their primary caregiver) who Non-Endorsed/
232 - - 232 Effective Clinical Care Process AMA- PCPI NCQA - - - - Planned - - - - TBD by NQF - -
Setting received tobacco cessation intervention at least once during the one-year
measurement period Submission
Chronic Obstructive Pulmonary Disease (COPD): Percentage of patients aged 18 years and older with a diagnosis of COPD who Full
051 - 0091 051 Effective Clinical Care Process AMA- PCPI - - Pulmonary B - 2014 - - - - TBD by NQF TBD by NQF - -
Spirometry Evaluation had spirometry evaluation results documented Endorsement
Percentage of patients aged 18 years and older with a diagnosis of COPD and
Chronic Obstructive Pulmonary Disease (COPD): who have an FEV1/FVC less than 60% and have symptoms who were Full
052 Inhaled Bronchodilator Therapy - 0102 052 Effective Clinical Care Process AMA- PCPI - - Pulmonary B - 2014 - Endorsement - - - TBD by NQF TBD by NQF - -
prescribed an inhaled bronchodilator
Percentage of visits for patients aged 18 years and older with a diagnosis of
obstructive sleep apnea that includes documentation of an assessment of Non-Endorsed/
276 Sleep Apnea: Assessment of Sleep Symptoms - - 276 Effective Clinical Care Process AMA- PCPI NCQA - - - - Planned - - - - TBD by NQF - -
sleep symptoms, including presence or absence of snoring and daytime
sleepiness Submission
Percentage of patients aged 18 years and older with a diagnosis of obstructive Non-Endorsed/
277 Sleep Apnea: Severity Assessment at Initial Diagnosis - - 277 sleep apnea who had an apnea hypopnea index (AHI) or a respiratory Effective Clinical Care Process AMA- PCPI NCQA - - - - Planned - - - - TBD by NQF - -
disturbance index (RDI) measured at the time of initial diagnosis Submission
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Sleep Apnea: Positive Airway Pressure Therapy Percentage of patients aged 18 years and older with a diagnosis of moderate Non-Endorsed/
278 - - 278 or severe obstructive sleep apnea who were prescribed positive airway Effective Clinical Care Process AMA- PCPI NCQA - - - - Planned - - - - TBD by NQF - -
Prescribed
pressure therapy Submission
Non-Endorsed/
Sleep Apnea: Assessment of Adherence to Positive obstructive sleep apnea who were prescribed positive airway pressure
Airway Pressure Therapy therapy who had documentation that adherence to positive airway pressure Submission
therapy was objectively measured
Percentage of patients, regardless of age, with a diagnosis of dementia whose Non-Endorsed/

280 Dementia: Staging of Dementia - - 280 severity of dementia was classified as mild, moderate or severe at least once Communication and Care Process AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
Coordination
within a 12 month period Submission
Percentage of patients, regardless of age, with a diagnosis of dementia for Non-Endorsed/

281 Dementia: Cognitive Assessment 149v2 - 281 whom an assessment of cognition is performed and the results reviewed at Effective Clinical Care Process AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
least once within a 12 month period Submission

282 Dementia: Functional Status Assessment - - 282 whom an assessment of functional status is performed and the results Effective Clinical Care Process AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
reviewed at least once within a 12 month period Submission
Percentage of patients, regardless of age, with a diagnosis of dementia and for Non-Endorsed/
283 Dementia: Neuropsychiatric Symptom Assessment - - 283 whom an assessment of neuropsychiatric symptoms is performed and results Effective Clinical Care Process AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
reviewed at least once in a 12 month period Submission
Percentage of patients, regardless of age, with a diagnosis of dementia who Non-Endorsed/

have one or more neuropsychiatric symptoms who received or were
284 Dementia: Management of Neuropsychiatric Symptoms - - 284 Effective Clinical Care Process AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
recommended to receive an intervention for neuropsychiatric symptoms Submission
within a 12 month period
Non-Endorsed/
Percentage of patients, regardless of age, with a diagnosis of dementia who
285 Dementia: Screening for Depressive Symptoms - - 285 were screened for depressive symptoms within a 12 month period Effective Clinical Care Process AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
Submission
Percentage of patients, regardless of age, with a diagnosis of dementia or their Non-Endorsed/

286 Dementia: Counseling Regarding Safety Concerns - - 286 caregiver(s) who were counseled or referred for counseling regarding safety Patient Safety Process AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
concerns within a 12 month period Submission

287 Dementia: Counseling Regarding Risks of Driving - - 287 caregiver(s) who were counseled regarding the risks of driving and the Effective Clinical Care Process AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
alternatives to driving at least once within a 12 month period Submission
Percentage of patients, regardless of age, with a diagnosis of dementia whose

Non-Endorsed/
caregiver(s) were provided with education on dementia disease management Planned
288 Dementia: Caregiver Education and Support - - 288 and health behavior changes AND referred to additional sources for support Effective Clinical Care Process AMA- PCPI - - - - - - - - - TBD by NQF - -
Submission

Cataracts: 20/40 or Better Visual Acuity within 90 Days uncomplicated cataract who had cataract surgery and no significant ocular Time-Limited
191 133v2 0565 191 conditions impacting the visual outcome of surgery and had best-corrected Effective Clinical Care Outcome AMA- PCPI NCQA - HEENT C - 2015 - - - - TBD by NQF TBD by NQF - -
Following Cataract Surgery Endorsement
visual acuity of 20/40 or better (distance or near) achieved within 90 days
following the cataract surgery

uncomplicated cataract who had cataract surgery and had any of a specified
Cataracts: Complications within 30 Days Following
list of surgical procedures in the 30 days following cataract surgery which Time-Limited
192 Cataract Surgery Requiring Additional Surgical 132v2 0564 192 Patient Safety Outcome AMA- PCPI NCQA - HEENT C - 2015 - - - - TBD by NQF TBD by NQF - -
Procedures would indicate the occurrence of any of the following major complications: Endorsement
retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL,
retinal detachment, or wound dehiscence
Breast Cancer: Hormonal Therapy for Stage IC -IIIC Percentage of female patients aged 18 years and older with Stage IC through
Estrogen Receptor/Progesterone Receptor (ER/PR) IIIC, ER or PR positive breast cancer who were prescribed tamoxifen or Full
071 - 0387 071 Effective Clinical Care Process AMA- PCPI ASCO NCCN Cancer B - 2014 - Endorsement - - - TBD by NQF TBD by NQF - -
Positive Breast Cancer aromatase inhibitor (AI) during the 12-month reporting period
Percentage of patients aged 18 through 80 years with AJCC Stage III colon
Colon Cancer: Chemotherapy for AJCC Stage III Colon cancer who are referred for adjuvant chemotherapy, prescribed adjuvant Full
072 - 0385 072 Effective Clinical Care Process AMA- PCPI ASCO NCCN Cancer B - 2014 - - - - TBD by NQF TBD by NQF - -
Cancer Patients chemotherapy, or have previously received adjuvant chemotherapy within the Endorsement
12-month reporting period
Percentage of patients, regardless of patient age, with a diagnosis of cancer

Oncology: Medical and Radiation – Pain Intensity Patient and Caregiver-Centered Full
143 Quantified 157v2 0384 143 currently receiving chemotherapy or radiation therapy in which pain intensity Experience and Outcomes Process AMA- PCPI - - Cancer B - 2014 - Endorsement - - - TBD by NQF TBD by NQF - -
is quantified
Percentage of visits for patients, regardless of age, with a diagnosis of cancer

144 Oncology: Medical and Radiation – Plan of Care for Pain - 0383 144 currently receiving chemotherapy or radiation therapy who report having Patient and Caregiver-Centered Process AMA- PCPI - - Cancer B - 2014 - Full - - - TBD by NQF TBD by NQF - -
Experience and Outcomes Endorsement
pain with a documented plan of care to address pain
Percentage of patients, regardless of age, with a diagnosis of cancer who are

seen in the ambulatory setting who have a baseline American Joint Committee Full
194 Oncology: Cancer Stage Documented - 0386 194 Effective Clinical Care Process AMA- PCPI ASCO - Cancer B - 2014 - - - - TBD by NQF TBD by NQF - -
on Cancer (AJCC) cancer stage or documentation that the cancer is metastatic Endorsement
in the medical record at least once during the 12 month reporting period
Percentage of computed tomography (CT) imaging reports for all patients,

Optimizing Patient Exposure to Ionizing Radiation: Non-Endorsed/
regardless of age, with the imaging study named according to a standardized Communication and Care
359 Utilization of a Standardized Nomenclature for - - 359 nomenclature and the standardized nomenclature is used in institution’s Coordination Structure AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
Computed Tomography (CT) Imaging Description Submission
computer systems
Percentage of computed tomography (CT) and cardiac nuclear medicine

Optimizing Patient Exposure to Ionizing Radiation:
Count of Potential High Dose Radiation Imaging (myocardial perfusion studies) imaging reports for all patients, regardless of Non-Endorsed/
360 - - 360 age, that document a count of known previous CT (any type of CT) and cardiac Patient Safety Structure AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
Studies: Computed Tomography (CT) and Cardiac
Nuclear Medicine Studies nuclear medicine (myocardial perfusion) studies that the patient has received Submission
in the 12-month period prior to the current study
Percentage of total computed tomography (CT) studies performed for all Non-Endorsed/
361 - - 361 patients, regardless of age, that are reported to a radiation dose index registry Patient Safety Structure AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
Reporting to a Radiation Dose Index Registry AND that include at a minimum selected data elements Submission
Percentage of final reports for computed tomography (CT) studies performed

Optimizing Patient Exposure to Ionizing Radiation: for all patients, regardless of age, which document that Digital Imaging and Non-Endorsed/
Computed Tomography (CT) Images Available for Communications in Medicine (DICOM) format image data are available to non- Communication and Care Planned
362 - - 362 Coordination Structure AMA- PCPI - - - - - - - - - TBD by NQF - -
Patient Follow-up and Comparison Purposes affiliated external entities on a secure, media free, reciprocally searchable Submission
basis with patient authorization for at least a 12-month period after the study
Percentage of final reports of computed tomography (CT) studies performed

for all patients, regardless of age, which document that a search for Digital
Search for Prior Computed Tomography (CT) Imaging Imaging and Communications in Medicine (DICOM) format images was Communication and Care Non-Endorsed/
363 - - 363 conducted for prior patient CT imaging studies completed at non-affiliated Structure AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
Studies Through a Secure, Authorized, Media-Free, Coordination
Shared Archive external entities within the past 12-months and are available through a Submission
secure, authorized, media free, shared archive prior to an imaging study being
performed
Optimizing Patient Exposure to Ionizing Radiation: Percentage of final reports for CT imaging studies of the thorax for patients
aged 18 years and older with documented follow-up recommendations for Non-Endorsed/
Appropriateness: Follow-up CT Imaging for Communication and Care
364 - - 364 incidentally detected pulmonary nodules (eg, follow-up CT imaging studies Process AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
Incidentally Detected Pulmonary Nodules According to needed or that no follow-up is needed) based at a minimum on nodule size Coordination Submission
Recommended Guidelines
AND patient risk factors
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Coronary Artery Disease (CAD): Beta-Blocker Therapy Percentage of patients aged 18 years and older with a diagnosis of coronary Full
007 – Prior Myocardial Infarction (MI) or Left Ventricular 145v2 0070 007 artery disease seen within a 12 month period who also have prior MI OR a Effective Clinical Care Process AMA-PCPI ACCF AHA Cardiovascular A -2016 - - - - Q2 TBD by NQF - -
Endorsement
Systolic Dysfunction (LVEF < 40%) current or LVEF < 40% who were prescribed beta-blocker therapy
Percentage of patients aged 18 years and older with a diagnosis of primary

Primary Open-Angle Glaucoma (POAG): Optic Nerve Full
012 143v2 0086 012 open-angle glaucoma (POAG) who have an optic nerve head evaluation during Effective Clinical Care Process AMA-PCPI NCQA - HEENT C - 2015 - - - - TBD by NQF TBD by NQF - -
Evaluation: one or more office visits within 12 months Endorsement
Percentage of patients aged 50 years and older with a diagnosis of age-related

macular degeneration (AMD) who had a dilated macular examination
014 Age-Related Macular Degeneration (AMD): Dilated - 0087 014 performed which included documentation of the presence or absence of Effective Clinical Care Process AMA-PCPI NCQA - HEENT C - 2015 - Full - - - TBD by NQF TBD by NQF - -
Macular Examination Endorsement
macular thickening or hemorrhage AND the level of macular degeneration
severity during one or more office visits within 12 months
Percentage of patients aged 18 years and older with a diagnosis of diabetic

Diabetic Retinopathy: Documentation of Presence or retinopathy who had a dilated macular or fundus exam performed which
Full
018 Absence of Macular Edema and Level of Severity of 167v2 0088 018 included documentation of the level of severity of retinopathy and the Effective Clinical Care Process AMA-PCPI NCQA - Endocrine A -2016 - - - - Q2 TBD by NQF - -
Endorsement
Retinopathy presence or absence of macular edema during one or more office visits within
12 months

retinopathy who had a dilated macular or fundus exam performed with
Diabetic Retinopathy: Communication with the Full
019 Physician Managing Ongoing Diabetes Care 142v2 0089 019 documented communication to the physician who manages the ongoing care Effective Clinical Care Process AMA-PCPI NCQA - Endocrine A -2016 - Endorsement - - - Q2 TBD by NQF - -
of the patient with diabetes mellitus regarding the findings of the macular or
fundus exam at least once within 12 months
Osteoporosis: Communication with the Physician Percentage of patients aged 50 years and older treated for a hip, spine or
024 Managing On-going Care Post-Fracture of Hip, Spine or - 0045 024 distal radial fracture with documentation of communication with the Communication and Care Process AMA-PCPI NCQA - Endocrine A -2016 - Full - - - - - - NCQA is the steward for this measure
Distal Radius for Men and Women Aged 50 Years and physician managing the patient’s on-going care that a fracture occurred and Coordination Endorsement
Older that the patient was or should be tested or treated for osteoporosis
Percentage of patients, regardless of age, with an emergency department

discharge diagnosis of acute myocardial infarction (AMI) who had Full
028 Aspirin at Arrival for Acute Myocardial Infarction (AMI) - 0092 028 Effective Clinical Care Process AMA-PCPI NCQA - Cardiovascular A -2016 - - - - TBD by NQF TBD by NQF - -
documentation of receiving aspirin within 24 hours before emergency Endorsement
department arrival or during emergency department stay
Percentage of surgical patients aged 18 years and older who receive an

anesthetic when undergoing procedures with the indications for prophylactic
Perioperative Care: Timing of Prophylactic Antiobiotic parenteral antibiotics for whom administration of a prophylactic parenteral Full Measure submitted and currently under review for maintenance of endorsement
030 —Administering Physician - 0269 030 antibiotic ordered has been initiated within one hour (if fluoroquinolone or Patient Safety Process AMA-PCPI NCQA - Surgery A -2016 - Endorsement - - - TBD by NQF - - by NQF's Surgery Committee
vancomycin, two hours) prior to the surgical incision (or start of procedure
when no incision is required)
Percentage of patients aged 18 years and older with a diagnosis of ischemic

Stroke and Stroke Rehabilitation: Venous stroke or intracranial hemorrhage who were administered venous Full
031 Thromboembolism (VTE) Prophylaxis for Ischemic - 0240 031 Effective Clinical Care Process AMA-PCPI NCQA - Neurology C - 2015 - - - - TBD by NQF TBD by NQF - -
thromboembolism (VTE) prophylaxis the day of or the day after hospital Endorsement
Stroke or Intracranial Hemorrhage admission

Stroke and Stroke Rehabilitation: Discharged on stroke or transient ischemic attack (TIA) with documented permanent, Full
032 - 0325 032 Effective Clinical Care Process AMA-PCPI NCQA - Neurology C - 2015 - - - - TBD by NQF TBD by NQF - -
Antithrombotic Therapy persistent, or paroxysmal atrial fibrillation who were prescribed an Endorsement
antithrombotic at discharge

Stroke and Stroke Rehabilitation: Anticoagulant
Therapy Prescribed for Atrial Fibrillation (AF) at stroke or transient ischemic attack (TIA) with documented permanent, Full
033 - 0241 033 persistent, or paroxysmal atrial fibrillation who were prescribed an Effective Clinical Care Process AMA-PCPI NCQA - Neurology C - 2015 - Endorsement - - - TBD by NQF TBD by NQF - -
Discharge
anticoagulant at discharge

Stroke and Stroke Rehabilitation: Screening for stroke or intracranial hemorrhage who receive any food, fluids or medication Full
035 - 0243 035 by mouth (PO) for whom a dysphagia screening was performed prior to PO Effective Clinical Care Process AMA-PCPI NCQA - Neurology C - 2015 - - - - TBD by NQF TBD by NQF - -
Dysphagia Endorsement
intake in accordance with a dysphagia screening tool approved by the
institution in which the patient is receiving care

stroke or intracranial hemorrhage for whom occupational, physical, or speech
Stroke and Stroke Rehabilitation: Rehabilitation Full
036 - 0244 036 rehabilitation services were ordered at or prior to inpatient discharge OR Effective Clinical Care Process AMA-PCPI NCQA - Neurology C - 2015 - - - - TBD by NQF TBD by NQF - -
Services Ordered documentation that no rehabilitation services are indicated at or prior to Endorsement
inpatient discharge
Osteoporosis: Management Following Fracture of Hip, Percentage of patients aged 50 years and older with fracture of the hip, spine,
Spine or Distal Radius for Men and Women Aged 50 or distal radius who had a central dual-energy X-ray absorptiometry (DXA) Full
040 - 0048 040 Effective Clinical Care Process AMA-PCPI NCQA - Endocrine A -2016 - Endorsement - - - - - - NCQA is the steward for this measure
Years and Older measurement ordered or performed or pharmacologic therapy prescribed
Osteoporosis: Pharmacologic Therapy for Men and Percentage of patients aged 50 years and older with a diagnosis of Full
041 - 0049 041 Effective Clinical Care Process AMA-PCPI NCQA - Endocrine A -2016 - - - - TBD by NQF TBD by NQF - NCQA is the steward for this measure
Women Aged 50 Years and Older osteoporosis who were prescribed pharmacologic therapy within 12 months Endorsement
Percentage of cardiac surgical patients aged 18 years and older undergoing

procedures with the indications for prophylactic parenteral antibiotics AND
Perioperative Care: Discontinuation of Prophylactic Full Measure submitted and currently under review for maintenance of endorsement
045 Parenteral Antibiotics (Cardiac Procedures) - 0637 045 who received a prophylactic parenteral antibiotic, who have an order for Patient Safety Process AMA-PCPI NCQA - Surgery - - Endorsement - - - - - - by NQF's Surgery Committee
discontinuation of prophylactic parenteral antibiotics within 48 hours of
surgical end time
Percentage of patients aged 65 years and older who have an advance care
plan or surrogate decision maker documented in the medical record or
047 Advance Care Plan - 0326 047 documentation in the medical record that an advance care plan was discussed Communication and Care Process AMA-PCPI NCQA - Care Coordination B - 2014 - Full - - - - - - NCQA is the steward for this measure
Coordination Endorsement
but the patient did not wish or was not able to name a surrogate decision
maker or provide an advance care plan
Percentage of female patients aged 65 years and older with a diagnosis of Non-Endorsed/
Urinary Incontinence: Characterization of Urinary
049 - 0099 049 urinary incontinence whose urinary incontinence was characterized at least Effective Clinical Care Process AMA-PCPI NCQA - GI/GU - - Lost - - - - - - NCQA is the steward for this measure
Incontinence in Women Aged 65 Years and Older once within 12 months Endorsement
Urinary Incontinence: Plan of Care for Urinary Patient and Caregiver-Centered
050 Incontinence in Women Aged 65 Years and Older - 0100 050 urinary incontinence with a documented plan of care for urinary incontinence Experience and Outcomes Process AMA-PCPI NCQA - GI/GU - - Lost - - - - - - NCQA is the steward for this measure
at least once within 12 months Endorsement
Emergency Medicine: 12-Lead Electrocardiogram Percentage of patients aged 40 years and older with an emergency Full
054 - 0090 054 department discharge diagnosis of non-traumatic chest pain who had a 12- Effective Clinical Care Process AMA-PCPI NCQA - Cardiovascular A -2016 - - - - TBD by NQF TBD by NQF - -
(ECG) Performed for Non-Traumatic Chest Pain Endorsement
lead electrocardiogram (ECG) performed
The PCPI and the American College of Emergency Physicians elected not to
submit the measure to NQF for maintenance of endorsement. PQRS data from
2011 suggested a relatively high rate of performance at 96.48% and we felt that
the measure would fail to meet the performance gap sub-criterion within the
Percentage of patients aged 60 years and older with an emergency Non-Endorsed/ “importance to measure and report” evaluation criterion. However,
Emergency Medicine: 12-Lead Electrocardiogram
055 - 0093 055 department discharge diagnosis of syncope who had a 12-lead Effective Clinical Care Process AMA-PCPI NCQA - Cardiovascular - - Lost - - - - - - Syncope is a frequent complaint in the emergency department, accounting for
(ECG) Performed for Syncope electrocardiogram (ECG) performed Endorsement one to three percent of all ED visits and hospital admissions in the US. An ECG
remains a critical component of the initial evaluation of a patient presenting with
syncope to determine the etiology and institute appropriate treatment strategies.
We still collectively support the measure and have plans to maintain it as part of
our emergency medicine measure set with no immediate plans for retirement.
Percentage of patients aged 18 years and older with a diagnosis of Non-Endorsed/
Emergency Medicine: Community-Acquired Bacterial community-acquired bacterial pneumonia (CAP) with vital signs documented Lost
056 Pneumonia (CAP): Vital Signs - 0232 056 Effective Clinical Care Process AMA-PCPI NCQA - Pulmonary - - - - - - - - -
and reviewed Endorsement
Emergency Medicine: Community-Acquired Bacterial Percentage of patients aged 18 years and older with a diagnosis of Full
059 - 0096 059 community-acquired bacterial pneumonia (CAP) with an appropriate empiric Effective Clinical Care Process AMA-PCPI NCQA - Pulmonary B - 2014 - - - - TBD by NQF TBD by NQF - -
Pneumonia (CAP): Empiric Antibiotic Endorsement
antibiotic prescribed
Hematology: Myelodysplastic Syndrome (MDS) and Percentage of patients aged 18 years and older with a diagnosis of
Full
067 Acute Leukemias: Baseline - 0377 067 myelodysplastic syndrome (MDS) or an acute leukemia who had baseline Effective Clinical Care Process AMA-PCPI ASH - Cancer B - 2014 - - - - TBD by NQF TBD by NQF - -
Cytogenetic Testing Performed on Bone Marrow cytogenetic testing performed on bone marrow Endorsement
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Hematology: Myelodysplastic Syndrome (MDS): myelodysplastic syndrome (MDS) who are receiving erythropoietin therapy Full
068 Documentation of Iron Stores in Patients Receiving - 0378 068 Effective Clinical Care Process AMA-PCPI ASH - Cancer B - 2014 - - - - TBD by NQF TBD by NQF - -
with documentation of iron stores within 60 days prior to initiating Endorsement
Erythropoietin Therapy erythropoietin therapy
Percentage of patients aged 18 years and older with a diagnosis of multiple

Hematology: Multiple Myeloma: Treatment with Full
069 - 0380 069 myeloma, not in remission, who were prescribed or received intravenous Effective Clinical Care Process AMA-PCPI ASH - Cancer B - 2014 - - - - TBD by NQF TBD by NQF - -
Bisphosphonates bisphosphonate therapy within the 12-month reporting period Endorsement
Percentage of patients aged 18 years and older seen within a 12 month

070 Hematology: Chronic Lymphocytic Leukemia (CLL): - 0379 070 reporting period with a diagnosis of chronic lymphocytic leukemia (CLL) Effective Clinical Care Process AMA-PCPI ASH - Cancer B - 2014 - Full - - - TBD by NQF TBD by NQF - -
Baseline Flow Cytometry made at any time during or prior to the reporting period who had baseline Endorsement
flow cytometry studies performed and documented in the chart
Percentage of patients, regardless of age, who undergo CVC insertion for

Prevention of Catheter-Related Bloodstream Infections whom CVC was inserted with all elements of maximal sterile barrier
technique [cap AND mask AND sterile gown AND sterile gloves AND a large Full Measure submitted and currently under review for maintenance of endorsement
076 (CRBSI): Central Venous Catheter (CVC) Insertion - 0464 076 Patient Safety Process AMA-PCPI - - Safety B - 2014 - - - - TBD by NQF - -
sterile sheet AND hand hygiene AND 2% chlorhexidine for cutaneous Endorsement by NQF's Patient Safety Committee
Protocol antisepsis (or acceptable alternative antiseptics per current guideline)]
followed
Percentage of calendar months within a 12-month period during which

patients aged 18 years and older with a diagnosis of End Stage Renal Disease Communication and Care Full
081 Adult Kidney Disease: Hemodialysis Adequacy: Solute - 0323 081 (ESRD) receiving hemodialysis three times a week for ≥ 90 days who have a Coordination Outcome AMA-PCPI - - Renal B - 2014 - Endorsement - - - Q2 TBD by NQF - -
spKt/V ≥ 1.2
Percentage of patients aged 18 years and older with a diagnosis of End Stage
082 Adult Kidney Disease: Peritoneal Dialysis Adequacy: - 0321 082 Renal Disease (ESRD) receiving peritoneal dialysis who have a total Kt/V ≥ 1.7 Communication and Care Outcome AMA-PCPI - - Renal B - 2014 - Full - - - Q2 TBD by NQF - -
Solute Coordination Endorsement
per week measured once every 4 months
Percentage of patients aged 18 years and older who are hepatitis C antibody
Full
083 Hepatitis C: Confirmation of Hepatitis C Viremia - 0393 083 positive seen for an initial evaluation for whom hepatitis C virus (HCV) RNA Effective Clinical Care Process AMA-PCPI - - Infectious disease C - 2015 - - - - Q3 TBD by NQF - -
testing was ordered or previously performed Endorsement
Percentage of patients aged 2 years and older with a diagnosis of AOE who Time-Limited
091 Acute Otitis Externa (AOE): Topical Therapy - 0653 091 were prescribed topical preparations Effective Clinical Care Process AMA-PCPI - - HEENT C - 2015 - Endorsement - - - TBD by NQF TBD by NQF - -
Acute Otitis Externa (AOE): Systemic Antimicrobial Percentage of patients aged 2 years and older with a diagnosis of AOE who Communication and Care Time-Limited
093 Therapy – Avoidance of - 0654 093 Process AMA-PCPI - - HEENT C - 2015 - - - - TBD by NQF TBD by NQF - -
were not prescribed systemic antimicrobial therapy Coordination Endorsement
Inappropriate Use:
Breast Cancer Resection Pathology Reporting: pT Percentage of breast cancer resection pathology reports that include the pT
Full
099 Category (Primary Tumor) and pN Category (Regional - 0391 099 category (primary tumor), the pN category (regional lymph nodes), and the Effective Clinical Care Process AMA-PCPI CAP - Cancer B - 2014 - - - - Q2 TBD by NQF - -
Lymph Nodes) with Histologic Grade histologic grade Endorsement
Colorectal Cancer Resection Pathology Reporting: pT Percentage of colon and rectum cancer resection pathology reports that
Category (Primary Tumor) and pN Category (Regional include the pT category (primary tumor), the pN category (regional lymph Full
100 - 0392 100 Effective Clinical Care Process AMA-PCPI CAP - Cancer B - 2014 - Endorsement - - - Q2 TBD by NQF - -
Lymph Nodes) with Histologic Grade nodes) and the histologic grade
Percentage of patients, regardless of age, with a diagnosis of prostate cancer

Prostate Cancer: Avoidance of Overuse of Bone Scan for at low risk of recurrence receiving interstitial prostate brachytherapy, OR Full
102 129v3 0389 102 external beam radiotherapy to the prostate, OR radical prostatectomy, OR Efficiency and Cost Reduction Process AMA-PCPI - - Cancer B - 2014 - - - - Q2 TBD by NQF - -
Staging Low Risk Prostate Cancer Patients Endorsement
cryotherapy who did not have a bone scan performed at any time since
diagnosis of prostate cancer

Prostate Cancer: Adjuvant Hormonal Therapy for High at high risk of recurrence receiving external beam radiotherapy to the Full
104 - 0390 104 Effective Clinical Care Process AMA-PCPI - - Cancer B - 2014 - - - - Q2 TBD by NQF - -
Risk Prostate Cancer Patients prostate who were prescribed adjuvant hormonal therapy (GnRH agonist or Endorsement
antagonist)
Percentage of patients aged 18 years and older with a new diagnosis or

recurrent episode of major depressive disorder (MDD) with evidence that
Adult Major Depressive Disorder (MDD): Non-Endorsed/
Comprehensive Depression Evaluation: Diagnosis and they met the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV- Lost
106 - 0103 106 TR criteria for MDD AND for whom there is an assessment of depression Effective Clinical Care Process AMA-PCPI - - Behavioral Health - - - - - - - - -
Severity Endorsement
severity during the visit in which a new diagnosis or recurrent episode was
identified
Percentage of patients aged 18 years and older with a diagnosis of major

Adult Major Depressive Disorder (MDD): Suicide Risk Full
107 161v2 0104 107 depressive disorder (MDD) with a suicide risk assessment completed during Effective Clinical Care Process AMA-PCPI - - Behavioral Health A -2016 - - - - TBD by NQF TBD by NQF - Endorsement renewed in 2/14
Assessment Endorsement
the visit in which a new diagnosis or recurrent episode was identified
The American Academy of Orthopedic Surgeons intends to potentially submit this

Non-Endorsed/ measure for endorsement. The measure lost endorsement because of time and
Percentage of patient visits for patients aged 21 years and older with a Patient and Caregiver-Centered
109 Osteoarthritis (OA): Function and Pain Assessment - 0050 109 diagnosis of osteoarthritis (OA) with assessment for function and pain Experience and Outcomes Process AMA-PCPI - - Musculoskeletal - - Lost - - - - - - resource constraints that precluded submission of measure for maintenance of
Endorsement endorsement. We continue to support this measure and may plan to resubmit at
the next available opportunity.

melanoma or a history of melanoma whose information was entered, at least
once within a 12 month period, into a recall system that includes:
137 Melanoma: Continuity of Care – Recall System - 0650 137 • A target date for the next complete physical skin exam, AND Effective Clinical Care Structure AMA-PCPI NCQA - Cancer B - 2014 - Full - - - TBD by NQF TBD by NQF - -
• A process to follow up with patients who either did not make an Endorsement
appointment within the specified timeframe or who missed a scheduled
appointment
Percentage of patient visits, regardless of age, with a new occurrence of Non-Endorsed/

melanoma who have a treatment plan documented in the chart that was Communication and Care
138 Melanoma: Coordination of Care - 0561 138 Process AMA-PCPI NCQA - Cancer - - Lost - - - - - - -
communicated to the physician(s) providing continuing care within one Coordination Endorsement
month of diagnosis

Age-Related Macular Degeneration (AMD): Counseling macular degeneration (AMD) or their caregiver(s) who were counseled within Time-Limited
140 on Antioxidant Supplement - 0566 140 12 months on the benefits and/or risks of the Age-Related Eye Disease Study Effective Clinical Care Process AMA-PCPI NCQA - HEENT C - 2015 - Endorsement - - - TBD by NQF TBD by NQF - -
(AREDS) formulation for preventing progression of AMD

Primary Open-Angle Glaucoma (POAG): Reduction of open-angle glaucoma (POAG) whose glaucoma treatment has not failed (the Communication and Care Full
141 Intraocular Pressure (IOP) by 15% OR Documentation - 0563 141 most recent IOP was reduced by at least 15% from the pre- intervention level) Process AMA-PCPI NCQA - HEENT C - 2015 - - - - TBD by NQF TBD by NQF - -
of a Plan of Care 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
Osteoarthritis (OA): Assessment for Use of Anti- Percentage of patient visits for patients aged 21 years and older with a Non-Endorsed/ The American Academy of Orthopedic Surgeons intends to potentially submit this
measure for endorsement. The measure lost endorsement because of time and
142 Inflammatory or Analgesic Over-the-Counter (OTC) - 0051 142 diagnosis of osteoarthritis (OA) with an assessment for use of anti- Effective Clinical Care Process AMA-PCPI - - Musculoskeletal - - Lost - - - - - -
Medications inflammatory or analgesic over-the-counter (OTC) medications Endorsement resource constraints that precluded submission of measure for maintenance of
endorsement.
Radiology: Exposure Time Reported for Procedures Percentage of final reports for procedures using fluoroscopy that include Full Measure submitted and currently under review for maintenance of endorsement
145 Using Fluoroscopy - 0510 145 documentation of radiation exposure or exposure time Patient Safety Process AMA-PCPI NCQA - Safety B - 2014 - Endorsement - - - TBD by NQF - - by NQF's Patient Safety Committee
Radiology: Inappropriate Use of “Probably Benign” Percentage of final reports for screening mammograms that are classified as Full
146 - 0508 146 Efficiency and Cost Reduction Process AMA-PCPI NCQA - Efficiency A -2016 - - - - Q3 TBD by NQF - -
Assessment Category in Mammography Screening “probably benign” Endorsement
Percentage of final reports for all patients, regardless of age, undergoing bone Non-Endorsed/
Nuclear Medicine: Correlation with Existing Imaging Communication and Care
147 - - 147 scintigraphy that include physician documentation of correlation with existing Structure AMA-PCPI - - - - - Lost - - - - - - -
Studies for All Patients Undergoing Bone Scintigraphy relevant imaging studies (e.g., x-ray, MRI, CT, etc.) that were performed Coordination Endorsement
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Percentage of patients aged 65 years and older with a history of falls who had Full
154 Falls: Risk Assessment - 0101 154 Patient Safety Process AMA-PCPI NCQA - Safety B - 2014 - - - - - - - NCQA is the steward for this measure
a risk assessment for falls completed within 12 months Endorsement
Percentage of patients aged 65 years and older with a history of falls who had Communication and Care Time-Limited
155 Falls: Plan of Care - 0101 155 Process AMA-PCPI NCQA - Safety B - 2014 - - - - - - - NCQA is the steward for this measure
a plan of care for falls documented within 12 months Coordination Endorsement
Percentage of patients, regardless of age, with a diagnosis of pancreatic or

lung cancer receiving 3D conformal radiation therapy with documentation in
156 Oncology: Radiation Dose Limits to Normal Tissues - 0382 156 medical record that radiation dose limits to normal tissues were established Patient Safety Process AMA-PCPI - - Cancer B - 2014 - Full - - - TBD by NQF TBD by NQF - -
Endorsement
prior to the initiation of a course of 3D conformal radiation for a minimum of
two tissues
Endoscopy/Polyp Surveillance: Colonoscopy Interval Percentage of patients aged 18 years and older receiving a surveillance
colonoscopy, with a history of a prior adenomatous polyp(s) in previous Communication and Care Full
185 for Patients with a History of Adenomatous Polyps – - 0659 185 Process AMA-PCPI NCQA - GI/GU C - 2015 - - - - TBD by NQF TBD by NQF - Received full endorsement 12/13
colonoscopy findings, who had an interval of 3 or more years since their last Coordination Endorsement
Avoidance of Inappropriate Use colonoscopy
Percentage of patients, regardless of age, undergoing surgical or therapeutic

procedures under general or neuraxial anesthesia of 60 minutes duration or
longer, except patients undergoing cardiopulmonary bypass, for whom either
active warming was used intraoperatively for the purpose of maintaining Full Measure submitted and currently under review for maintenance of endorsement
193 Perioperative Temperature Management - 0454 193 normothermia, OR at least one body temperature equal to or greater than 36 Patient Safety Process AMA-PCPI - - Surgery A -2016 - Endorsement - - - TBD by NQF - - by NQF's Surgery Committee
degrees Centigrade (or 96.8 degrees Fahrenheit) was recorded within the 30
minutes immediately before or the 15 minutes immediately after anesthesia
end time
Percentage of final reports for carotid imaging studies (neck magnetic

resonance angiography [MRA], neck computed tomography angiography
195 Radiology: Stenosis Measurement in Carotid Imaging - 0507 195 [CTA], neck duplex ultrasound, carotid angiogram) performed that include Effective Clinical Care Process AMA-PCPI NCQA - Neurology C - 2015 - Full - - - Q3 TBD by NQF - -
Reports Endorsement
direct or indirect reference to measurements of distal internal carotid
diameter as the denominator for stenosis measurement
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
Melanoma: Overutilization of Imaging Studies in Full
224 - 0562 224 symptoms suggesting systemic spread, seen for an office visit during the one- Efficiency and Cost Reduction Process AMA-PCPI NCQA - Cancer B - 2014 - - - - TBD by NQF TBD by NQF - -
Melanoma year measurement period, for whom no diagnostic imaging studies were Endorsement
ordered
Percentage of patients aged 40 years and older undergoing a screening

Communication and Care Full
225 Radiology: Reminder System for Mammograms - 0509 225 mammogram whose information is entered into a reminder system with a Coordination Structure AMA-PCPI NCQA - Efficiency A -2016 - Endorsement - - - Q3 TBD by NQF - -
target due date for the next mammogram
Chronic Wound Care: Use of Wound Surface Culture Percentage of patient visits for those patients aged 18 years and older with a Non-Endorsed/
245 Technique in Patients with Chronic Skin Ulcers - - 245 diagnosis of chronic skin ulcer without the use of a wound surface culture Effective Clinical Care Efficiency AMA-PCPI NCQA - - - - Planned - - - - TBD by NQF - -
(Overuse Measure technique Submission
Percentage of patient visits for those patients aged 18 years and older with a Non-Endorsed/
Chronic Wound Care: Use of Wet to Dry Dressings in
246 - - 246 diagnosis of chronic skin ulcer without a prescription or recommendation to Effective Clinical Care Efficiency AMA-PCPI NCQA - - - - Planned - - - - TBD by NQF - -
Patients with Chronic Skin Ulcers (Overuse Measure) use wet to dry dressings Submission
Percentage of patients aged 18 years and older with a diagnosis of current

Substance Use Disorders: Counseling Regarding Non-Endorsed/
Psychosocial and Pharmacologic Treatment Options for alcohol dependence who were counseled regarding psychosocial AND Planned
247 - - 247 pharmacologic treatment options for alcohol dependence within the 12- Effective Clinical Care Process AMA-PCPI NCQA - - - - - - - - TBD by NQF - -
Alcohol Dependence Submission
month reporting period
Substance Use Disorders: Screening for Depression Percentage of patients aged 18 years and older with a diagnosis of current Non-Endorsed/
248 - - 248 substance abuse or dependence who were screened for depression within the Effective Clinical Care Process AMA-PCPI NCQA - - - - Planned - - - - TBD by NQF - -
Among Patients with Substance Abuse or Dependence
12-month reporting period Submission
Percentage of patients aged 50 years and older receiving a screening

Endoscopy/Polyp Surveillance: Appropriate Follow-Up
colonoscopy without biopsy or polypectomy who had a recommended follow- Communication and Care Full
320 Interval for Normal Colonoscopy in Average Risk - 0658 320 Process AMA-PCPI - - GI/GU C - 2015 - - - - TBD by NQF TBD by NQF - Received full endorsement 12/13
Patients: up interval of at least 10 years for repeat colonoscopy documented in their Coordination Endorsement
colonoscopy report
Percentage of medical records of patients aged 18 years and older with a

diagnosis of major depressive disorder (MDD) and a specific diagnosed
Non-Endorsed/
Adult Major Depressive Disorder (MDD): Coordination comorbid condition (diabetes, coronary artery disease, ischemic stroke, Planned
325 of Care of Patients with Specific Comorbid Conditions - - 325 intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Effective Clinical Care Process AMA-PCPI - - - - - - - - - TBD by NQF - -
Submission
Renal Disease [ESRD] or congestive heart failure) being treated by another
clinician with communication to the clinician treating the comorbid condition

nonvalvular atrial fibrillation (AF) or atrial flutter whose assessment of the
Atrial Fibrillation and Atrial Flutter: Chronic specified thromboembolic risk factors indicate one or more high-risk factors Full
326 - 1525 326 Patient Safety Process AMA-PCPI ACCF AHA Cardiovascular A -2016 - - - - TBD by NQF TBD by NQF - -
Anticoagulation Therapy or more than one moderate risk factor, as determined by CHADS2 risk Endorsement
stratification, who are prescribed warfarin OR another oral anticoagulant
drug that is FDA approved for the prevention of thromboembolism

Pediatric Kidney Disease: ESRD Patients Receiving patients aged 17 years and younger with a diagnosis of End Stage Renal Full
328 Dialysis: Hemoglobin Level < 10 g/Dl - 1667 328 Disease (ESRD) receiving hemodialysis or peritoneal dialysis have a Effective Clinical Care Outcome AMA-PCPI - - Renal B - 2014 - Endorsement - - - Q2 TBD by NQF - -
hemoglobin level < 10 g/dL
Non-Endorsed/
329 Adult Kidney Disease: Catheter Use at Initiation of - - 329 Renal Disease (ESRD) who initiate maintenance hemodialysis during the Effective Clinical Care Process AMA-PCPI - - - - - Planned - - - - TBD by NQF - -
Hemodialysis measurement period, whose mode of vascular access is a catheter at the time
Submission
maintenance hemodialysis is initiated
Percentage of patients aged 18 years and older with a diagnosis of End Stage Non-Endorsed/
Adult Kidney Disease: Catheter Use for Greater Than or
330 - - 330 Renal Disease (ESRD) receiving maintenance hemodialysis for greater than or Effective Clinical Care Process AMA-PCPI - - - - - Planned - - - - TBD by NQF - -
Equal to 90 Days equal to 90 days whose mode of vascular access is a catheter Submission
Percentage of patients, aged 18 years and older, with a diagnosis of acute Non-Endorsed/
Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis
331 (Appropriate Use) - - 331 sinusitis who were prescribed an antibiotic within 7 days of diagnosis or Effective Clinical Care Process AMA-PCPI - - - - - Planned - - - - TBD by NQF - -
within 10 days after onset of symptoms Submission
Adult Sinusitis: Appropriate Choice of Antibiotic: Percentage of patients aged 18 years and older with a diagnosis of acute Non-Endorsed/
332 Amoxicillin Prescribed for Patients with Acute Bacterial - - 332 bacterial sinusitis that were prescribed amoxicillin, without clavulante, as a Effective Clinical Care Process AMA-PCPI - - - - - Planned - - - - TBD by NQF - -
Sinusitis first line antibiotic at the time of diagnosis Submission
Percentage of patients aged 18 years and older with a diagnosis of acute Non-Endorsed/
Adult Sinusitis: Computerized Tomography for Acute sinusitis who had a computerized tomography (CT) scan of the paranasal
333 - - 333 Efficiency and Cost Reduction Efficiency AMA-PCPI - - - - - Planned - - - - TBD by NQF - -
Sinusitis (Overuse) sinuses ordered at the time of diagnosis or received within 28 days after date Submission
of diagnosis
Adult Sinusitis: More than One Computerized Percentage of patients aged 18 years and older with a diagnosis of chronic Non-Endorsed/
334 Tomography (CT) Scan Within 90 Days for Chronic - - 334 sinusitis who had more than one CT scan of the paranasal sinuses ordered or Effective Clinical Care Efficiency AMA-PCPI - - - - - Planned - - - - TBD by NQF - -
Sinusitis (Overuse) received within 90 days after the date of diagnosis Submission
Percentage of patients, regardless of age, who gave birth during a 12-month

Maternity Care: Elective Delivery or Early Induction period who delivered a live singleton at ≥ 37 and < 39 weeks of gestation Non-Endorsed/
335 - - 335 Patient Safety Process AMA-PCPI - - - - - Planned - - - - TBD by NQF - -
Without Medical Indication at ≥ 37 and < 39 Weeks completed who had elective deliveries or early inductions without medical
indication Submission

period who were seen for post-partum care within 8 weeks of giving birth Non-Endorsed/
Maternity Care: Post-Partum Follow-Up and Care Communication and Care
336 - - 336 who received a breast feeding evaluation and education, post-partum Process AMA-PCPI - - - - - Planned - - - - TBD by NQF - -
Coordination depression screening, post-partum glucose screening for gestational diabetes Coordination Submission
patients, and family and contraceptive planning
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Child and Adolescent Major Depressive Disorder Percentage of patient visits for those patients aged 6 through 17 years with a Full
382 177v2 1365 382 Patient Safety Process AMA-PCPI - - Behavioral Health A -2016 - - - - TBD by NQF TBD by NQF - -
(MDD): Suicide Risk Assessment diagnosis of major depressive disorder with an assessment for suicide risk Endorsement
- APMA
Diabetes Mellitus: Diabetic Foot and Ankle Care, Percentage of patients aged 18 years and older with a diagnosis of diabetes Full Non-Endorsed/ 2014 (scheduled to be This measure was reviewed in the Endocrine review in March 2014. There were Working with NQF staff to resolve issues identifed by review committee and then
126 Peripheral Neuropathy – - 0417 0126 mellitus who had a neurological examination of their lower extremities within Effective Clinical Care Process APMA - - Endocrine - Planned - - - - resubmitted by June 6, issues identified by the committee. The measure was withdrawn for reivew by
Endorsement resubmitting for review in June 2014 (submission deadline June 6, 2014)
Neurological Evaluation 12 months Submission 2014) measure developer and will be revised and resubmitted for June 2014 review.
Non-Endorsed/ 2014 (scheduled to be This measure was reviewed in the Endocrine review in March 2014. There were
Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Percentage of patients aged 18 years and older with a diagnosis of diabetes Full Working with NQF staff to resolve issues identifed by review committee and then
127 Prevention – Evaluation of Footwear - 0416 0127 mellitus who were evaluated for proper footwear and sizing Effective Clinical Care Process APMA - - Endocrine - Endorsement Planned - - - - resubmitted by June 6, issues identified by the committee. The measure was withdrawn for reivew by resubmitting for review in June 2014 (submission deadline June 6, 2014)
Submission 2014) measure developer and will be revised and resubmitted for June 2014 review.
- AQC
Percentage of patients aged birth and older referred to a physician (preferably

Not endorsed - Non-Endorsed/
Referral for Otologic Evaluation for Patients with Acute a physician specially trained in disorders of the ear) for an otologic evaluation Communication and Care
261 or Chronic Dizziness - - 0261 subsequent to an audiologic evaluation after presenting with acute or chronic Coordination Process AQC - - - - not pursing No Plan to - - - - - - -
endorsement Submit
dizziness
- ASBS
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,
Non-Endorsed/
Image Confirmation of Successful Excision of Image– mammographic or sonographic mass or architectural distortion, focal
262 Localized Breast Lesion - - 0262 suspicious abnormalities on magnetic resonance imaging (MRI) or other Patient Safety Process ASBS - - N/A - non-endorsed No Plan to - - - - N/A Measure will be reviewed and any necessary updates will be made by 8/1/2014 N/A
Submit
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.
The percent of patients undergoing breast cancer operations who obtained Non-Endorsed/
263 Preoperative Diagnosis of Breast Cancer - - 0263 the diagnosis of breast cancer preoperatively by a minimally invasive biopsy Effective Clinical Care Process ASBS - - N/A - non-endorsed No Plan to - - - - N/A Measure will be reviewed and any necessary updates will be made by 8/1/2014 N/A
method Submit
The percentage of clinically node negative (clinical stage T1N0M0 or Non-Endorsed/

264 Sentinel Lymph Node Biopsy for Invasive Breast Cancer - - 264 T2N0M0) breast cancer patients who undergo a sentinel lymph node (SLN) Effective Clinical Care Process ASBS - - N/A - non-endorsed No Plan to - - - - N/A Measure will be reviewed and any necessary updates will be made by 8/1/2014 N/A
procedure Submit
- CAP
Percentage of esophageal biopsy reports that document the presence of Full

249 Barrett's Esophagus - - 0249 Effective Clinical Care Structure CAP - - Cancer C - 2015 - - - - Q4 TBD - Q4 Annual update submitted December 2013
Barrett’s mucosa that also include a statement about dysplasia Endorsement
Percentage of radical prostatectomy pathology reports that include the pT

category, the pN category, the Gleason score and a statement about margin Full
250 Radical Prostatectomy Pathology Reporting - - 0250 Effective Clinical Care Structure CAP - - Cancer C - 2015 - Endorsement - - - Q4 TBD - Q4 Annual update submitted December 2013
status
This is a measure based on whether quantitative evaluation of Human

Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) by Full
251 Epidermal Growth Factor Receptor 2 Testing (HER2) - - 251 immunohistochemistry (IHC) uses the system recommended in the ASCO/CAP Effective Clinical Care Structure CAP - - Cancer C - 2015 - - - - Q4 TBD - Q4 Annual update submitted December 2013
Endorsement
for Breast Cancer Patients Guidelines for Human Epidermal Growth Factor Receptor 2 Testing in breast
cancer
- FOTO
Emailed NQF in April 2013 about continued Endorsement of our Measures. FOTO
was informed our measures were assigned to the “Musculoskeletal review
committee which convenes this year projected to be in Q4." Recontact with NQF
Functional Deficit: Change in Risk-Adjusted Functional Percentage of patients aged 18 or older that receive treatment for a functional Communication and Care Person and Family Centered Care- Full Full in October 2013 to determine review session and deadline date and we were
217 - 0422 0217 deficit secondary to a diagnosis that affects the knee in which the change in Process F0T0 - - - - - - - September, 2014 informed that our seven measures are assigned to the second phase of the -
Status for Patients with Knee Impairments Coordination Phase 2 Endorsement Endorsement
their Risk-Adjusted Functional Status is measured “Person and Family Centered Care” project and that we should move forward
with completing the maintenance forms for these measures for submission
deadline
Emailed NQFof September
in April 12, 2014.
2013 about We areEndorsement
continued currently preparing our update
of our Measures. FOTO
information
was informed for submission
our measures to NQF
were assigned by this
to the deadline.
“Musculoskeletal review
Percentage of patients aged 18 or older that receive treatment for a functional in October 2013 to determine review session and deadline date and we were
Functional Deficit: Change in Risk-Adjusted Functional Communication and Care Person and Family Centered Care- Full Full
218 Status for Patients with Hip Impairments - 0423 0218 deficit secondary to a diagnosis that affects the hip in which the change in Coordination Outcome FOTO - - Phase 2 - Endorsement Endorsement - - - - September, 2014 informed that our seven measures are assigned to the second phase of the -
their Risk-Adjusted Functional Status is measured “Person and Family Centered Care” project and that we should move forward
deadline
in April 12, 2014.
information for submission to NQF by this deadline.
was informed our measures were assigned to the “Musculoskeletal review
Functional Deficit: Change in Risk-Adjusted Functional Percentage of patients aged 18 or older that receive treatment for a functional in October 2013 to determine review session and deadline date and we were
219 Status for Patients with Lower Leg, Foot or Ankle - 0424 219 deficit secondary to a diagnosis that affects the lower leg, foot or ankle in Communication and Care Outcome FOTO - - Person and Family Centered Care- - Full Full - - - - September, 2014 informed that our seven measures are assigned to the second phase of the -
Coordination Phase 2 Endorsement Endorsement
Impairments which the change in their Risk-Adjusted Functional Status is measured “Person and Family Centered Care” project and that we should move forward
deadline
in April 12, 2014.
information
our measures to NQF
to the deadline.
220 - 0425 220 deficit secondary to a diagnosis that affects the lumbar spine in which the Outcome FOTO - - - - - - - September, 2014 informed that our seven measures are assigned to the second phase of the -
Status for Patients with Lumbar Spine Impairments change in their Risk-Adjusted Functional Status is measured Coordination Phase 2 Endorsement Endorsement
“Person and Family Centered Care” project and that we should move forward
deadline
in April 12, 2014.
information
our measures to NQF
to the deadline.
221 Status for Patients with Shoulder Impairments - 0426 221 deficit secondary to a diagnosis that affects the shoulder in which the change Coordination Outcome FOTO - - Phase 2 - Endorsement Endorsement - - - - September, 2014 informed that our seven measures are assigned to the second phase of the -
in their Risk-Adjusted Functional Status is measured “Person and Family Centered Care” project and that we should move forward
deadline
in April 12, 2014.
information
our measures to NQF
to the deadline.
222 Status for Patients with Elbow, Wrist or Hand - 0427 222 deficit secondary to a diagnosis that affects the elbow, wrist or hand in which Communication and Care Outcome FOTO - - Person and Family Centered Care- - Full Full - - - - September, 2014 informed that our seven measures are assigned to the second phase of the -
Coordination Phase 2 Endorsement Endorsement
Impairments the change in their Risk-Adjusted Functional Status is measured “Person and Family Centered Care” project and that we should move forward
deadline
in April 12, 2014.
information
our measures to NQF
to the deadline.
Status for Patients with Neck, Cranium, Mandible, deficit secondary to a diagnosis that affects the neck, cranium, mandible, Communication and Care Person and Family Centered Care- Full Full
223 - 0428 223 Outcome FOTO - - - - - - - September, 2014 informed that our seven measures are assigned to the second phase of the -
Thoracic Spine, Ribs, or Other General Orthopedic thoracic spine, ribs, or other general orthopedic impairment in which the Coordination Phase 2 Endorsement Endorsement “Person and Family Centered Care” project and that we should move forward
Impairments change in their Risk-Adjusted Functional Status is measured
non-endorsed: with completing the maintenance forms for these measures for submission
Withdrew the deadline of September 12, 2014. We are currently preparing our update
measure at information for submission to NQF by this deadline.
- HRS NQF’s
suggestion from
the current
cardiac project
because both
NQF and we felt Withdrew the measure at NQF’s suggestion from the current cardiac project
HRS-3: Implantable Cardioverter-Defibrillator (ICD) Patients with physician-specific risk-standardized rates of procedural because both NQF and we felt it was better considered in concert with the
348 - - 0348 Effective Clinical Care Outcome HRS - - see column V - it was better Non-Endorsed - - - - - -
Complications Rate complications following the first time implantation of an ICD considered in hospital-level analysis corollary when that comes up for endorsement
maintenance.
concert with the
hospital-level
analysis
corollary when
- ACCF-AHA that comes up
for
Percentage of patients evaluated in an outpatient setting who within the endorsement
previous 12 months have experienced an acute myocardial infarction (MI), maintenance.
coronary artery bypass graft (CABG) surgery, a percutaneous coronary
Cardiac Rehabilitation Patient Referral from an Full Q1 - Submitted for maintenance endorsement 2013 Q4. In-Person meeting
243 - 0643 0243 intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who Effective Clinical Care Process ACCF-AHA - - Cardiovascular A -2016 - - - - - 12/21/2013 Measure Testing Completed
Outpatient Setting have chronic stable angina (CSA) and have not already participated in an early Endorsement scheduled for 4/21-4/22/14
outpatient cardiac rehabilitation/secondary prevention (CR) program for the
qualifying event/diagnosis who were referred to a CR program
- MNCM
Patients ages 18 through 75 with a diagnosis of diabetes, who meet all the
numerator targets of this composite measure:
• A1c < 8.0%
• LDL < 100 mg/dL
Full Full Cholesterol component changes necessary based on Nov 2013 ACC/AHA new
319 Diabetes Composite: Optimal Diabetes Care - 0729 0319 • blood pressure < 140/90 mmHg Effective Clinical Care Outcome MNCM - - Endocrine B - 2014 - - - - 12/1/2014 Delayed cycle for meaintence endorsement related to new guidelines
• tobacco non-user and Endorsement Endorsement guidelines.
(for patients with a diagnosis of ischemic vascular disease) daily aspirin use
unless contraindicated
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Percent of patients aged 18 to 75 with ischemic vascular disease (IVD) who

have optimally managed modifiable risk factors demonstrated by meeting all Full Full Cholesterol component changes necessary based on Nov 2013 ACC/AHA new
349 Optimal Vascular Composite - 0076 0349 of the numerator targets of this patient level all-or-none composite measure: Effective Clinical Care Outcome MNCM - - Cardiovascular A -2016 - - - - - Annual maintenance completed in April 2013
Endorsement Endorsement guidelines.
LDL less than 100, blood pressure less than 140/90, tobacco-free status, and
daily aspirin use
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
Full Full
370 Depression Remission at Twelve Months 159v2 0710 370 as PHQ-9 score less than 5. This measure applies to both patients with newly Effective Clinical Care Outcome MNCM - - Behavioral B - 2014 - - - - 7/25/2014 - Annual maintenance completed in April 2013
diagnosed and existing depression whose current PHQ-9 score indicates a Endorsement Endorsement
need for treatment
Adult patients age 18 and older with the diagnosis of major depression or
371 Depression Utilization of the PHQ-9 Tool 160v2 0712 371 dysthymia who have a PHQ-9 tool administered at least once during a 4 Effective Clinical Care Process MNCM - - Behavioral B - 2014 Full Full - - - - 7/25/2014 - Annual maintenance completed in April 2013
Endorsement Endorsement
month period in which there was a qualifying visit.
- NCQA
Percentage of children 2-18 years of age who were diagnosed with

066 Appropriate Testing for Children with Pharyngitis 146v2 0002 0066 pharyngitis, ordered an antibiotic and received a group A streptococcus Efficiency and Cost Reduction Process NCQA - - HEENT C - 2015 Full Full - - - Q4 2015 - Q4 2013 - Annual update submitted 12/2013
(strep) test for the episode
Percentage of patients 18-85 years of age who had a diagnosis of hypertension

Full Full
236 Controlling High Blood Pressure 165v2 0018 0236 and whose blood pressure was adequately controlled (<140/90 mmHg) Effective Clinical Care Outcome NCQA - - Cardiovascular C - 2015 - - - Q4 2015 - Q1 2013 - Annual update submitted 03/2013
during the measurement period. Endorsement Endorsement
Percentage of patients 66 years of age and older who were ordered high-risk
medications. Two rates are reported.
Full Full
238 Use of High-Risk Medications in the Elderly 156v2 0022 238 a. Percentage of patients who were ordered at least one high-risk medication. Patient Safety Process NCQA - - Patient Safety C - 2015 Endorsement Endorsement - - - Q4 2015 - Q4 2013 - Annual update submitted 12/2013
b. Percentage of patients who were ordered at least two different high-risk
medications.
Percentage of patients 3-17 years of age who had an outpatient visit with a
Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and
who had evidence of the following during the measurement period. Three
Weight Assessment and Counseling for Nutrition and rates are reported. Full Full
239 155v2 0024 239 Community/Population Health Process NCQA - - Health & Well-Being C - 2015 - - - Q4 2015 - Q4 2013 - Annual update submitted 12/2013
Physical Activity for Children and Adolescents - Percentage of patients with height, weight, and body mass index (BMI) Endorsement Endorsement
percentile documentation
- Percentage of patients with counseling for nutrition
- Percentage of patients with counseling for physical activity
Percentage of women 16-24 years of age who were identified as sexually

Full Full
310 Chlamydia Screening for Women 153v2 0033 310 active and who had at least one test for chlamydia during the measurement Community/Population Health Process NCQA - - Perinatal & Reproductive Health C - 2015 - - - Q4 2015 - Q4 2013 - Annual update submitted 12/2013
period Endorsement Endorsement
Percentage of patients 5-64 years of age who were identified as having

Full Full
311 Use of Appropriate Medications for Asthma 126v2 0036 311 persistent asthma and were appropriately prescribed medication during the Effective Clinical Care Process NCQA - - Pulmonary/Critical Care C - 2015 Endorsement Endorsement - - - Q4 2015 - Q4 2013 - Annual update submitted 12/2013
measurement period
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 Full Full
240 Childhood Immunization Status 117v2 0038 240 Community/Population Health Process NCQA - - Health & Well-Being C - 2015 - - - Q4 2015 - Q4 2013 - Annual update submitted 12/2013
pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two Endorsement Endorsement
or three rotavirus (RV); and two influenza (flu) vaccines by their second
birthday
Percentage of patients 18-50 years of age with a diagnosis of low back pain
Full Full Under maintenance review under the Musculoskeletal project. Currently in Public
312 Use of Imaging Studies for Low Back Pain 166v3 0052 312 who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days Efficiency and Cost Reduction Process NCQA - - Musculoskeletal B - 2014 - - - - 2014 -
of the diagnosis. Endorsement Endorsement and Member comment phase.
Percentage of children 3 months-18 years of age who were diagnosed with

Appropriate Treatment for Children with Upper upper respiratory infection (URI) and were not dispensed an antibiotic Full Full
065 Respiratory Infection (URI) 154v2 0069 065 Efficiency and Cost Reduction Process NCQA - - Infectious Diseases C - 2015 Endorsement Endorsement - - - Q4 2015 - -
prescription on or three days after the episode
ercentage 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
ADHD: Follow-Up Care for Children Prescribed prescribing authority during the 30-Day Initiation Phase. Full Full Will go through maintenance review under the Behavioral Health Phase III
366 Attention-Deficit/Hyperactivity Disorder (ADHD) 136v3 0108 366 Effective Clinical Care Process NCQA - - Behavioral Health Phase III B - 2014 - - - - 2014 -
b. Percentage of children who remained on ADHD medication for at least 210 Endorsement Endorsement project beginning in Q3 2014. Initial submission deadline is 7/25/14.
Medication 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
Percentage of patients 18-75 years of age with diabetes who had hemoglobin Full Full Under maintenance review under the Endocrine Phase I project. Currently in
001 Diabetes: Hemoglobin A1c Poor Control 122v2 0059 001 A1c > 9.0% during the measurement period Effective Clinical Care Outcome NCQA - - Endocrine Phase I B - 2014 Endorsement Endorsement - - - - 2014 Public and Member comment phase. -
111 Pneumonia Vaccination Status for Older Adults 127v2 0043 111 Percentage of patients 65 years of age and older who have ever received a Effective Clinical Care Process NCQA - - Health & Well-Being C - 2015 Full Full - - - Q4 2015 - Q4 2013 - Annual update submitted 12/2013
pneumococcal vaccine Endorsement Endorsement
Non-
Endorsed/Has Non-
(2372 - New Percentage of women 50 through 74 years of age who had a mammogram to Endorsed/ Under maintenance review under the Health & Well-Being project. Currently in
112 Breast Cancer Screening 125v2 112 Effective Clinical Care Process NCQA - - Health & Well-Being B - 2014 been submitted - - - - 2014 -
NQF #) screen for breast cancer within 27 months for current Sybmitted Public and Member comment phase.
Pending Review
2014 project.
Percentage of patients 50 through 75 years of age who had appropriate Full Full
113 Colorectal Cancer Screening 130v2 0034 113 screening for colorectal cancer Effective Clinical Care Process NCQA - - Health & Well-Being C - 2015 Endorsement Endorsement - - - Q4 2015 - Q4 2013 - Annual update submitted 12/2013
318 Falls: Screening for Fall Risk 139v2 0101 318 Percentage of patients 65 years of age and older who were screened for future Patient Safety Process NCQA - - Patient Safety C - 2015 Full Full - - - Q1 2015 - Q1 2014 - Annual update submitted 03/2014
fall risk at least once during the measurement period Endorsement Endorsement
Diabetes: Low Density Lipoprotein (LDL-C) Control Percentage of patients 18–75 years of age with diabetes whose LDL-C was Full Full Will go through maintenance review under the Endocrine Phase III project
002 163v2 0064 002 Effective Clinical Care Outcome NCQA - - Endocrine Phase III B - 2014 - - - - 2014 -
(<100 mg/dL) adequately controlled (< 100 mg/dL) during the measurement period Endorsement Endorsement beginning in Q4 2014. Initial submission deadline is 12/5/14.
Percentage of patients 18 through 75 years of age with a diagnosis of diabetes

(type 1 and type 2) who had a retinal or dilated eye exam in the measurement Full Full Under maintenance review under the Endocrine Phase I project. Currently in
117 Diabetes: Eye Exam 131v2 0055 117 period or a negative retinal or dilated eye exam (negative for retinopathy) in Effective Clinical Care Process NCQA - - Endocrine Phase I B - 2014 Endorsement Endorsement - - - - 2014 Public and Member comment phase. -
the year prior to the measurement period
The percentage of patients 18-75 years of age with diabetes who had a Full Full Under maintenance review under the Endocrine Phase I project. Currently in
119 Diabetes: Medical Attention for Neuropathy 134v2 0062 119 nephropathy screening test or evidence of nephropathy during the Effective Clinical Care Process NCQA - - Endocrine Phase I B - 2014 - - - - 2014 -
Endorsement Endorsement Public and Member comment phase.
measurement period
Percentage of patients aged 18-75 years of age with diabetes who had a foot Full Full Under maintenance review under the Endocrine Phase I project. Currently in
163 Diabetes: Foot Exam 123v2 0056 163 Effective Clinical Care Process NCQA - - Endocrine Phase I B - 2014 - - - - 2014 -
exam during the measurement period Endorsement Endorsement Public and Member comment phase.
Percentage of patients aged 18 years and older who were diagnosed with RA
Rheumatoid Arthritis (RA): Disease Modifying Anti- and were prescribed, dispensed, or administered at least one ambulatory Full Full Under maintenance review under the Musculoskeletal project. Currently in Public
108 Rheumatic Drug (DMARD) Therapy - 0054 108 Effective Clinical Care Process NCQA - - Musculoskeletal B - 2014 Endorsement Endorsement - - - - 2014 and Member comment phase. -
prescription for a DMARD
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The percentage of patients aged 18 through 79 years with a diagnosis of back Full Full Currently open for maintenance review under the Musculoskeletal project.
148 Back Pain: Initial Visit - 0322 148 pain or undergoing back surgery who had back pain and function assessed Efficiency and Cost Reduction Process NCQA - - Musculoskeletal B - 2014 - - - - 2014 -
Endorsement Endorsement However, NCQA is not seeking NQF re-endorsement for this measure.
during the initial visit to the clinician for the episode of back pain
Percentage of patients aged 18 through 79 years with a diagnosis of back pain

Full Full Currently open for maintenance review under the Musculoskeletal project.
149 Back Pain: Physical Exam - 0319 149 or undergoing back surgery who received a physical examination at the initial Effective Clinical Care Process NCQA - - Musculoskeletal B - 2014 - - - - 2014 -
visit to the clinician for the episode of back pain Endorsement Endorsement However, NCQA is not seeking NQF re-endorsement for this measure.
The percentage of patients aged 18 through 79 years with a diagnosis of back

150 Back Pain: Advice for Normal Activities - 0314 150 pain or undergoing back surgery who received advice for normal activities at Effective Clinical Care Process NCQA - - Musculoskeletal B - 2014 Full Full - - - - 2014 Currently open for maintenance review under the Musculoskeletal project. -
Endorsement Endorsement However, NCQA is not seeking NQF re-endorsement for this measure.
the initial visit to the clinician for the episode of back pain
The percentage of patients aged 18 through 79 years with a diagnosis of back

pain or undergoing back surgery who received advice against bed rest lasting Full Full Currently open for maintenance review under the Musculoskeletal project.
151 Back Pain: Advice Against Bed Rest - 0313 151 Effective Clinical Care Process NCQA - - Musculoskeletal B - 2014 - - - - 2014 -
four days or longer at the initial visit to the clinician for the episode of back Endorsement Endorsement However, NCQA is not seeking NQF re-endorsement for this measure.
pain
Percentage of patients 18 years of age and older who were discharged alive
for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or
Ischemic Vascular Disease (IVD): Use of Aspirin or percutaneous coronary interventions (PCI) in the 12 months prior to the Full Full
204 Another Antithrombotic 164v2 0068 204 measurement period, or who had an active diagnosis of ischemic vascular Effective Clinical Care Process NCQA - - Cardiovascular C - 2015 Endorsement Endorsement - - - Q1 2015 - Q1 2014 - Annual update submitted 03/2014
disease (IVD) during the measurement period and who had documentation of
use of aspirin or another antithrombotic during the measurement period
Percentage of patients 18-85 years of age who had a diagnosis of hypertension

236 Controlling High Blood Pressure 165v2 0018 236 and whose blood pressure was adequately controlled (< 140/90 mmHg) Effective Clinical Care Outcome NCQA - - Cardiovascular C - 2015 Full Full - - - Q4 2015 - Q1 2013 - Annual update submitted 03/2013
during the measurement period.
Percentage of patients 18 years of age and older who were discharged alive
for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or
percutaneous coronary interventions (PCI) in the 12 months prior to the
Ischemic Vascular Disease (IVD): Complete Lipid Full Full
241 182v3 0075 241 measurement period, or who had an active diagnosis of ischemic vascular Effective Clinical Care Outcome NCQA - - Cardiovascular C - 2015 - - - Q1 2015 - Q1 2014 - Annual update submitted 03/2014
Profile and LDL-C Control (< 100 mg/dL) disease (IVD) during the measurement period, and who had each of the Endorsement Endorsement
following during the measurement period: a complete lipid profile and LDL-C
was adequately controlled (< 100 mg/dL)
HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Percentage of patients aged 6 weeks and older with a diagnosis of HIV/AIDS Full Full
160 Prophylaxis 52v2 0405 160 who were prescribed Pneumocystis Jiroveci Pneumonia (PCP) prophylaxis Effective Clinical Care Process NCQA - - Infectious Diseases C - 2015 Endorsement Endorsement - - - Q1 2015 - Q1 2014 - Annual update submitted 03/2014
Percentage of patients 18 years of age and older who were diagnosed with
major depression and treated with antidepressant medication, and who
remained on antidepressant medication treatment. Two rates are reported
a. Percentage of patients who remained on an antidepressant medication for Full Full Endorsement maintenance was completed on 2/28/14 and endorsement was
009 Anti-Depressant Medication Management 128v2 0105 009 Effective Clinical Care Process NCQA - - Behavioral Health Phase II C - 2015 - - - - 2015 -
at least 84 days (12 weeks). Endorsement Endorsement renewed.
b. Percentage of patients who remained on an antidepressant medication for
at least 180 days (6 months).
Percentage of adults 18 through 64 years of age with a diagnosis of acute

Antibiotic Treatment for Adults with Acute Bronchitis: Full Full
116 - 0058 116 bronchitis who were not prescribed or dispensed an antibiotic prescription on Efficiency and Cost Reduction Process NCQA - - Infectious Diseases C - 2015 - - - Q4 2015 - -
Avoidance of Inappropriate Use or 3 days after the episode Endorsement Endorsement
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.
Initiation and Engagement of Alcohol and Other Drug a. Percentage of patients who initiated treatment within 14 days of the Full Full
305 Dependence Treatment 137v2 0004 305 diagnosis. Effective Clinical Care Process NCQA - - Behavioral Health C - 2015 Endorsement Endorsement - - - Q4 2015 - Q4 2013 - Annual update submitted 12/2013
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.
Percentage of women 21-64 years of age, who received one or more Pap tests Full Full
309 Cervical Cancer Screening 124v2 0032 309 Effective Clinical Care Process NCQA - - Health & Well-Being C - 2015 - - - Q4 2015 - Q4 2013 - Annual update submitted 12/2013
to screen for cervical cancer Endorsement Endorsement
Percentage of patients 5-17 years of age with diabetes with a HbA1c test Full Full Under maintenance review under the Endocrine Phase I project. Currently in
365 Hemoglobin A1c Test for Pediatric Patients 148v2 0060 365 Effective Clinical Care Process NCQA - - Endocrine Phase I B - 2014 - - - - 2014 -
during the measurement period Endorsement Endorsement Public and Member comment phase.
Percentage of patients, regardless of age, with a diagnosis of HIV/AIDS with at Non-Endorsed/

least two medical visits during the measurement year with a minimum of 90 No Plan to This measure went through maintenance review under the Infectious Diseases
368 HIV/AIDS: Medical Visit 62v2 0403 368 Effective Clinical Care Process NCQA - - N/A - Non-endorsed - - - - - - project back in 2012. The measure was not recommended for re-endorsement.
days between each visit Submit
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 Full Full Will go through maintenance review under the Behavioral Health Phase III
372 Maternal Depression Screening 82v1 1401 372 Effective Clinical Care Process NCQA - - Behavioral Health Phase III B - 2014 - - - - 2014 Q1 2013 - Annual update submitted 03/2013
child during child’s first 6 months, and who had a maternal depression Endorsement Endorsement project beginning in Q3 2014. Initial submission deadline is 7/25/14.
screening for the mother at least once between 0 and 6 months of life.
- Quality Insights of Pennsylvania

Preventive Care and Screening: Screening for Clinical depression on the date of the encounter using an age appropriate Full Full
134 2v3 0418 0134 Community/Population Health Process CMS - - Behavioral Health A -2016 - - - Q1 2016 N/A Q1- Re-Endorsed 2/28/14
Depression and Follow-Up Plan standardized depression screening tool AND if positive, a follow-up plan is Endorsement Endorsement
documented on the date of the positive screen.
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
Documentation of Current Medications in the Medical immediate resources available on the date of the encounter. This list must Full Full
130 Record 68v3 0419 0130 include ALL known prescriptions, over-the-counters, herbals, and Patient Safety Process CMS - - Patient Safety B - 2014 Endorsement Endorsement - - - Q2 2017 N/A Q1- No activity
vitamin/mineral/dietary (nutritional) supplements AND must contain the
medications’ name, dosage, frequency and route of administration.
Percentage of patients aged 18 years and older with a documented BMI

during the current encounter or during the previous six months AND when
the BMI is outside of normal parameters, a follow-up plan is documented
128 Preventive Care and Screening: Body Mass Index (BMI) 69v2 0421 128 during the encounter or during the previous six months of the encounter Community/Population Health Process CMS - - Health and Well Being A -2016 Full Full - - - Q1 2016 N/A Q1 - Annual Update submitted March 2014. CMS is considering changing
Screening and Follow-Up Endorsement Endorsement Comprehensive Review Due Date based on release of new guidelines
Normal Parameters: Age 65 years and older BMI ≥ 23 and < 30; Age 18 – 64
years BMI ≥ 18.5 and < 25
Percentage of children, age 0-20 years, who have had tooth decay or cavities
378 Children Who Have Dental Decay or Cavities 75v2 - 378 Effective Clinical Care Process CMS - - - - - - - - - - - - -
during the measurement period
Percentage of patients with referrals, regardless of age, for which the referring
Communication and Care
374 Closing the Referral Loop: Receipt of Specialist Report 50v2 - 374 provider receives a report from the provider to whom the patient was Coordination Process CMS - - - - - - - - - - - - -
referred
Functional Status Assessment for Complex Chronic Percentage of patients aged 65 years and older with heart failure who Patient and Caregiver-Centered
377 90v3 - 377 completed initial and follow-up patient-reported functional status Process CMS - - - - - - - - - - - - -
Conditions Experience and Outcomes
assessments
Percentage of patients aged 18 years and older seen during the measurement Non-Endorsed/
Preventive Care and Screening: Screening for High period who were screened for high blood pressure (BP) AND a recommended
317 22v2 - 317 Community/Population Health Process CMS - - Cardiovascular A -2016 Non-Endorsed Planned - - - Q1 ? Measure is being re-tooled by Interagency Workgroup Q1 - N/A
Blood Pressure and Follow-Up Documented follow-up plan is documented based on the current blood pressure reading as Submission
indicated
Percentage of isolated Coronary Artery Bypass Graft (CABG) surgeries for

Coronary Artery Bypass Graft (CABG): Preoperative patients aged 18 years and older who received a beta-blocker within 24 hours Full Full
044 Beta-Blocker in Patients with Isolated CABG Surgery - 0236 044 Effective Clinical Care Process CMS - - Surgery A -2016 Endorsement Endorsement - - - Q1 2016 - Q1 - N/A
prior to surgical incision
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Percentage of visits for patients aged 18 years and older with documentation Communication and Care Full Full
131 Pain Assessment and Follow-Up - 0420 131 of a pain assessment using a standardized tool(s) on each visit AND Process CMS - - Health and Well Being A -2016 - - - Q1 2014 - Q1 - measure has been submitted for comprehensive review
Coordination Endorsement Endorsement
documentation of a follow-up plan when pain is present
Percentage of patients aged 65 years and older with a documented elder Non-
maltreatment screen using an Elder Maltreatment Screening Tool on the date Endorsed/ Q1 - measure has been submitted for initial comprehensive reivew. In person
181 Elder Maltreatment Screen and Follow-Up Plan - - 181 Patient Safety Process CMS - - Safety B - 2014 Not endorsed - - - - 2014 -
of encounter AND a documented follow-up plan on the date of the positive Sybmitted meeting April 18th or 19th
screen Pending Review
Percentage of visits for patients aged 18 years and older with documentation
of a current functional outcome assessment using a standardized functional Non-Endorsed/
182 Functional Outcome Assessment - - 182 outcome assessment tool on the date of encounter AND documentation of a Communication and Care Process CMS - - Person and Family Centered Care C - 2015 Not endorsed Planned - - - - - - -
Coordination
care plan based on identified functional outcome deficiencies on the date of Submission
the identified deficiencies
Percentage of patients 18 years and older with Left Ventricular Function Non-
Heart Failure (HF): Left Ventricular Function (LVF) (LVF) testing documented as being performed within the previous 12 months Endorsed/
228 - - 228 Effective Clinical Care Process CMS - - Cardiovascular A -2016 Not endorsed - - - - 2014 - Q1 - measure has been submitted for comprehensive review
Testing or LVF testing performed prior to discharge for patients who are hospitalized Sybmitted
with a principal
Percentage diagnosis
of patients of Heart
aged Failure
20 through 79(HF) during
years whosethe reporting
risk factors*period
have Pending Review
been assessed and a fasting LDL test has been performed AND percentage of
patients aged 20 through 79 years who had a fasting LDL-C test performed
and whose risk-stratified fasting LDL-C is at or below the recommended LDL-
C goal.
Preventive Care and Screening: Cholesterol – Fasting Non-Endorsed/
*There are three criteria for this measure based on the patient’s risk category.
316 Low Density Lipoprotein (LDL-C) Test Performed AND 61v3 & 64v3 - 316 1. Highest Level of Risk: Coronary Heart Disease (CHD) or CHD Risk Effective Clinical Care Outcome CMS - - Cardiovascular A -2016 Not endorsed Planned - - - - - Measure is being re-tooled by Interagency Workgroup Q1 - N/A
Risk-Stratified Fasting LDL-C Submission
Equivalent OR 10-Year Framingham Risk >20%
2. Moderate Level of Risk: Multiple (2+) Risk Factors OR 10-Year Framingham
Risk 10-20%
3. Lowest Level of Risk: 0 or 1 Risk Factor OR 10-Year Framingham Risk <10%
Percentage of patients aged 18-85 years of age with a diagnosis of

373 Hypertension: Improvement in Blood Pressure 65v3 - 373 hypertension whose blood pressure improved during the measurement Effective Clinical Care Outcome CMS - - - - - - - - - - - - -
period.
Percentage of patients aged 18 years and older with primary total knee
Patient and Caregiver-Centered
375 Functional Status Assessment for Knee Replacement 66v2 - 375 arthroplasty (TKA) who completed baseline and follow-up (patient-reported) Process CMS - - - - - - - - - - - - -
functional status assessments. Experience and Outcomes
Percentage of patients aged 18 years and older with primary total hip
Patient and Caregiver-Centered
376 Functional Status Assessment for Hip Replacement 56v2 - 376 arthroplasty (THA) who completed baseline and follow-up (patient-reported) Experience and Outcomes Process CMS - - - - - - - - - - - - -
functional status assessments
Primary Caries Prevention Intervention as Offered by Percentage of children, age 0-20 years, who received a fluoride varnish
379 74v3 - 379 Effective Clinical Care Process CMS - - - - - - - - - - - - -
Primary Care Providers, including Dentists application during the measurement period.
Average percentage of time in which patients aged 18 and older with atrial
ADE Prevention and Monitoring: Warfarin Time in fibrillation who are on chronic warfarin therapy have International
380 179v2 - 380 Patient Safety Outcome CMS - - - - - - - - - - - - -
Therapeutic Range Normalized Ratio (INR) test results within the therapeutic range (i.e., TTR)
during the measurement period
Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS,

381 HIV/AIDS: RNA Control for Patients with HIV 77v2 - 381 with at least two visits during the measurement year, with at least 90 days Effective Clinical Care Outcome CMS - - - - - - - - - - - - -
between each visit, whose most recent HIV RNA level is <200 copies/mL.
- ACCF
Cardiac Stress Imaging Not Meeting Appropriate Use

Percentage of stress
322 Criteria:
single-photon emissionPreoperative Evaluation in(SPECT)
computed tomography Low-Risk Surgery perfusion
myocardial - imaging (MPI),670
stress echocardiogram
322 (ECHO), cardiac computed tomography angiography (CCTA), or cardiac magnetic resonance
Efficiency
(CMR)
andperformed
Cost Reduction
in low risk surgery patients
Efficiency
18 years or older for preoperative
ACC evaluation during
- the 12-month
- reporting period Cardiovascular B - 2014 Full EndorsementFull Endorsement - - - Q2 2015 - measure maintenance phase
Patients

all stress single-photon emission323 Criteria: Routine
computed tomography (SPECT)Testing After Percutaneous
myocardial Coronary
perfusion imaging (MPI), stress echocardiogram
- 671
(ECHO), cardiac computed
323 tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed
Efficiencyinand
patients
Cost Reduction
aged 18 years and older routinely
Efficiency
after percutaneous coronary
ACC intervention (PCI),
- with reference-to timing of test after
Cardiovascular
PCI and symptom status B - 2014 Full EndorsementFull Endorsement - - - Q2 2015 - measure maintenance phase
Intervention (PCI)

Percentage of all stress single-photon
324 emission computed
Criteria: tomography
Testing (SPECT) myocardial
in Asymptomatic, perfusion imaging- (MPI), stress echocardiogram
Low-Risk Patients 672 (ECHO),
324 cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance
Efficiency
(CMR)
and
performed
Cost Reduction
in asymptomatic, low coronary
Efficiencyheart disease (CHD) risk
ACCpatients 18 years and
- older for initial-detection and risk assessment
Cardiovascular B - 2014 Full EndorsementFull Endorsement - - - Q2 2015 - measure maintenance phase
- AMA-PCPI
Percentage of patients 18 years and older who were screened for tobacco use
Preventive Care and Screening: Tobacco Use: Screening AMA- Full
226 and Cessation Intervention 138v2 0028 0226 one or more times within 24 months AND who received cessation counseling Community/Population Health Process PCPI - - Behavioral Health A -2016 - Endorsement - - - Q2 TBD by NQF - -
intervention if identified as a tobacco user

008 Heart Failure (HF): Beta-Blocker Therapy for Left 144v2 0083 0008 failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < Effective Clinical Care Process AMA- PCPI ACCF AHA Cardiovascular A -2016 - Full - - - Q2 TBD by NQF - -
Ventricular Systolic Dysfunction (LVSD) 40% who were prescribed beta-blocker therapy either within a 12 month Endorsement
period when seen in the outpatient setting OR at each hospital discharge
within 30 days following discharge in the office by the physician, prescribing Full
046 Medication Reconciliation - 0097 046 Patient Safety Process AMA- PCPI NCQA - Care Coordination B - 2014 - - - - - - - NCQA is the steward for this measure
practitioner, registered nurse, or clinical pharmacist providing on-going care Endorsement
Percentage of patients aged 6 months and older seen for a visit between
Preventive Care and Screening: Influenza Full
110 Immunization 147v2 0041 110 October 1 and March 31 who received an influenza immunization OR who Community/Population Health Process AMA- PCPI - - Population Health: Prevention - - Endorsement - - - Q2 TBD by NQF - -
reported previous receipt of an influenza immunization
Coronary Artery Disease (CAD): Angiotensin- Percentage of patients aged 18 years and older with a diagnosis of coronary
Converting Enzyme (ACE) Inhibitor or Angiotensin artery disease seen within a 12 month period who also have diabetes OR a Full
118 - 0066 118 Effective Clinical Care Process AMA- PCPI AACF AHA Cardiovascular A -2016 - - - - Q2 TBD by NQF - -
Receptor Blocker (ARB) Therapy -- Diabetes or Left current or prior Left Ventricular Ejection Fraction (LVEF) < 40% who were Endorsement
Ventricular Systolic Dysfunction (LVEF < 40%) prescribed ACE inhibitor or ARB therapy
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
Full
197 Coronary Artery Disease (CAD): Lipid Control - 0074 197 Correct measure description: Percentage of patients aged 18 years and older Effective Clinical Care Process AMA- PCPI ACCF AHA Cardiovascular A -2016 - - - - TBD by NQF TBD by NQF - -
with a diagnosis of coronary artery disease seen within a 12 month period Endorsement
who have a LDL-C result <100 mg/dL OR patients who have a LDL-C result
>=100 mg/dL and have a documented plan of care to achieve LDL-C
<100mg/dL, including at a minimum the prescription of a statin

Adult Kidney Disease: Laboratory Testing (Lipid kidney disease (CKD) (stage 3, 4, or 5, not receiving Renal Replacement Full
121 Profile) - 1668 121 Therapy [RRT]) who had a fasting lipid profile performed at least once within Effective Clinical Care Process AMA- PCPI - - Renal B - 2014 - Endorsement - - - Q2 TBD by NQF - -
a 12-month period
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 Non-Endorsed/
122 Adult Kidney Disease: Blood Pressure Management - - 122 Effective Clinical Care Outcome AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
Replacement Therapy [RRT]) and proteinuria with a blood pressure < 130/80
mmHg OR ≥ 130/80 mmHg with a documented plan of care Submission
Percentage of calendar months within a 12-month period during which a

hemoglobin level is measured for patients aged 18 years and older with a
Adult Kidney Disease: Patients On Erythropoiesis- diagnosis of advanced chronic kidney disease (CKD) (stage 4 or 5, not
Full
123 Stimulating Agent (ESA) - Hemoglobin Level > 12.0 - 1666 123 receiving Renal Replacement Therapy [RRT]) or End Stage Renal Disease Effective Clinical Care Outcome AMA- PCPI - - Renal B - 2014 - - - - Q2 TBD by NQF - -
g/dL (ESRD) (who are on hemodialysis or peritoneal dialysis) who are also Endorsement
receiving erythropoiesis-stimulating agent (ESA) therapy have a hemoglobin
level > 12.0 g/dL
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Screening or Therapy for Osteoporosis for Women dual-energy X- ray absorptiometry (DXA) measurement ordered or Full
039 - 0046 039 Effective Clinical Care Process AMA- PCPI NCQA - Endocrine A -2016 - - - - - - - NCQA is the steward for this measure
Aged 65 Years and Older performed at least once since age 60 or pharmacologic therapy prescribed Endorsement
within 12 months

Percentage of female patients aged 65 years and older who were assessed for
048 Absence of Urinary Incontinence in Women Aged 65 - 0098 048 Effective Clinical Care Process AMA- PCPI NCQA - GI/GU - - Lost - - - - - - NCQA is the steward for this measure
Years and Older the presence or absence of urinary incontinence within 12 months Endorsement
Measure replaced by measure NQF #2152: Preventive Care and Screening:

173 Preventive Care and Screening: Unhealthy Alcohol Use - - 173 Percentage of patients aged 18 years and older who were screened for Community/Population Health Process AMA- PCPI - - Behavioral Health - - - - - - - - - Unhealthy Alcohol Use: Screening and Brief Counseling. Measure 2152 endorsed
– Screening unhealthy alcohol use using a systematic screening method within 24 months
via NQF Behavioral Health project in March 2014

arthritis (RA) who have documentation of a tuberculosis (TB) screening Non-Endorsed/
176 Rheumatoid Arthritis (RA): Tuberculosis Screening - - 176 performed and results interpreted within 6 months prior to receiving a first Effective Clinical Care Process AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
course of therapy using a biologic disease-modifying anti-rheumatic drug Submission
(DMARD)
Rheumatoid Arthritis (RA): Periodic Assessment of
177 Disease Activity - - 177 arthritis (RA) who have an assessment and classification of disease activity Effective Clinical Care Process AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
within 12 months Submission
178 Rheumatoid Arthritis (RA): Functional Status - - 178 arthritis (RA) for whom a functional status assessment was performed at least Effective Clinical Care Process AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
Assessment
once within 12 months Submission
Rheumatoid Arthritis (RA): Assessment and
179 - - 179 arthritis (RA) who have an assessment and classification of disease prognosis Effective Clinical Care Process AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
Classification of Disease Prognosis at least once within 12 months Submission

arthritis (RA) who have been assessed for glucocorticoid use and, for those on Non-Endorsed/
Rheumatoid Arthritis (RA): Glucocorticoid Communication and Care
180 Management - - 180 prolonged doses of prednisone ≥ 10 mg daily (or equivalent) with Coordination Process AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
improvement or no change in disease activity, documentation of Submission
glucocorticoid management plan within 12 months

Perioperative Care: Timing of Prophylactic Parenteral procedures with the indications for prophylactic parenteral antibiotics, who Full
020 - 0270 020 have an order for prophylactic parenteral antibiotic to be given within one Patient Safety Process AMA- PCPI NCQA - Surgery A -2016 - - - - - - - The plan is to retire this measure
Antibiotic – Ordering Physician Endorsement
hour (if fluoroquinolone or vancomycin, two hours), prior to the surgical
incision (or start of procedure when no incision is required)

Perioperative Care: Selection of Prophylactic Antibiotic procedures with the indications for a first OR second generation Full Measure submitted and currently under review for maintenance of endorsement
021 - 0268 021 Patient Safety Process AMA- PCPI NCQA - Surgery A -2016 - - - - TBD by NQF '- -
– First OR Second Generation Cephalosporin cephalosporin prophylactic antibiotic, who had an order for a first OR second Endorsement by NQF's Surgery Committee
generation cephalosporin for antimicrobial prophylaxis
Percentage of non-cardiac surgical patients aged 18 years and older

undergoing procedures with the indications for prophylactic parenteral
Perioperative Care: Discontinuation of Prophylactic antibiotics AND who received a prophylactic parenteral antibiotic, who have Full Measure submitted and currently under review for maintenance of endorsement
022 Parenteral Antibiotics (Non-Cardiac Procedures) - 0271 022 Patient Safety Process AMA- PCPI NCQA - Surgery A -2016 - Endorsement - - - TBD by NQF - - by NQF's Surgery Committee
an order for discontinuation of prophylactic parenteral antibiotics within 24
hours of surgical end time

procedures for which VTE prophylaxis is indicated in all patients, who had an
Perioperative Care: Venous Thromboembolism (VTE) order for Low Molecular Weight Heparin (LMWH), Low-Dose Unfractionated Full
023 - 0239 023 Patient Safety Process AMA- PCPI NCQA - Safety B - 2014 - - - - TBD by NQF TBD by NQF - -
Prophylaxis (When Indicated in ALL Patients) Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical Endorsement
prophylaxis to be given within 24 hours prior to incision time or within 24
hours after surgery end time

Hepatitis C: Ribonucleic Acid (RNA) Testing Before hepatitis C who started antiviral treatment within the 12 month reporting Full
084 - 0395 084 Effective Clinical Care Process AMA- PCPI - - Infectious disease C - 2015 - - - - Q3 TBD by NQF - -
Initiating Treatment period for whom quantitative hepatitis C virus (HCV) RNA testing was Endorsement
performed within 12 months prior to initiation of antiviral treatment

hepatitis C who started antiviral treatment within the 12 month reporting Full
085 Hepatitis C: HCV Genotype Testing Prior to Treatment - 0396 085 period for whom hepatitis C virus (HCV) genotype testing was performed Effective Clinical Care Process AMA- PCPI - - Infectious disease C - 2015 - Endorsement - - - TBD by NQF TBD by NQF - -
within 12 months prior to initiation of antiviral treatment
Hepatitis C: Hepatitis C Virus (HCV) Ribonucleic Acid Percentage of patients aged 18 years and older with a diagnosis of chronic
hepatitis C who are receiving antiviral treatment for whom quantitative Full
087 (RNA) Testing Between 4-12 Weeks After Initiation of - 0398 087 Effective Clinical Care Process AMA- PCPI - - Infectious disease C - 2015 - - - - Q3 TBD by NQF - -
hepatitis C virus (HCV) RNA testing was performed between 4-12 weeks after Endorsement
Treatment the initiation of antiviral treatment

Hepatitis C: Hepatitis A Vaccination in Patients with Full
183 Hepatitis C Virus (HCV) - 0399 183 hepatitis C who have received at least one injection of hepatitis A vaccine, or Community/Population Health Process AMA- PCPI - - Infectious disease C - 2015 - Endorsement - - - Q3 TBD by NQF - -
who have documented immunity to hepatitis A

Heart Failure (HF): Angiotensin-Converting Enzyme
failure (HF) with a current or prior left ventricular ejection fraction (LVEF) <
005 (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) 135v2 0081 005 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 Effective Clinical Care Process AMA- PCPI ACCF AHA Cardiovascular A -2016 - Full - - - Q2 TBD by NQF - -
Therapy for Left Ventricular Systolic Dysfunction Endorsement
month period when seen in the outpatient setting OR at each hospital
(LVSD) discharge

Heart Failure: Left Ventricular Ejection Fraction (LVEF) failure for whom the quantitative or qualitative results of a recent or prior Full
198 - 0079 198 Effective Clinical Care Process AMA- PCPI ACCF AHA Cardiovascular A -2016 - - - - Q2 TBD by NQF - -
Assessment [any time in the past] LVEF assessment is documented within a 12 month Endorsement
period

Full
006 Coronary Artery Disease (CAD): Antiplatelet Therapy - 0067 006 artery disease seen within a 12 month period who were prescribed aspirin or Effective Clinical Care Process AMA- PCPI ACCF AHA Cardiovascular A -2016 - Endorsement - - - Q2 TBD by NQF - -
clopidogrel

artery disease seen within a 12 month period who have a LDL-C result < 100 Full
197 Coronary Artery Disease (CAD): Lipid Control - 0074 197 mg/dL OR patients who have a LDL-C result ≥ 100 mg/dL and have a Effective Clinical Care Process AMA- PCPI ACCF AHA Cardiovascular A -2016 - - - - Q2 TBD by NQF - -
Endorsement
documented plan of care to achieve LDL-C < 100 mg/dL, including at a
minimum the prescription of a statin

artery disease seen within a 12 month period with results of an evaluation of Non-Endorsed/
242 Coronary Artery Disease (CAD): Symptom Management - - 242 level of activity and an assessment of whether anginal symptoms are present Effective Clinical Care Process AMA- PCPI ACCF AHA - - - Planned - - - - TBD by NQF - -
or absent with appropriate management of anginal symptoms within a 12 Submission
month period
Percentage of patients aged 6 months and older with a diagnosis of HIV/AIDS

HIV/AIDS: CD4+ Cell Count or CD4+ Percentage for whom a CD4+ cell count or CD4+ cell percentage was performed at least Full
159 Performed - 0404 159 Effective Clinical Care Process AMA- PCPI NCQA - Infectious disease C - 2015 - Endorsement - - - - - - NCQA is the steward for this measure
once every 6 months
HIV/AIDS: Sexually Transmitted Disease Screening for Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS Full
205 - 0409 205 for whom chlamydia, gonorrhea and syphilis screenings were performed at Effective Clinical Care Process AMA- PCPI NCQA - Infectious disease C - 2015 - - - - - - - NCQA is the steward for this measure
Chlamydia, Gonorrhea, and Syphilis Endorsement
least once since the diagnosis of HIV infection
Asthma: Pharmacologic Therapy for Persistent Asthma Percentage of patients aged 5 through 64 years with a diagnosis of persistent Full
053 - 0047 053 Effective Clinical Care Process AMA- PCPI NCQA - Pulmonary B - 2014 - - - - TBD by NQF TBD by NQF - -
- Ambulatory Care Setting asthma who were prescribed long-term control medication Endorsement
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Asthma: Assessment of Asthma Control – Ambulatory Percentage of patients aged 5 through 64 years with a diagnosis of asthma Non-Endorsed/
064 - 0001 064 who were evaluated at least once during the measurement period for asthma Effective Clinical Care Process AMA- PCPI NCQA - - - - Planned - - - - TBD by NQF - -
Care Setting
control (comprising asthma impairment and asthma risk) Submission
Percentage of patients aged 5 through 64 years with a diagnosis of asthma (or

Non-Endorsed/
Asthma: Tobacco Use: Screening - Ambulatory Care their primary caregiver) who were queried about tobacco use and exposure to
Setting second hand smoke within their home environment at least once during the Submission
one-year measurement period
Percentage of patients aged 5 through 64 years with a diagnosis of asthma

Non-Endorsed/
232 Asthma: Tobacco Use: Intervention - Ambulatory Care - - 232 who were identified as tobacco users (or their primary caregiver) who Effective Clinical Care Process AMA- PCPI NCQA - - - - Planned - - - - TBD by NQF - -
Setting received tobacco cessation intervention at least once during the one-year
Submission
measurement period
Chronic Obstructive Pulmonary Disease (COPD): Percentage of patients aged 18 years and older with a diagnosis of COPD who Full
051 - 0091 051 Effective Clinical Care Process AMA- PCPI - - Pulmonary B - 2014 - - - - TBD by NQF TBD by NQF - -
Spirometry Evaluation had spirometry evaluation results documented Endorsement
Percentage of patients aged 18 years and older with a diagnosis of COPD and
Chronic Obstructive Pulmonary Disease (COPD): Full
052 Inhaled Bronchodilator Therapy - 0102 052 who have an FEV1/FVC less than 60% and have symptoms who were Effective Clinical Care Process AMA- PCPI - - Pulmonary B - 2014 - Endorsement - - - TBD by NQF TBD by NQF - -
prescribed an inhaled bronchodilator
Non-Endorsed/
276 Sleep Apnea: Assessment of Sleep Symptoms - - 276 obstructive sleep apnea that includes documentation of an assessment of Effective Clinical Care Process AMA- PCPI NCQA - - - - Planned - - - - TBD by NQF - -
sleep symptoms, including presence or absence of snoring and daytime
Submission
sleepiness
Percentage of patients aged 18 years and older with a diagnosis of obstructive Non-Endorsed/
277 Sleep Apnea: Severity Assessment at Initial Diagnosis - - 277 sleep apnea who had an apnea hypopnea index (AHI) or a respiratory Effective Clinical Care Process AMA- PCPI NCQA - - - - Planned - - - - TBD by NQF - -
disturbance index (RDI) measured at the time of initial diagnosis Submission
Percentage of patients aged 18 years and older with a diagnosis of moderate Non-Endorsed/
Sleep Apnea: Positive Airway Pressure Therapy
278 Prescribed - - 278 or severe obstructive sleep apnea who were prescribed positive airway Effective Clinical Care Process AMA- PCPI NCQA - - - - Planned - - - - TBD by NQF - -
pressure therapy Submission
Sleep Apnea: Assessment of Adherence to Positive obstructive sleep apnea who were prescribed positive airway pressure Non-Endorsed/
Airway Pressure Therapy therapy who had documentation that adherence to positive airway pressure
therapy was objectively measured Submission

280 Dementia: Staging of Dementia - - 280 severity of dementia was classified as mild, moderate or severe at least once Process AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
within a 12 month period Coordination Submission

281 Dementia: Cognitive Assessment 149v2 - 281 whom an assessment of cognition is performed and the results reviewed at Effective Clinical Care Process AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
least once within a 12 month period Submission

282 Dementia: Functional Status Assessment - - 282 whom an assessment of functional status is performed and the results Effective Clinical Care Process AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
reviewed at least once within a 12 month period Submission
Percentage of patients, regardless of age, with a diagnosis of dementia and for Non-Endorsed/
283 Dementia: Neuropsychiatric Symptom Assessment - - 283 whom an assessment of neuropsychiatric symptoms is performed and results Effective Clinical Care Process AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
reviewed at least once in a 12 month period Submission

Non-Endorsed/
have one or more neuropsychiatric symptoms who received or were Planned
284 Dementia: Management of Neuropsychiatric Symptoms - - 284 recommended to receive an intervention for neuropsychiatric symptoms Effective Clinical Care Process AMA- PCPI - - - - - - - - - TBD by NQF - -
Submission
Non-Endorsed/
285 Dementia: Screening for Depressive Symptoms - - 285 Effective Clinical Care Process AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
were screened for depressive symptoms within a 12 month period
Submission

286 Dementia: Counseling Regarding Safety Concerns - - 286 caregiver(s) who were counseled or referred for counseling regarding safety Patient Safety Process AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
concerns within a 12 month period Submission

287 Dementia: Counseling Regarding Risks of Driving - - 287 caregiver(s) who were counseled regarding the risks of driving and the Effective Clinical Care Process AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
alternatives to driving at least once within a 12 month period Submission

caregiver(s) were provided with education on dementia disease management
288 Dementia: Caregiver Education and Support - - 288 Effective Clinical Care Process AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
and health behavior changes AND referred to additional sources for support Submission

uncomplicated cataract who had cataract surgery and no significant ocular
Cataracts: 20/40 or Better Visual Acuity within 90 Days Time-Limited
191 Following Cataract Surgery 133v2 0565 191 conditions impacting the visual outcome of surgery and had best-corrected Effective Clinical Care Outcome AMA- PCPI NCQA - HEENT C - 2015 - Endorsement - - - TBD by NQF TBD by NQF - -
visual acuity of 20/40 or better (distance or near) achieved within 90 days
following the cataract surgery

uncomplicated cataract who had cataract surgery and had any of a specified
Cataracts: Complications within 30 Days Following list of surgical procedures in the 30 days following cataract surgery which Time-Limited
192 Cataract Surgery Requiring Additional Surgical 132v2 0564 192 Patient Safety Outcome AMA- PCPI NCQA - HEENT C - 2015 - - - - TBD by NQF TBD by NQF - -
would indicate the occurrence of any of the following major complications: Endorsement
Procedures retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL,
retinal detachment, or wound dehiscence
Breast Cancer: Hormonal Therapy for Stage IC -IIIC Percentage of female patients aged 18 years and older with Stage IC through
Full
071 Estrogen Receptor/Progesterone Receptor (ER/PR) - 0387 071 IIIC, ER or PR positive breast cancer who were prescribed tamoxifen or Effective Clinical Care Process AMA- PCPI ASCO NCCN Cancer B - 2014 - - - - TBD by NQF TBD by NQF - -
Positive Breast Cancer aromatase inhibitor (AI) during the 12-month reporting period Endorsement
Percentage of patients aged 18 through 80 years with AJCC Stage III colon
Colon Cancer: Chemotherapy for AJCC Stage III Colon cancer who are referred for adjuvant chemotherapy, prescribed adjuvant Full
072 Cancer Patients - 0385 072 chemotherapy, or have previously received adjuvant chemotherapy within the Effective Clinical Care Process AMA- PCPI ASCO NCCN Cancer B - 2014 - Endorsement - - - TBD by NQF TBD by NQF - -
12-month reporting period
Oncology: Medical and Radiation – Pain Intensity Percentage of patients, regardless of patient age, with a diagnosis of cancer Patient and Caregiver-Centered Full
143 157v2 0384 143 currently receiving chemotherapy or radiation therapy in which pain intensity Process AMA- PCPI - - Cancer B - 2014 - - - - TBD by NQF TBD by NQF - -
Quantified Experience and Outcomes Endorsement
is quantified
Percentage of visits for patients, regardless of age, with a diagnosis of cancer

Patient and Caregiver-Centered Full
144 Oncology: Medical and Radiation – Plan of Care for Pain - 0383 144 currently receiving chemotherapy or radiation therapy who report having Process AMA- PCPI - - Cancer B - 2014 - - - - TBD by NQF TBD by NQF - -
pain with a documented plan of care to address pain Experience and Outcomes Endorsement
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Percentage of patients, regardless of age, with a diagnosis of cancer who are

seen in the ambulatory setting who have a baseline American Joint Committee Full
194 Oncology: Cancer Stage Documented - 0386 194 Effective Clinical Care Process AMA- PCPI ASCO - Cancer B - 2014 - - - - TBD by NQF TBD by NQF - -
on Cancer (AJCC) cancer stage or documentation that the cancer is metastatic Endorsement
in the medical record at least once during the 12 month reporting period
Percentage of computed tomography (CT) imaging reports for all patients,

Optimizing Patient Exposure to Ionizing Radiation: Non-Endorsed/
regardless of age, with the imaging study named according to a standardized Communication and Care
359 Utilization of a Standardized Nomenclature for - - 359 Structure AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
Computed Tomography (CT) Imaging Description nomenclature and the standardized nomenclature is used in institution’s Coordination Submission
computer systems
Percentage of computed tomography (CT) and cardiac nuclear medicine

(myocardial perfusion studies) imaging reports for all patients, regardless of Non-Endorsed/
360 Count of Potential High Dose Radiation Imaging - - 360 age, that document a count of known previous CT (any type of CT) and cardiac Patient Safety Structure AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
Studies: Computed Tomography (CT) and Cardiac
nuclear medicine (myocardial perfusion) studies that the patient has received Submission
Nuclear Medicine Studies in the 12-month period prior to the current study
Percentage of total computed tomography (CT) studies performed for all Non-Endorsed/
361 - - 361 patients, regardless of age, that are reported to a radiation dose index registry Patient Safety Structure AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
Reporting to a Radiation Dose Index Registry
AND that include at a minimum selected data elements Submission
Percentage of final reports for computed tomography (CT) studies performed

Optimizing Patient Exposure to Ionizing Radiation: for all patients, regardless of age, which document that Digital Imaging and Non-Endorsed/
362 Computed Tomography (CT) Images Available for - - 362 Communications in Medicine (DICOM) format image data are available to non- Coordination Structure AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
Patient Follow-up and Comparison Purposes affiliated external entities on a secure, media free, reciprocally searchable Submission
basis with patient authorization for at least a 12-month period after the study
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 Non-Endorsed/
363 Search for Prior Computed Tomography (CT) Imaging - - 363 conducted for prior patient CT imaging studies completed at non-affiliated Communication and Care Structure AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
Studies Through a Secure, Authorized, Media-Free, Coordination
external entities within the past 12-months and are available through a Submission
Shared Archive secure, authorized, media free, shared archive prior to an imaging study being
performed
Percentage of final reports for CT imaging studies of the thorax for patients
Optimizing Patient Exposure to Ionizing Radiation: aged 18 years and older with documented follow-up recommendations for Non-Endorsed/
Appropriateness: Follow-up CT Imaging for Communication and Care
364 - - 364 incidentally detected pulmonary nodules (eg, follow-up CT imaging studies Process AMA- PCPI - - - - - Planned - - - - TBD by NQF - -
Incidentally Detected Pulmonary Nodules According to needed or that no follow-up is needed) based at a minimum on nodule size Coordination Submission
Recommended Guidelines
AND patient risk factors
Coronary Artery Disease (CAD): Beta-Blocker Therapy Percentage of patients aged 18 years and older with a diagnosis of coronary
Full
007 – Prior Myocardial Infarction (MI) or Left Ventricular 145v2 0070 007 artery disease seen within a 12 month period who also have prior MI OR a Effective Clinical Care Process AMA-PCPI ACCF AHA Cardiovascular A -2016 - Endorsement - - - Q2 TBD by NQF - -
Systolic Dysfunction (LVEF < 40%) current or LVEF < 40% who were prescribed beta-blocker therapy
Primary Open-Angle Glaucoma (POAG): Optic Nerve Percentage of patients aged 18 years and older with a diagnosis of primary Full
012 143v2 0086 012 open-angle glaucoma (POAG) who have an optic nerve head evaluation during Effective Clinical Care Process AMA-PCPI NCQA - HEENT C - 2015 - - - - TBD by NQF TBD by NQF - -
Evaluation: Endorsement
one or more office visits within 12 months

macular degeneration (AMD) who had a dilated macular examination
Age-Related Macular Degeneration (AMD): Dilated Full
014 - 0087 014 performed which included documentation of the presence or absence of Effective Clinical Care Process AMA-PCPI NCQA - HEENT C - 2015 - - - - TBD by NQF TBD by NQF - -
Macular Examination macular thickening or hemorrhage AND the level of macular degeneration Endorsement
severity during one or more office visits within 12 months

Diabetic Retinopathy: Documentation of Presence or retinopathy who had a dilated macular or fundus exam performed which
Absence of Macular Edema and Level of Severity of included documentation of the level of severity of retinopathy and the Full
018 167v2 0088 018 Effective Clinical Care Process AMA-PCPI NCQA - Endocrine A -2016 - Endorsement - - - Q2 TBD by NQF - -
Retinopathy presence or absence of macular edema during one or more office visits within
12 months

Diabetic Retinopathy: Communication with the retinopathy who had a dilated macular or fundus exam performed with Full
019 142v2 0089 019 documented communication to the physician who manages the ongoing care Effective Clinical Care Process AMA-PCPI NCQA - Endocrine A -2016 - - - - Q2 TBD by NQF - -
Physician Managing Ongoing Diabetes Care Endorsement
of the patient with diabetes mellitus regarding the findings of the macular or
fundus exam at least once within 12 months
Managing On-going Care Post-Fracture of Hip, Spine or distal radial fracture with documentation of communication with the Communication and Care Full
024 - 0045 024 Process AMA-PCPI NCQA - Endocrine A -2016 - - - - - - - NCQA is the steward for this measure
Distal Radius for Men and Women Aged 50 Years and physician managing the patient’s on-going care that a fracture occurred and Coordination Endorsement
Percentage of patients, regardless of age, with an emergency department

discharge diagnosis of acute myocardial infarction (AMI) who had Full
028 Aspirin at Arrival for Acute Myocardial Infarction (AMI) - 0092 028 documentation of receiving aspirin within 24 hours before emergency Effective Clinical Care Process AMA-PCPI NCQA - Cardiovascular A -2016 - Endorsement - - - TBD by NQF TBD by NQF - -
department arrival or during emergency department stay
Percentage of surgical patients aged 18 years and older who receive an

anesthetic when undergoing procedures with the indications for prophylactic
Perioperative Care: Timing of Prophylactic Antiobiotic parenteral antibiotics for whom administration of a prophylactic parenteral Full Measure submitted and currently under review for maintenance of endorsement
030 - 0269 030 Patient Safety Process AMA-PCPI NCQA - Surgery A -2016 - - - - TBD by NQF - -
—Administering Physician antibiotic ordered has been initiated within one hour (if fluoroquinolone or Endorsement by NQF's Surgery Committee
vancomycin, two hours) prior to the surgical incision (or start of procedure
when no incision is required)

Stroke and Stroke Rehabilitation: Venous
stroke or intracranial hemorrhage who were administered venous Full
031 Thromboembolism (VTE) Prophylaxis for Ischemic - 0240 031 thromboembolism (VTE) prophylaxis the day of or the day after hospital Effective Clinical Care Process AMA-PCPI NCQA - Neurology C - 2015 - Endorsement - - - TBD by NQF TBD by NQF - -
Stroke or Intracranial Hemorrhage
admission

032 Stroke and Stroke Rehabilitation: Discharged on - 0325 032 stroke or transient ischemic attack (TIA) with documented permanent, Effective Clinical Care Process AMA-PCPI NCQA - Neurology C - 2015 - Full - - - TBD by NQF TBD by NQF - -
Antithrombotic Therapy persistent, or paroxysmal atrial fibrillation who were prescribed an Endorsement
antithrombotic at discharge
Stroke and Stroke Rehabilitation: Anticoagulant Percentage of patients aged 18 years and older with a diagnosis of ischemic
stroke or transient ischemic attack (TIA) with documented permanent, Full
033 Therapy Prescribed for Atrial Fibrillation (AF) at - 0241 033 Effective Clinical Care Process AMA-PCPI NCQA - Neurology C - 2015 - - - - TBD by NQF TBD by NQF - -
Discharge persistent, or paroxysmal atrial fibrillation who were prescribed an Endorsement
anticoagulant at discharge

stroke or intracranial hemorrhage who receive any food, fluids or medication
Stroke and Stroke Rehabilitation: Screening for Full
035 Dysphagia - 0243 035 by mouth (PO) for whom a dysphagia screening was performed prior to PO Effective Clinical Care Process AMA-PCPI NCQA - Neurology C - 2015 - Endorsement - - - TBD by NQF TBD by NQF - -
intake in accordance with a dysphagia screening tool approved by the
institution in which the patient is receiving care

Stroke and Stroke Rehabilitation: Rehabilitation stroke or intracranial hemorrhage for whom occupational, physical, or speech Full
036 - 0244 036 rehabilitation services were ordered at or prior to inpatient discharge OR Effective Clinical Care Process AMA-PCPI NCQA - Neurology C - 2015 - - - - TBD by NQF TBD by NQF - -
Services Ordered Endorsement
documentation that no rehabilitation services are indicated at or prior to
inpatient discharge
Full
040 Spine or Distal Radius for Men and Women Aged 50 - 0048 040 or distal radius who had a central dual-energy X-ray absorptiometry (DXA) Effective Clinical Care Process AMA-PCPI NCQA - Endocrine A -2016 - - - - - - - NCQA is the steward for this measure
Years and Older measurement ordered or performed or pharmacologic therapy prescribed Endorsement
Osteoporosis: Pharmacologic Therapy for Men and Percentage of patients aged 50 years and older with a diagnosis of Full
041 Women Aged 50 Years and Older - 0049 041 osteoporosis who were prescribed pharmacologic therapy within 12 months Effective Clinical Care Process AMA-PCPI NCQA - Endocrine A -2016 - Endorsement - - - TBD by NQF TBD by NQF - NCQA is the steward for this measure
Percentage of cardiac surgical patients aged 18 years and older undergoing

Perioperative Care: Discontinuation of Prophylactic procedures with the indications for prophylactic parenteral antibiotics AND Full Measure submitted and currently under review for maintenance of endorsement
045 - 0637 045 who received a prophylactic parenteral antibiotic, who have an order for Patient Safety Process AMA-PCPI NCQA - Surgery - - - - - - - -
Parenteral Antibiotics (Cardiac Procedures) Endorsement by NQF's Surgery Committee
discontinuation of prophylactic parenteral antibiotics within 48 hours of
surgical end time
047 Advance Care Plan - 0326 047 documentation in the medical record that an advance care plan was discussed Process AMA-PCPI NCQA - Care Coordination B - 2014 - - - - - - - NCQA is the steward for this measure
but the patient did not wish or was not able to name a surrogate decision Coordination Endorsement
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Urinary Incontinence: Characterization of Urinary Percentage of female patients aged 65 years and older with a diagnosis of Non-Endorsed/
049 - 0099 049 urinary incontinence whose urinary incontinence was characterized at least Effective Clinical Care Process AMA-PCPI NCQA - GI/GU - - Lost - - - - - - NCQA is the steward for this measure
Incontinence in Women Aged 65 Years and Older
once within 12 months Endorsement
Urinary Incontinence: Plan of Care for Urinary Patient and Caregiver-Centered
050 - 0100 050 urinary incontinence with a documented plan of care for urinary incontinence Process AMA-PCPI NCQA - GI/GU - - Lost - - - - - - NCQA is the steward for this measure
Incontinence in Women Aged 65 Years and Older at least once within 12 months Experience and Outcomes Endorsement
Percentage of patients aged 40 years and older with an emergency

054 Emergency Medicine: 12-Lead Electrocardiogram - 0090 054 department discharge diagnosis of non-traumatic chest pain who had a 12- Effective Clinical Care Process AMA-PCPI NCQA - Cardiovascular A -2016 - Full - - - TBD by NQF TBD by NQF - -
(ECG) Performed for Non-Traumatic Chest Pain Endorsement
lead electrocardiogram (ECG) performed
The PCPI and the American College of Emergency Physicians elected not to
submit the measure to NQF for maintenance of endorsement. PQRS data from
2011 suggested a relatively high rate of performance at 96.48% and we felt that
the measure would fail to meet the performance gap sub-criterion within the
Percentage of patients aged 60 years and older with an emergency Non-Endorsed/ “importance to measure and report” evaluation criterion. However,
Emergency Medicine: 12-Lead Electrocardiogram
055 - 0093 055 department discharge diagnosis of syncope who had a 12-lead Effective Clinical Care Process AMA-PCPI NCQA - Cardiovascular - - Lost - - - - - - Syncope is a frequent complaint in the emergency department, accounting for
(ECG) Performed for Syncope
electrocardiogram (ECG) performed Endorsement one to three percent of all ED visits and hospital admissions in the US. An ECG
remains a critical component of the initial evaluation of a patient presenting with
syncope to determine the etiology and institute appropriate treatment strategies.
We still collectively support the measure and have plans to maintain it as part of
our emergency medicine measure set with no immediate plans for retirement.
Percentage of patients aged 18 years and older with a diagnosis of Non-Endorsed/
Emergency Medicine: Community-Acquired Bacterial
056 Pneumonia (CAP): Vital Signs - 0232 056 community-acquired bacterial pneumonia (CAP) with vital signs documented Effective Clinical Care Process AMA-PCPI NCQA - Pulmonary - - Lost - - - - - - -
and reviewed Endorsement

059 Emergency Medicine: Community-Acquired Bacterial - 0096 059 community-acquired bacterial pneumonia (CAP) with an appropriate empiric Effective Clinical Care Process AMA-PCPI NCQA - Pulmonary B - 2014 - Full - - - TBD by NQF TBD by NQF - -
Pneumonia (CAP): Empiric Antibiotic Endorsement
antibiotic prescribed
Hematology: Myelodysplastic Syndrome (MDS) and Percentage of patients aged 18 years and older with a diagnosis of
Full
067 Acute Leukemias: Baseline - 0377 067 myelodysplastic syndrome (MDS) or an acute leukemia who had baseline Effective Clinical Care Process AMA-PCPI ASH - Cancer B - 2014 - - - - TBD by NQF TBD by NQF - -
Cytogenetic Testing Performed on Bone Marrow cytogenetic testing performed on bone marrow Endorsement

Hematology: Myelodysplastic Syndrome (MDS):
myelodysplastic syndrome (MDS) who are receiving erythropoietin therapy Full
068 Documentation of Iron Stores in Patients Receiving - 0378 068 with documentation of iron stores within 60 days prior to initiating Effective Clinical Care Process AMA-PCPI ASH - Cancer B - 2014 - Endorsement - - - TBD by NQF TBD by NQF - -
Erythropoietin Therapy
erythropoietin therapy
Hematology: Multiple Myeloma: Treatment with Percentage of patients aged 18 years and older with a diagnosis of multiple Full
069 - 0380 069 myeloma, not in remission, who were prescribed or received intravenous Effective Clinical Care Process AMA-PCPI ASH - Cancer B - 2014 - - - - TBD by NQF TBD by NQF - -
Bisphosphonates Endorsement
bisphosphonate therapy within the 12-month reporting period
Percentage of patients aged 18 years and older seen within a 12 month

Hematology: Chronic Lymphocytic Leukemia (CLL): reporting period with a diagnosis of chronic lymphocytic leukemia (CLL) Full
070 - 0379 070 Effective Clinical Care Process AMA-PCPI ASH - Cancer B - 2014 - - - - TBD by NQF TBD by NQF - -
Baseline Flow Cytometry made at any time during or prior to the reporting period who had baseline Endorsement
flow cytometry studies performed and documented in the chart
Percentage of patients, regardless of age, who undergo CVC insertion for

whom CVC was inserted with all elements of maximal sterile barrier
Prevention of Catheter-Related Bloodstream Infections
(CRBSI): Central Venous Catheter (CVC) Insertion technique [cap AND mask AND sterile gown AND sterile gloves AND a large Full Measure submitted and currently under review for maintenance of endorsement
076 - 0464 076 sterile sheet AND hand hygiene AND 2% chlorhexidine for cutaneous Patient Safety Process AMA-PCPI - - Safety B - 2014 - Endorsement - - - TBD by NQF - - by NQF's Patient Safety Committee
Protocol
antisepsis (or acceptable alternative antiseptics per current guideline)]
followed

patients aged 18 years and older with a diagnosis of End Stage Renal Disease Communication and Care Full
081 Adult Kidney Disease: Hemodialysis Adequacy: Solute - 0323 081 Outcome AMA-PCPI - - Renal B - 2014 - - - - Q2 TBD by NQF - -
(ESRD) receiving hemodialysis three times a week for ≥ 90 days who have a Coordination Endorsement
spKt/V ≥ 1.2
Adult Kidney Disease: Peritoneal Dialysis Adequacy: Communication and Care Full
082 - 0321 082 Renal Disease (ESRD) receiving peritoneal dialysis who have a total Kt/V ≥ 1.7 Outcome AMA-PCPI - - Renal B - 2014 - - - - Q2 TBD by NQF - -
Solute per week measured once every 4 months Coordination Endorsement
Percentage of patients aged 18 years and older who are hepatitis C antibody
positive seen for an initial evaluation for whom hepatitis C virus (HCV) RNA Full
083 Hepatitis C: Confirmation of Hepatitis C Viremia - 0393 083 Effective Clinical Care Process AMA-PCPI - - Infectious disease C - 2015 - Endorsement - - - Q3 TBD by NQF - -
testing was ordered or previously performed
Percentage of patients aged 2 years and older with a diagnosis of AOE who Time-Limited
091 Acute Otitis Externa (AOE): Topical Therapy - 0653 091 Effective Clinical Care Process AMA-PCPI - - HEENT C - 2015 - - - - TBD by NQF TBD by NQF - -
were prescribed topical preparations Endorsement
Acute Otitis Externa (AOE): Systemic Antimicrobial

Percentage of patients aged 2 years and older with a diagnosis of AOE who Communication and Care Time-Limited
093 Therapy – Avoidance of - 0654 093 were not prescribed systemic antimicrobial therapy Coordination Process AMA-PCPI - - HEENT C - 2015 - Endorsement - - - TBD by NQF TBD by NQF - -
Inappropriate Use:
Breast Cancer Resection Pathology Reporting: pT Percentage of breast cancer resection pathology reports that include the pT
099 Category (Primary Tumor) and pN Category (Regional - 0391 099 category (primary tumor), the pN category (regional lymph nodes), and the Effective Clinical Care Process AMA-PCPI CAP - Cancer B - 2014 - Full - - - Q2 TBD by NQF - -
Endorsement
Lymph Nodes) with Histologic Grade histologic grade
Colorectal Cancer Resection Pathology Reporting: pT Percentage of colon and rectum cancer resection pathology reports that
Full
100 Category (Primary Tumor) and pN Category (Regional - 0392 100 include the pT category (primary tumor), the pN category (regional lymph Effective Clinical Care Process AMA-PCPI CAP - Cancer B - 2014 - - - - Q2 TBD by NQF - -
Lymph Nodes) with Histologic Grade nodes) and the histologic grade Endorsement

at low risk of recurrence receiving interstitial prostate brachytherapy, OR
Prostate Cancer: Avoidance of Overuse of Bone Scan for Full
102 Staging Low Risk Prostate Cancer Patients 129v3 0389 102 external beam radiotherapy to the prostate, OR radical prostatectomy, OR Efficiency and Cost Reduction Process AMA-PCPI - - Cancer B - 2014 - Endorsement - - - Q2 TBD by NQF - -
cryotherapy who did not have a bone scan performed at any time since
diagnosis of prostate cancer

Prostate Cancer: Adjuvant Hormonal Therapy for High at high risk of recurrence receiving external beam radiotherapy to the Full
104 - 0390 104 Effective Clinical Care Process AMA-PCPI - - Cancer B - 2014 - - - - Q2 TBD by NQF - -
Risk Prostate Cancer Patients prostate who were prescribed adjuvant hormonal therapy (GnRH agonist or Endorsement
antagonist)
Percentage of patients aged 18 years and older with a new diagnosis or

Adult Major Depressive Disorder (MDD): recurrent episode of major depressive disorder (MDD) with evidence that Non-Endorsed/
they met the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV-
106 Comprehensive Depression Evaluation: Diagnosis and - 0103 106 Effective Clinical Care Process AMA-PCPI - - Behavioral Health - - Lost - - - - - - -
Severity TR criteria for MDD AND for whom there is an assessment of depression Endorsement
severity during the visit in which a new diagnosis or recurrent episode was
identified
Percentage of patients aged 18 years and older with a diagnosis of major

Adult Major Depressive Disorder (MDD): Suicide Risk depressive disorder (MDD) with a suicide risk assessment completed during Full
107 Assessment 161v2 0104 107 Effective Clinical Care Process AMA-PCPI - - Behavioral Health A -2016 - Endorsement - - - TBD by NQF TBD by NQF - Endorsement renewed in 2/14
the visit in which a new diagnosis or recurrent episode was identified
The American Academy of Orthopedic Surgeons intends to potentially submit this

Percentage of patient visits for patients aged 21 years and older with a Patient and Caregiver-Centered Non-Endorsed/ measure for endorsement. The measure lost endorsement because of time and
109 Osteoarthritis (OA): Function and Pain Assessment - 0050 109 Process AMA-PCPI - - Musculoskeletal - - Lost - - - - - - resource constraints that precluded submission of measure for maintenance of
diagnosis of osteoarthritis (OA) with assessment for function and pain Experience and Outcomes
Endorsement endorsement. We continue to support this measure and may plan to resubmit at
the next available opportunity.
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 Full
137 Melanoma: Continuity of Care – Recall System - 0650 137 Effective Clinical Care Structure AMA-PCPI NCQA - Cancer B - 2014 - - - - TBD by NQF TBD by NQF - -
• A process to follow up with patients who either did not make an Endorsement
appointment within the specified timeframe or who missed a scheduled
appointment
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Percentage of patient visits, regardless of age, with a new occurrence of

melanoma who have a treatment plan documented in the chart that was Communication and Care Non-Endorsed/
138 Melanoma: Coordination of Care - 0561 138 Process AMA-PCPI NCQA - Cancer - - Lost - - - - - - -
communicated to the physician(s) providing continuing care within one Coordination
month of diagnosis Endorsement

Age-Related Macular Degeneration (AMD): Counseling macular degeneration (AMD) or their caregiver(s) who were counseled within Time-Limited
140 - 0566 140 Effective Clinical Care Process AMA-PCPI NCQA - HEENT C - 2015 - - - - TBD by NQF TBD by NQF - -
on Antioxidant Supplement 12 months on the benefits and/or risks of the Age-Related Eye Disease Study Endorsement
(AREDS) formulation for preventing progression of AMD

Primary Open-Angle Glaucoma (POAG): Reduction of open-angle glaucoma (POAG) whose glaucoma treatment has not failed (the
141 Intraocular Pressure (IOP) by 15% OR Documentation - 0563 141 most recent IOP was reduced by at least 15% from the pre- intervention level) Communication and Care Process AMA-PCPI NCQA - HEENT C - 2015 - Full - - - TBD by NQF TBD by NQF - -
of a Plan of Care 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
Osteoarthritis (OA): Assessment for Use of Anti- Percentage of patient visits for patients aged 21 years and older with a Non-Endorsed/ The American Academy of Orthopedic Surgeons intends to potentially submit this
measure for endorsement. The measure lost endorsement because of time and
142 Inflammatory or Analgesic Over-the-Counter (OTC) - 0051 142 diagnosis of osteoarthritis (OA) with an assessment for use of anti- Effective Clinical Care Process AMA-PCPI - - Musculoskeletal - - Lost - - - - - -
resource constraints that precluded submission of measure for maintenance of
Medications inflammatory or analgesic over-the-counter (OTC) medications Endorsement endorsement.
Radiology: Exposure Time Reported for Procedures Percentage of final reports for procedures using fluoroscopy that include Full Measure submitted and currently under review for maintenance of endorsement
145 Using Fluoroscopy - 0510 145 documentation of radiation exposure or exposure time Patient Safety Process AMA-PCPI NCQA - Safety B - 2014 - Endorsement - - - TBD by NQF - - by NQF's Patient Safety Committee
146 Radiology: Inappropriate Use of “Probably Benign” - 0508 146 Percentage of final reports for screening mammograms that are classified as Efficiency and Cost Reduction Process AMA-PCPI NCQA - Efficiency A -2016 - Full - - - Q3 TBD by NQF - -
Assessment Category in Mammography Screening “probably benign” Endorsement
Percentage of final reports for all patients, regardless of age, undergoing bone Non-Endorsed/
Nuclear Medicine: Correlation with Existing Imaging Communication and Care
147 - - 147 scintigraphy that include physician documentation of correlation with existing Structure AMA-PCPI - - - - - Lost - - - - - - -
Studies for All Patients Undergoing Bone Scintigraphy relevant imaging studies (e.g., x-ray, MRI, CT, etc.) that were performed Coordination Endorsement
Percentage of patients aged 65 years and older with a history of falls who had Time-Limited
154 Falls: Risk Assessment - 0101 154 a risk assessment for falls completed within 12 months Patient Safety Process AMA-PCPI NCQA - Safety B - 2014 - Endorsement - - - - - - NCQA is the steward for this measure
Percentage of patients aged 65 years and older with a history of falls who had Communication and Care Time-Limited
155 Falls: Plan of Care - 0101 155 Process AMA-PCPI NCQA - Safety B - 2014 - - - - - - - NCQA is the steward for this measure
a plan of care for falls documented within 12 months Coordination Endorsement
Percentage of patients, regardless of age, with a diagnosis of pancreatic or

lung cancer receiving 3D conformal radiation therapy with documentation in
Full
156 Oncology: Radiation Dose Limits to Normal Tissues - 0382 156 medical record that radiation dose limits to normal tissues were established Patient Safety Process AMA-PCPI - - Cancer B - 2014 - - - - TBD by NQF TBD by NQF - -
prior to the initiation of a course of 3D conformal radiation for a minimum of Endorsement
two tissues
Percentage of patients aged 18 years and older receiving a surveillance

Endoscopy/Polyp Surveillance: Colonoscopy Interval
for Patients with a History of Adenomatous Polyps – colonoscopy, with a history of a prior adenomatous polyp(s) in previous Communication and Care Full
185 - 0659 185 colonoscopy findings, who had an interval of 3 or more years since their last Coordination Process AMA-PCPI NCQA - GI/GU C - 2015 - Endorsement - - - TBD by NQF TBD by NQF - Received full endorsement 12/13
Avoidance of Inappropriate Use
colonoscopy
Percentage of patients, regardless of age, undergoing surgical or therapeutic

procedures under general or neuraxial anesthesia of 60 minutes duration or
longer, except patients undergoing cardiopulmonary bypass, for whom either
active warming was used intraoperatively for the purpose of maintaining Full Measure submitted and currently under review for maintenance of endorsement
193 Perioperative Temperature Management - 0454 193 Patient Safety Process AMA-PCPI - - Surgery A -2016 - - - - TBD by NQF - -
normothermia, OR at least one body temperature equal to or greater than 36 Endorsement by NQF's Surgery Committee
degrees Centigrade (or 96.8 degrees Fahrenheit) was recorded within the 30
minutes immediately before or the 15 minutes immediately after anesthesia
end time
Percentage of final reports for carotid imaging studies (neck magnetic

resonance angiography [MRA], neck computed tomography angiography
Radiology: Stenosis Measurement in Carotid Imaging Full
195 - 0507 195 [CTA], neck duplex ultrasound, carotid angiogram) performed that include Effective Clinical Care Process AMA-PCPI NCQA - Neurology C - 2015 - - - - Q3 TBD by NQF - -
Reports direct or indirect reference to measurements of distal internal carotid Endorsement
diameter as the denominator for stenosis measurement
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
Melanoma: Overutilization of Imaging Studies in symptoms suggesting systemic spread, seen for an office visit during the one- Full
224 Melanoma - 0562 224 Efficiency and Cost Reduction Process AMA-PCPI NCQA - Cancer B - 2014 - Endorsement - - - TBD by NQF TBD by NQF - -
year measurement period, for whom no diagnostic imaging studies were
ordered
Percentage of patients aged 40 years and older undergoing a screening

225 Radiology: Reminder System for Mammograms - 0509 225 mammogram whose information is entered into a reminder system with a Structure AMA-PCPI NCQA - Efficiency A -2016 - - - - Q3 TBD by NQF - -
target due date for the next mammogram
Chronic Wound Care: Use of Wound Surface Culture Percentage of patient visits for those patients aged 18 years and older with a Non-Endorsed/
245 Technique in Patients with Chronic Skin Ulcers - - 245 diagnosis of chronic skin ulcer without the use of a wound surface culture Effective Clinical Care Efficiency AMA-PCPI NCQA - - - - Planned - - - - TBD by NQF - -
(Overuse Measure technique Submission
Percentage of patient visits for those patients aged 18 years and older with a Non-Endorsed/
246 Chronic Wound Care: Use of Wet to Dry Dressings in - - 246 diagnosis of chronic skin ulcer without a prescription or recommendation to Effective Clinical Care Efficiency AMA-PCPI NCQA - - - - Planned - - - - TBD by NQF - -
Patients with Chronic Skin Ulcers (Overuse Measure)
use wet to dry dressings Submission
Substance Use Disorders: Counseling Regarding Percentage of patients aged 18 years and older with a diagnosis of current Non-Endorsed/
alcohol dependence who were counseled regarding psychosocial AND
247 Psychosocial and Pharmacologic Treatment Options for - - 247 Effective Clinical Care Process AMA-PCPI NCQA - - - - Planned - - - - TBD by NQF - -
Alcohol Dependence pharmacologic treatment options for alcohol dependence within the 12- Submission
month reporting period
Percentage of patients aged 18 years and older with a diagnosis of current Non-Endorsed/
Substance Use Disorders: Screening for Depression
248 Among Patients with Substance Abuse or Dependence - - 248 substance abuse or dependence who were screened for depression within the Effective Clinical Care Process AMA-PCPI NCQA - - - - Planned - - - - TBD by NQF - -
12-month reporting period Submission
Percentage of patients aged 50 years and older receiving a screening

Endoscopy/Polyp Surveillance: Appropriate Follow-Up colonoscopy without biopsy or polypectomy who had a recommended follow- Communication and Care Full
320 Interval for Normal Colonoscopy in Average Risk - 0658 320 Process AMA-PCPI - - GI/GU C - 2015 - - - - TBD by NQF TBD by NQF - Received full endorsement 12/13
up interval of at least 10 years for repeat colonoscopy documented in their Coordination Endorsement
Patients: colonoscopy report
Percentage of medical records of patients aged 18 years and older with a

diagnosis of major depressive disorder (MDD) and a specific diagnosed Non-Endorsed/
Adult Major Depressive Disorder (MDD): Coordination comorbid condition (diabetes, coronary artery disease, ischemic stroke,
325 - - 325 Effective Clinical Care Process AMA-PCPI - - - - - Planned - - - - TBD by NQF - -
of Care of Patients with Specific Comorbid Conditions intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Submission
Renal Disease [ESRD] or congestive heart failure) being treated by another
clinician with communication to the clinician treating the comorbid condition

nonvalvular atrial fibrillation (AF) or atrial flutter whose assessment of the
Atrial Fibrillation and Atrial Flutter: Chronic specified thromboembolic risk factors indicate one or more high-risk factors Full
326 Anticoagulation Therapy - 1525 326 or more than one moderate risk factor, as determined by CHADS2 risk Patient Safety Process AMA-PCPI ACCF AHA Cardiovascular A -2016 - Endorsement - - - TBD by NQF TBD by NQF - -
stratification, who are prescribed warfarin OR another oral anticoagulant
drug that is FDA approved for the prevention of thromboembolism

Pediatric Kidney Disease: ESRD Patients Receiving patients aged 17 years and younger with a diagnosis of End Stage Renal Full
328 - 1667 328 Effective Clinical Care Outcome AMA-PCPI - - Renal B - 2014 - - - - Q2 TBD by NQF - -
Dialysis: Hemoglobin Level < 10 g/Dl Disease (ESRD) receiving hemodialysis or peritoneal dialysis have a Endorsement
hemoglobin level < 10 g/dL
Non-Endorsed/
Adult Kidney Disease: Catheter Use at Initiation of Renal Disease (ESRD) who initiate maintenance hemodialysis during the
329 - - 329 Effective Clinical Care Process AMA-PCPI - - - - - Planned - - - - TBD by NQF - -
Hemodialysis measurement period, whose mode of vascular access is a catheter at the time Submission
maintenance hemodialysis is initiated
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Adult Kidney Disease: Catheter Use for Greater Than or Percentage of patients aged 18 years and older with a diagnosis of End Stage Non-Endorsed/
330 - - 330 Renal Disease (ESRD) receiving maintenance hemodialysis for greater than or Effective Clinical Care Process AMA-PCPI - - - - - Planned - - - - TBD by NQF - -
Equal to 90 Days
equal to 90 days whose mode of vascular access is a catheter Submission
Percentage of patients, aged 18 years and older, with a diagnosis of acute Non-Endorsed/
Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis
331 - - 331 sinusitis who were prescribed an antibiotic within 7 days of diagnosis or Effective Clinical Care Process AMA-PCPI - - - - - Planned - - - - TBD by NQF - -
(Appropriate Use) within 10 days after onset of symptoms Submission
Adult Sinusitis: Appropriate Choice of Antibiotic: Percentage of patients aged 18 years and older with a diagnosis of acute Non-Endorsed/
332 Amoxicillin Prescribed for Patients with Acute Bacterial - - 332 bacterial sinusitis that were prescribed amoxicillin, without clavulante, as a Effective Clinical Care Process AMA-PCPI - - - - - Planned - - - - TBD by NQF - -
Sinusitis first line antibiotic at the time of diagnosis Submission
Percentage of patients aged 18 years and older with a diagnosis of acute Non-Endorsed/
Adult Sinusitis: Computerized Tomography for Acute sinusitis who had a computerized tomography (CT) scan of the paranasal
333 - - 333 Efficiency and Cost Reduction Efficiency AMA-PCPI - - - - - Planned - - - - TBD by NQF - -
Sinusitis (Overuse) sinuses ordered at the time of diagnosis or received within 28 days after date
of diagnosis Submission
Adult Sinusitis: More than One Computerized Percentage of patients aged 18 years and older with a diagnosis of chronic Non-Endorsed/
334 Tomography (CT) Scan Within 90 Days for Chronic - - 334 sinusitis who had more than one CT scan of the paranasal sinuses ordered or Effective Clinical Care Efficiency AMA-PCPI - - - - - Planned - - - - TBD by NQF - -
Sinusitis (Overuse) received within 90 days after the date of diagnosis Submission

Non-Endorsed/
335 Maternity Care: Elective Delivery or Early Induction - - 335 period who delivered a live singleton at ≥ 37 and < 39 weeks of gestation Patient Safety Process AMA-PCPI - - - - - Planned - - - - TBD by NQF - -
Without Medical Indication at ≥ 37 and < 39 Weeks completed who had elective deliveries or early inductions without medical
Submission
indication
- HRSA
The percentage of patients, regardless of age, with a diagnosis of HIV with a Full Full
338 HIV Viral Load Suppression - 2082 0338 HIV viral load less than 200 copies/mL at last HIV viral load test during the Effective Clinical Care Outcome HRSA - - Infectious Disease C - 2015 - - - Q1 - eMeasure in progress annual update submitted
measurement year
Percentage of patients, regardless of age, with a diagnosis of HIV prescribed

Full Full
339 Prescription of HIV Antiretroviral Therapy - 2083 0339 antiretroviral therapy for the treatment of HIV infection during the Effective Clinical Care Process HRSA - - Infectious Disease C - 2015 - - - Q1 - eMeasure in progress annual update submitted
measurement year Endorsement Endorsement
Percentage of patients, regardless of age with a diagnosis of HIV who had at

Full Full
340 HIV Medical Visit Frequency - 2079 340 least one medical visit in each 6 month period of the 24 month measurement Efficiency and Cost Reduction Process HRSA - - Infectious Disease C - 2015 Endorsement Endorsement - - - Q1 - eMeasure in progress annual update submitted
period, with a minimum of 60 days between medical visits
Percentage of patients, regardless of age, with a diagnosis of HIV who did not Full Full
341 Gap in HIV Medical Visits - 2080 341 Efficiency and Cost Reduction Process HRSA - - Infectious Disease C - 2015 - - - Q1 - eMeasure in progress annual update submitted
have a medical visit in the last 6 months Endorsement Endorsement
- AAD
Percentage of new patients whose biopsy results have been reviewed and Communication and Care Non-Endorsed/
265 Biopsy Follow-Up - - 0265 communicated to the primary care/referring physician and patient by the Process AAD - - - - - Lost - - - - - - -
Coordination
performing physician Endorsement
Percentage of patients whose providers are ensuring active tuberculosis

Tuberculosis Prevention for Psoriasis and Psoriatic Non-Endorsed/
prevention either through yearly negative standard tuberculosis screening Q1 - Measure Testing planned for beginning Summer 2104, and then to be
337 Arthritis Patients on a Biological Immune Response - - 0337 Effective Clinical Care Process AAD - - - - - Planned - - - - - -
Modifier tests or are reviewing the patient’s history to determine if they have had Submission submitted for NQF endorsement
appropriate management for a recent or prior positive test

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 Full Q1 Measure Testing for endorsement/maintenance planned for Summer/Fall Measure Maintainance planned for second half of 2014, Planned submission for
137 Melanoma: Continuity of Care - 0650 137 date for the next complete physical skin exam, & - A process to follow up with Effective Clinical Care Process AAD - - Cancer Project C - 2015 - Endorsement - - - - 2015 2014 re-esndorsement in 2015
patients who either did not make an appointment within the specified time
frame or who missed a scheduled appointment
Percentage of patients with melanoma, without signs or symptoms, for whom Efficient Use of Healthcare Full Q1 Measure Testing for endorsement/maintenance planned for Summer/Fall Measure Maintainance planned for second half of 2014, Planned submission for
224 Melanoma: Overutilization of Imaging Studies - 0562 224 Process AAD - - Cancer Project C - 2015 - - - - - 2015
no diagnostic imaging studies were ordered. Resources/Affordable Care Endorsement 2014 re-esndorsement in 2015
Percentage of patient visits, regardless of patient age, with a new occurrence

Non-Endorsed/
of melanoma. They must have a treatment plan documented in the chart that
138 Melanoma: Coordination of Care - - 138 was communicated to the physician(s) providing continuing care within one Care Coordination Process AAD - - - - - Lost - - - - - - -
Endorsement
month of diagnosis.
- ACEP
Percentage of pregnant female patients aged 14 to 50 who present to the

Ultrasound Determination of Pregnancy Location for Test Results worksheet that we received from NQF was drafted in Q1 of 2014.
emergency department (ED) with a chief complaint of abdominal pain or Time-Limited
254 Pregnant Patients with - 0651 0254 vaginal bleeding who receive a trans-abdominal or trans-vaginal ultrasound Effective Clinical Care Process ACEP - - To Be Determined - - Endorsement - - - - - The test results are currently undergoing final review, and we expect to upload -
Abdominal Pain and submit them to the NQF portal within the next two weeks
to determine pregnancy location
Percentage of Rh-negative pregnant women aged 14-50 years at risk of fetal

255 Rh Immunoglobulin (Rhogam) for Rh-Negative - 0652 0255 blood exposure who receive Rh-Immunoglobulin (Rhogam) in the emergency Effective Clinical Care Process ACEP - - To Be Determined - - Time-Limited - - - - - - -
Pregnant Women at Risk of Fetal Blood Exposure Endorsement
department (ED)
- AMA-PCPI/NCQA
within 30 days following discharge in the office by the physician, prescribing Full Full
046 Medication Reconciliation - 0097 046 Patient Safety Process AMA- PCPI NCQA - Patient Safety C - 2015 - - - Q1 2015 - Q1 2014 - Annual update submitted 03/2014
practitioner, registered nurse, or clinical pharmacist providing on-going care Endorsement Endorsement
Screening or Therapy for Osteoporosis for Women dual-energy X- ray absorptiometry (DXA) measurement ordered or Full Full Will go through maintenance review under the Endocrine Phase II project
039 - 0046 039 Effective Clinical Care Process AMA- PCPI NCQA - Endocrine Phase II B - 2014 - - - - 2014 -
Aged 65 Years and Older performed at least once since age 60 or pharmacologic therapy prescribed Endorsement Endorsement beginning in Q3 2014. Initial submission deadline is 6/6/14.
within 12 months

Absence of Urinary Incontinence in Women Aged 65 Percentage of female patients aged 65 years and older who were assessed for Lost
048 - 0098 048 the presence or absence of urinary incontinence within 12 months Effective Clinical Care Process AMA- PCPI NCQA - N/A - - - - - - - - -
Years and Older Endorsement
HIV/AIDS: CD4+ Cell Count or CD4+ Percentage Percentage of patients aged 6 months and older with a diagnosis of HIV/AIDS Full Full
159 - 0404 159 for whom a CD4+ cell count or CD4+ cell percentage was performed at least Effective Clinical Care Process AMA- PCPI NCQA - Infectious disease C - 2015 - - - Q1 2015 - Q1 2014 - Annual update submitted 03/2014
Performed Endorsement Endorsement
once every 6 months
Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS

HIV/AIDS: Sexually Transmitted Disease Screening for Full Full
205 - 0409 205 for whom chlamydia, gonorrhea and syphilis screenings were performed at Effective Clinical Care Process AMA- PCPI NCQA - Infectious disease C - 2015 - - - Q1 2015 - Q1 2014 - Annual update submitted 03/2014
Chlamydia, Gonorrhea, and Syphilis least once since the diagnosis of HIV infection Endorsement Endorsement
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Managing On-going Care Post-Fracture of Hip, Spine or distal radial fracture with documentation of communication with the Communication and Care Full Full Will go through maintenance review under the Endocrine Phase II project
024 - 0045 024 Process AMA-PCPI NCQA - Endocrine Phase II B - 2014 - - - - 2014 -
Distal Radius for Men and Women Aged 50 Years and physician managing the patient’s on-going care that a fracture occurred and Coordination Endorsement Endorsement beginning in Q3 2014. Initial submission deadline is 6/6/14.
Full Full Will go through maintenance review under the Endocrine Phase II project
040 Spine or Distal Radius for Men and Women Aged 50 - 0048 040 or distal radius who had a central dual-energy X-ray absorptiometry (DXA) Effective Clinical Care Process AMA-PCPI NCQA - Endocrine Phase II B - 2014 - - - - 2014 -
Years and Older measurement ordered or performed or pharmacologic therapy prescribed Endorsement Endorsement beginning in Q3 2014. Initial submission deadline is 6/6/14.
041 Osteoporosis: Pharmacologic Therapy for Men and - 0049 041 Percentage of patients aged 50 years and older with a diagnosis of Effective Clinical Care Process AMA-PCPI NCQA - Endocrine Phase II B - 2014 Full Full - - - - 2014 Will go through maintenance review under the Endocrine Phase II project -
Women Aged 50 Years and Older osteoporosis who were prescribed pharmacologic therapy within 12 months Endorsement Endorsement beginning in Q3 2014. Initial submission deadline is 6/6/14.
Communication and Care Full Full
047 Advance Care Plan - 0326 047 documentation in the medical record that an advance care plan was discussed Process AMA-PCPI NCQA - Care Coordination C - 2015 - - - Q1 2015 - Q1 2014 - Annual update submitted 03/2014
Coordination Endorsement Endorsement
but the patient did not wish or was not able to name a surrogate decision
Urinary Incontinence: Characterization of Urinary
049 Incontinence in Women Aged 65 Years and Older - 0099 049 urinary incontinence whose urinary incontinence was characterized at least Effective Clinical Care Process AMA-PCPI NCQA - N/A - - Lost - - - - - - -
once within 12 months Endorsement
050 Urinary Incontinence: Plan of Care for Urinary - 0100 050 urinary incontinence with a documented plan of care for urinary incontinence Patient and Caregiver-Centered Process AMA-PCPI NCQA - N/A - - Lost - - - - - - -
Incontinence in Women Aged 65 Years and Older Experience and Outcomes
at least once within 12 months Endorsement
Percentage of patients aged 65 years and older with a history of falls who had Full Full
154 Falls: Risk Assessment - 0101 154 Patient Safety Process AMA-PCPI NCQA - Patient Safety C - 2015 - - - Q1 2015 - Q1 2014 - Annual update submitted 03/2014
a risk assessment for falls completed within 12 months Endorsement Endorsement
Percentage of patients aged 65 years and older with a history of falls who had Communication and Care Full Full
155 Falls: Plan of Care - 0101 155 a plan of care for falls documented within 12 months Coordination Process AMA-PCPI NCQA - Patient Safety C - 2015 Endorsement Endorsement - - - Q1 2015 - Q1 2014 - Annual update submitted 03/2014
- SVS
Percentage of patients aged 18 years and older with a diagnosis of advanced

Hemodialysis Vascular Access Decision-Making by Non-Endorsed/
Chronic Kidney Disease (CKD) (stage 3, 4 or 5) or End Stage Renal Disease Measure was not re-endorsed by NQF upon maintenance review during the 2011
172 Surgeon to Maximize Placement of Autogenous Arterial - 0259 0172 (ESRD) requiring hemodialysis vascular access documented by surgeon to Effective Clinical Care Process SVS - - NA - Not Endorsed No Plan to - - - - NA NA maintenance cycle. No current plans for re-submission.
Venous (AV) Fistula Submit
have received autogenous AV fistula
Statin Therapy at Discharge after Lower Extremity Percentage of patients aged 18 years and older undergoing infra-inguinal Full- Full
257 - 1519 0257 Effective Clinical Care Process SVS - - Surgery A -2016 Endorsement - - - Q1 Unknown NA None.
Bypass (LEB) lower extremity bypass who are prescribed a statin medication at discharge Endorsement
2012
Rate of Open Repair of Small or Moderate Non- Percent of patients undergoing open repair of small or moderate sized non- Non-Endorsed/
Ruptured Abdominal Aortic Aneurysms (AAA) without Communication and Care
258 - - 258 ruptured abdominal aortic aneurysms who do not experience a major Outcome SVS - - NA - Not Endorsed No Plan to - - - - NA NA No current plans for submission.
Major Complications (Discharged to Home by Post- complication (discharge to home no later than post-operative day #7) Coordination Submit
Operative Day #7
Rate of Endovascular Aneurysm Repair (EVAR) of

Percent of patients undergoing endovascular repair of small or moderate non- Non-Endorsed/
Small or Moderate Non-Ruptured Abdominal Aortic ruptured abdominal aortic aneurysms (AAA) that do not experience a major Communication and Care No Plan to
259 Aneurysms (AAA) without Major Complications - - 259 Coordination Outcome SVS - - NA - Not Endorsed - - - - NA NA No current plans for submission.
complication (discharged to home no later than post-operative day #2) Submit
(Discharged to Home by Post-Operative Day #2)
Rate of Carotid Endarterectomy (CEA) for Percent of asymptomatic patients undergoing CEA who are discharged to Communication and Care Non-Endorsed/
260 Asymptomatic Patients, without Major Complications - - 260 Process SVS - - NA - Not Endorsed No Plan to - - - - NA NA No current plans for submission.
home no later than post-operative day #2 Coordination
(Discharged to Home by Post-Operative Day #2) Submit
Rate of Carotid Artery Stenting (CAS) for Asymptomatic Non-Endorsed/

Percent of asymptomatic patients undergoing CAS who are discharged to
344 Patients, Without Major Complications (Discharged to - - 344 home no later than post-operative day #2 Effective Clinical Care Outcome svs - - NA - Not Endorsed No Plan to - - - - NA NA No current plans for submission.
Home by Post-Operative Day #2) Submit
Full-
345 Rate of Postoperative Stroke or Death in Asymptomatic - - 345 Percent of asymptomatic patients undergoing CAS who experience stroke or Effective Clinical Care Outcome SVS - - Surgery A -2016 Endorsement Full - - - Q1 Unknown NA None.
Patients Undergoing Carotid Artery Stenting (CAS) death following surgery while in the hospital Endorsement
2012
Rate of Postoperative Stroke or Death in Asymptomatic Full-

Percent of asymptomatic patients undergoing CEA who experience stroke or Full
346 Patients undergoing Carotid - - 346 Effective Clinical Care Outcome SVS - - Surgery A -2016 Endorsement - - - Q1 Unknown NA None.
Endarterectomy (CEA) death following surgery while in the hospital 2012 Endorsement
Rate of Endovascular Aneurysm Repair (EVAR) of Full-

Percent of patients undergoing endovascular repair of small or moderate Full
347 Small or Moderate Non-Ruptured Abdominal Aortic - - 347 abdominal aortic aneurysms (AAA) who die while in the hospital Effective Clinical Care Outcome svs - - Surgery A -2016 Endorsement Endorsement - - - - Unknown NA None.
Aneurysms (AAA) Who Die While in Hospital 2012
Page 29 of 119
Comprehensive
PQRS Number Measure Title Measure Description NQS Domain Measure Type NQF Project Committee NQF Cycle Annual Update Due Review Additional information (e.g., Testing Results, Revisions), including Synopsis of NQF Endorsement Activity and/or NQF Communications since
Date Month/Year Completed or Anticipated the most Recent Quarterly Update
CMS NQF PQRS #1 #2 #3
2013 2014 2014 2014 2014
Page 30 of 119
Measure Number
eCQM Quality Appropriate

Measure Title CMS eCQM ID NQF NQF Number Measure Description NQS Domain Measure Type Meaningful Measure Area High Priority Use
(Q#)
Diabetes: Hemoglobin A1c (HbA1c) Poor Control Percentage of patients 18-75 years of age with diabetes who had Intermediate Management of Chronic
(>9%) CMS122v10 N/A 0059 001 hemoglobin A1c > 9.0% during the measurement period. Effective Clinical Care Outcome Conditions X -
Heart Failure (HF): Angiotensin-Converting Percentage of patients aged 18 years and older with a diagnosis
Enzyme (ACE) Inhibitor or Angiotensin Receptor of heart failure (HF) with a current or prior left ventricular
ejection fraction (LVEF) < 40% who were prescribed ACE Management of Chronic
Blocker (ARB) or Angiotensin Receptor-Neprilysin CMS135v10 0081e 0081 005 inhibitor or ARB or ARNI therapy either within a 12-month Effective Clinical Care Process Conditions - -
Inhibitor (ARNI) Therapy for Left Ventricular
Systolic Dysfunction (LVSD) period when seen in the outpatient setting OR at each hospital
discharge.

Coronary Artery Disease (CAD): Antiplatelet N/A N/A 0067 006 of coronary artery disease (CAD) seen within a 12-month period Effective Clinical Care Process Management of Chronic - -
Therapy who were prescribed aspirin or clopidogrel. Conditions
Coronary Artery Disease (CAD): Beta-Blocker Percentage of patients aged 18 years and older with a diagnosis
of coronary artery disease seen within a 12-month period who Management of Chronic
Therapy – Prior Myocardial Infarction (MI) or Left CMS145v10 0070e 0070 007 also have a prior MI or a current or prior LVEF < 40% who were Effective Clinical Care Process Conditions - -
Ventricular Systolic Dysfunction (LVEF < 40%)
prescribed beta-blocker therapy.

of heart failure (HF) with a current or prior left ventricular
Heart Failure (HF): Beta-Blocker Therapy for Left CMS144v10 0083e 0083 008 ejection fraction (LVEF) < 40% who were prescribed beta- Effective Clinical Care Process Management of Chronic - -
Ventricular Systolic Dysfunction (LVSD) Conditions
blocker therapy either within a 12-month period when seen in
the outpatient setting OR at each hospital discharge.
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
Anti-Depressant Medication Management CMS128v10 N/A N/A 009 treatment. Two rates are reported. Effective Clinical Care Process Prevention, Treatment, and - -
a. Percentage of patients who remained on an antidepressant Management of Mental Health
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).

Primary Open-Angle Glaucoma (POAG): Optic of primary open-angle glaucoma (POAG) who have an optic Management of Chronic
CMS143v10 0086e N/A 012 Effective Clinical Care Process - -
Nerve Evaluation nerve head evaluation during one or more office visits within 12 Conditions
months.

of age-related macular degeneration (AMD) who had a dilated
Age-Related Macular Degeneration (AMD): Dilated macular examination performed which included documentation Management of Chronic
N/A N/A 0087 014 of the presence or absence of macular thickening or geographic Effective Clinical Care Process - -
Macular Examination atrophy or hemorrhage AND the level of macular degeneration Conditions
severity during one or more office visits within the 12 month
performance period.

of diabetic retinopathy who had a dilated macular or fundus
Diabetic Retinopathy: Communication with the exam performed with documented communication to the Communication and Care Transfer of Health Information
Physician Managing Ongoing Diabetes Care CMS142v10 N/A N/A 019 physician who manages the ongoing care of the patient with Coordination Process and Interoperability X -
diabetes mellitus regarding the findings of the macular or fundus
exam at least once within 12 months.
2021 Measures List

Page 31 of 119
Quality
Measure Title CMS eCQM ID eCQM NQF Number Measure Description NQS Domain Measure Type Meaningful Measure Area High Priority Appropriate
NQF (Q#) Use
Percentage of patients aged 50 years and older treated for a

fracture with documentation of communication, between the
Communication with the Physician or Other physician treating the fracture and the physician or other
Clinician Managing On-Going Care Post-Fracture for N/A N/A N/A 024 clinician managing the patient’s on-going care, that a fracture Communication and Care Process Transfer of Health Information X -
occurred and that the patient was or should be considered for Coordination and Interoperability
Men and Women Aged 50 Years and Older osteoporosis treatment or testing. This measure is submitted by
the physician who treats the fracture and who therefore is held
accountable for the communication.
Screening for Osteoporosis for Women Aged 65-85 Percentage of female patients aged 65-85 years of age who ever
N/A N/A 0046 039 had a central dual-energy X-ray absorptiometry (DXA) to check Effective Clinical Care Process Preventive Care - -
Years of Age for osteoporosis.
Percentage of patients aged 65 years and older who have an

advance care plan or surrogate decision maker documented in
Advance Care Plan N/A N/A 0326 047 the medical record or documentation in the medical record that Communication and Care Process Care is Personalized and X -
an advance care plan was discussed but the patient did not wish Coordination Aligned with Patient’s Goals
or was not able to name a surrogate decision maker or provide
an advance care plan.
Urinary Incontinence: Assessment of Presence or Percentage of female patients aged 65 years and older who were
Absence of Urinary Incontinence in Women Aged N/A N/A N/A 048 assessed for the presence or absence of urinary incontinence Effective Clinical Care Process Preventive Care - -
65 Years and Older within 12 months.
Percentage of female patients aged 65 years and older with a Person and Caregiver-
Urinary Incontinence: Plan of Care for Urinary N/A N/A N/A 050 diagnosis of urinary incontinence with a documented plan of Centered Experience and Process Management of Chronic X -
Incontinence in Women Aged 65 Years and Older care for urinary incontinence at least once within 12 months. Outcomes Conditions

Chronic Obstructive Pulmonary Disease (COPD): N/A N/A 0102 052 of COPD (FEV1/FVC < 70%) and who have an FEV1 less than Effective Clinical Care Process Management of Chronic - -
Long-Acting Inhaled Bronchodilator Therapy 60% predicted and have symptoms who were prescribed a long- Conditions
acting inhaled bronchodilator.
Percentage of episodes for patients 3 months of age and older

Appropriate Treatment for Upper Respiratory CMS154v10 N/A 0069 065 with a diagnosis of upper respiratory infection (URI) that did not Efficiency and Cost Reduction Process Appropriate Use of Healthcare X X
Infection (URI)
result in an antibiotic dispensing event.
The percentage of episodes for patients 3 years and older with a

Appropriate Testing for Pharyngitis CMS146v10 N/A N/A 066 diagnosis of pharyngitis that resulted in an antibiotic dispensing Efficiency and Cost Reduction Process Appropriate Use of Healthcare X X
event and a group A streptococcus (strep) test.
Percentage of patients, regardless of age, who undergo central

Prevention of Central Venous Catheter (CVC) - venous catheter (CVC) insertion for whom CVC was inserted with Healthcare Associated
Related Bloodstream Infections N/A N/A 2726 076 all elements of maximal sterile barrier technique, hand hygiene, Patient Safety Process Infections X -
skin preparation and, if ultrasound is used, sterile ultrasound
techniques followed.
Acute Otitis Externa (AOE): Systemic Antimicrobial N/A N/A 0654 093 Percentage of patients aged 2 years and older with a diagnosis of Efficiency and Cost Reduction Process Appropriate Use of Healthcare X X
Therapy – Avoidance of Inappropriate Use AOE who were not prescribed systemic antimicrobial therapy.
Percentage of patients, regardless of age, with a diagnosis of

prostate cancer at low (or very low) risk of recurrence receiving
Prostate Cancer: Avoidance of Overuse of Bone interstitial prostate brachytherapy, OR external beam
Scan for Staging Low Risk Prostate Cancer Patients CMS129v11 0389e 0389 102 radiotherapy to the prostate, OR radical prostatectomy, who did Efficiency and Cost Reduction Process Appropriate Use of Healthcare X X
not have a bone scan performed at any time since diagnosis of
prostate cancer.
2021 Measures List

Page 32 of 119
Quality
NQF (Q#) Use
Percentage of patients, regardless of age, with a diagnosis of

Prostate Cancer: Combination Androgen prostate cancer at high or very high risk of recurrence receiving
Deprivation Therapy for High Risk or Very High N/A N/A 0390 104 external beam radiotherapy to the prostate who were prescribed Effective Clinical Care Process Management of Chronic - -
Conditions
Risk Prostate Cancer androgen deprivation therapy in combination with external
beam radiotherapy to the prostate.
All patient visits during which a new diagnosis of MDD or a new

Adult Major Depressive Disorder (MDD): Suicide CMS161v10 0104e N/A 107 diagnosis of recurrent MDD was identified for patients aged 18 Effective Clinical Care Process Prevention, Treatment, and - -
Risk Assessment years and older with a suicide risk assessment completed during Management of Mental Health
the visit.
Percentage of patients aged 6 months and older seen for a visit

Preventive Care and Screening: Influenza CMS147v11 0041e 0041 110 between October 1 and March 31 who received an influenza Community/Population Process Preventive Care - -
Immunization immunization OR who reported previous receipt of an influenza Health
immunization.
Percentage of patients 66 years of age and older who have ever Community/Population
Pneumococcal Vaccination Status for Older Adults CMS127v10 N/A N/A 111 received a pneumococcal vaccine. Health Process Preventive Care - -
Percentage of women 50 - 74 years of age who had a

Breast Cancer Screening CMS125v10 N/A 2372 112 mammogram to screen for breast cancer in the 27 months prior Effective Clinical Care Process Preventive Care - -
to the end of the measurement period.
Percentage of patients 50-75 years of age who had appropriate

Colorectal Cancer Screening CMS130v10 N/A 0034 113 screening for colorectal cancer. Effective Clinical Care Process Preventive Care - -
Avoidance of Antibiotic Treatment for Acute The percentage of episodes for patients ages 3 months and older
Bronchitis/Bronchiolitis N/A N/A 0058 116 with a diagnosis of acute bronchitis/bronchiolitis that did not Efficiency and Cost Reduction Process Appropriate Use of Healthcare X X
result in an antibiotic dispensing event.
Percentage of patients 18-75 years of age with diabetes

and an active diagnosis of retinopathy in any part of the
measurement period who had a retinal or dilated eye exam by an
eye care
Diabetes: Eye Exam CMS131v10 N/A 0055 117 professional during the measurement period or diabetics with no Effective Clinical Care Process Management of Chronic - -
Conditions
diagnosis of retinopathy in any part of the measurement period
who had a retinal or dilated eye exam by an eye care professional
during the measurement period or in the 12 months prior to the
measurement period.
Coronary Artery Disease (CAD): Angiotensin- Percentage of patients aged 18 years and older with a diagnosis
Converting Enzyme (ACE) Inhibitor or Angiotensin of coronary artery disease seen within a 12 month period who Management of Chronic
Receptor Blocker (ARB) Therapy - Diabetes or Left N/A N/A 0066 118 also have diabetes OR a current or prior Left Ventricular Ejection Effective Clinical Care Process Conditions - -
Fraction (LVEF) < 40% who were prescribed ACE inhibitor or
Ventricular Systolic Dysfunction (LVEF < 40%) ARB therapy.
The percentage of patients 18-75 years of age with diabetes who Management of Chronic
Diabetes: Medical Attention for Nephropathy CMS134v10 N/A 0062 119 had a nephropathy screening test or evidence of nephropathy Effective Clinical Care Process - -
during the measurement period. Conditions
Diabetes Mellitus: Diabetic Foot and Ankle Care, Percentage of patients aged 18 years and older with a diagnosis
Peripheral Neuropathy – Neurological Evaluation N/A N/A 0417 126 of diabetes mellitus who had a neurological examination of their Effective Clinical Care Process Preventive Care - -
lower extremities within 12 months.
Diabetes Mellitus: Diabetic Foot and Ankle Care, Percentage of patients aged 18 years and older with a diagnosis
Ulcer Prevention – Evaluation of Footwear N/A N/A 0416 127 of diabetes mellitus who were evaluated for proper footwear and Effective Clinical Care Process Preventive Care - -
sizing.
2021 Measures List

Page 33 of 119
Quality
NQF (Q#) Use
Percentage of patients aged 18 years and older with a BMI

Preventive Care and Screening: Body Mass Index documented during the current encounter or within the previous Community/Population
(BMI) Screening and Follow-Up Plan CMS69v10 N/A N/A 128 twelve months AND who had a follow-up plan documented if Health Process Preventive Care - -
most recent BMI was outside of normal parameters.
Percentage of visits for patients aged 18 years and older for

Documentation of Current Medications in the which the eligible professional or eligible clinician attests to
Medical Record CMS68v11 N/A N/A 130 documenting a list of current medications using all immediate Patient Safety Process Medication Management X -
resources available on the date of the encounter.
Percentage of patients aged 12 years and older screened for

depression on the date of the encounter or up to 14 days prior to
Preventive Care and Screening: Screening for CMS2v11 N/A N/A 134 the date of the encounter using an age-appropriate standardized Community/Population Process Prevention, Treatment, and - -
Depression and Follow-Up Plan depression screening tool AND if positive, a follow-up plan is Health Management of Mental Health
documented on the date of the eligible encounter.
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: Communication and Care
Melanoma: Continuity of Care – Recall System N/A N/A N/A 137 • A target date for the next complete physical skin exam, AND Coordination Structure Preventive Care X -
• A process to follow up with patients who either did not make
an appointment within the specified timeframe or who missed a
scheduled appointment.
Percentage of patient visits, regardless of age, with a new

Melanoma: Coordination of Care N/A N/A N/A 138 occurrence of melanoma that have a treatment plan documented Communication and Care Process Transfer of Health Information X -
in the chart that was communicated to the physician(s) providing Coordination and Interoperability
continuing care within one month of diagnosis.

of primary open-angle glaucoma (POAG) whose glaucoma
Primary Open-Angle Glaucoma (POAG): Reduction treatment has not failed (the most recent IOP was reduced by at
of Intraocular Pressure (IOP) by 15% OR N/A N/A 0563 141 least 15% from the pre-intervention level) OR if the most recent Communication and Care Outcome Management of Chronic X -
Documentation of a Plan of Care IOP was not reduced by at least 15% from the pre-intervention Coordination Conditions
level, a plan of care was documented within the 12 month
performance period.
Oncology: Medical and Radiation – Pain Intensity Percentage of patient visits, regardless of patient age, with a Person and Caregiver- Management of Chronic
Quantified CMS157v10 0384e 0384 143 diagnosis of cancer currently receiving chemotherapy or Centered Experience and Process Conditions X -
radiation therapy in which pain intensity is quantified. Outcomes
Percentage of visits for patients, regardless of age, with a

Oncology: Medical and Radiation – Plan of Care for diagnosis of cancer currently receiving chemotherapy or Person and Caregiver- Patient Focused Episode of
Pain N/A N/A 0383 144 radiation therapy who report having pain with a documented Centered Experience and Process Care X -
Outcomes
plan of care to address pain.
Radiology: Exposure Dose Indices or Exposure Final reports for procedures using fluoroscopy that document
Time and Number of Images Reported for N/A N/A N/A 145 radiation exposure indices, or exposure time and number of Patient Safety Process Appropriate Use of Healthcare X -
Procedures Using Fluoroscopy fluorographic images (if radiation exposure indices are not
available).
2021 Measures List

Page 34 of 119
Quality
NQF (Q#) Use
Percentage of final reports for all patients, regardless of age,

Nuclear Medicine: Correlation with Existing undergoing bone scintigraphy that include physician
Imaging Studies for All Patients Undergoing Bone N/A N/A N/A 147 documentation of correlation with existing relevant imaging Communication and Care Process Transfer of Health Information X -
Coordination and Interoperability
Scintigraphy studies (e.g., x-ray, Magnetic Resonance Imaging (MRI),
Computed Tomography (CT), etc.) that were performed.
Percentage of patients aged 65 years and older with a history of

Falls: Plan of Care N/A N/A 0101 155 falls that had a plan of care for falls documented within 12 Communication and Care Process Preventable Healthcare Harm X -
months. Coordination
Percentage of patients aged 18 years and older undergoing

Coronary Artery Bypass Graft (CABG): Prolonged N/A N/A 0129 164 isolated CABG surgery who require postoperative intubation > Effective Clinical Care Outcome Preventable Healthcare Harm X -
Intubation
24 hours.

Coronary Artery Bypass Graft (CABG):
Postoperative Renal Failure N/A N/A 0114 167 isolated CABG surgery (without pre-existing renal failure) who Effective Clinical Care Outcome Preventable Healthcare Harm X -
develop postoperative renal failure or require dialysis.

Coronary Artery Bypass Graft (CABG): Surgical Re- isolated CABG surgery who require a return to the operating
Exploration N/A N/A 0115 168 room (OR) during the current hospitalization for mediastinal Effective Clinical Care Outcome Preventable Healthcare Harm X -
bleeding with or without tamponade, graft occlusion, valve
dysfunction, or other cardiac reason.
If a patient has been newly prescribed a biologic disease-

Tuberculosis Screening Prior to First Course modifying anti-rheumatic drug (DMARD) therapy, then the Management of Chronic
Biologic Therapy N/A N/A N/A 176 medical record should indicate TB testing in the preceding 12- Effective Clinical Care Process Conditions - -
month period.

Rheumatoid Arthritis (RA): Periodic Assessment of of rheumatoid arthritis (RA) who have an assessment of disease Management of Chronic
N/A N/A 2523 177 activity using an ACR-preferred RA disease activity assessment Effective Clinical Care Process - -
Disease Activity tool at ≥50% of encounters for RA for each patient during the Conditions
measurement year.
Rheumatoid Arthritis (RA): Functional Status Percentage of patients aged 18 years and older with a diagnosis
N/A N/A N/A 178 of rheumatoid arthritis (RA) for whom a functional status Effective Clinical Care Process Patient's Experience of Care - -
Assessment assessment was performed at least once within 12 months.

of rheumatoid arthritis (RA) who have been assessed for
Rheumatoid Arthritis (RA): Glucocorticoid glucocorticoid use and, for those on prolonged doses of Management of Chronic
Management N/A N/A N/A 180 prednisone > 5 mg daily (or equivalent) with improvement or no Effective Clinical Care Process Conditions - -
change in disease activity, documentation of glucocorticoid
management plan within 12 months.
Percentage of patients aged 65 years and older with a

documented elder maltreatment screen using an Elder
Elder Maltreatment Screen and Follow-Up Plan N/A N/A N/A 181 Maltreatment Screening tool on the date of encounter AND a Patient Safety Process Preventive Care X -
documented follow-up plan on the date of the positive screen.
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 Communication and Care
Functional Outcome Assessment N/A N/A N/A 182 the encounter AND documentation of a care plan based on Coordination Process Functional Outcomes X -
identified functional outcome deficiencies on the date of the
identified deficiencies.
Colonoscopy Interval for Patients with a History of Percentage of patients aged 18 years and older receiving a
surveillance colonoscopy, with a history of prior adenomatous Communication and Care
Adenomatous Polyps – Avoidance of Inappropriate N/A N/A N/A 185 polyp(s) in previous colonoscopy findings, which had an interval Coordination Process Appropriate Use of Healthcare X X
Use of 3 or more years since their last colonoscopy.

Stroke and Stroke Rehabilitation: Thrombolytic of acute ischemic stroke who arrive at the hospital within two
Therapy N/A N/A N/A 187 hours of time last known well and for whom IV alteplase was Effective Clinical Care Process Medication Management - -
initiated within three hours of time last known well.
2021 Measures List

Page 35 of 119
Quality
NQF (Q#) Use
Percentage of cataract surgeries for patients aged 18 years and

older with a diagnosis of uncomplicated cataract and no
Cataracts: 20/40 or Better Visual Acuity within 90 significant ocular conditions impacting the visual outcome of
CMS133v10 0565e 0565 191 Effective Clinical Care Outcome Functional Outcomes X -
Days Following Cataract Surgery surgery and had best-corrected visual acuity of 20/40 or better
(distance or near) achieved in the operative eye within 90 days
following the cataract surgery.

HIV/AIDS: Sexually Transmitted Disease Screening of HIV/AIDS for whom chlamydia, gonorrhea, and syphilis Management of Chronic
for Chlamydia, Gonorrhea, and Syphilis N/A N/A 0409 205 screenings were performed at least once since the diagnosis of Effective Clinical Care Process Conditions - -
HIV infection.
A patient-reported outcome measure of risk-adjusted change in

functional status for patients 14 years+ with knee impairments.
The change in functional status (FS) is assessed using the FOTO
Lower Extremity Physical Function (LEPF) patient-reported Patient-Reported
Functional Status Change for Patients with Knee outcome measure (PROM). The measure is adjusted to patient Communication and Care Outcome-Based
Impairments N/A N/A N/A 217 characteristics known to be associated with FS outcomes (risk- Coordination Performance Functional Outcomes X -
adjusted) and used as a performance measure at the patient Measure
level, at the individual clinician level, and at the clinic level to
assess quality. The measure is available as a computer adaptive
test, for reduced patient burden, or a short form (static measure).

functional status for patients 14 years+ with hip impairments.
The change in functional status (FS) is assessed using the FOTO
Lower Extremity Physical Function (LEPF) patient-reported Patient-Reported
Functional Status Change for Patients with Hip N/A N/A N/A 218 outcome measure (PROM). The measure is adjusted to patient Communication and Care Outcome-Based Functional Outcomes X -
Impairments characteristics known to be associated with FS outcomes (risk Coordination Performance

functional status for patients 14 years+ with foot, ankle or lower
leg impairments. The change in functional status (FS) is assessed
using the FOTO Lower Extremity Physical Function (LEPF)
patient- reported outcome measure (PROM). The measure is Patient-Reported
Functional Status Change for Patients with Lower Communication and Care Outcome-Based
Leg, Foot or Ankle Impairments N/A N/A N/A 219 adjusted to patient characteristics known to be associated with Coordination Performance Functional Outcomes X -
FS outcomes (risk-adjusted) and used as a performance measure
at the patient level, at the individual clinician level, and at the Measure
clinic level to assess quality. The measure is available as a
computer adaptive test, for reduced patient burden, or a short
form (static measure).

functional status for patients 14 years+ with low back
impairments. The change in functional status (FS) is assessed
using the FOTO Low Back FS patient-reported outcome measure Patient-Reported
Functional Status Change for Patients with Low (PROM). The measure is adjusted to patient characteristics Communication and Care Outcome-Based
N/A N/A N/A 220 Functional Outcomes X -
Back Impairments known to be associated with FS outcomes (risk adjusted) and Coordination Performance
used as a performance measure at the patient level, at the Measure
individual clinician level, and at the clinic level to assess quality.
The measure is available as a computer adaptive test, for reduced
patient burden, or a short form (static measure).
2021 Measures List

Page 36 of 119
Quality
NQF (Q#) Use

functional status for patients 14 years+ with shoulder
impairments. The change in functional status (FS) is assessed
using the FOTO Shoulder FS patient-reported outcome measure Patient-Reported
Functional Status Change for Patients with N/A N/A N/A 221 (PROM). The measure is adjusted to patient characteristics Communication and Care Outcome-Based Functional Outcomes X -
Shoulder Impairments known to be associated with FS outcomes (risk adjusted) and Coordination Performance
used as a performance measure at the patient level, at the Measure
individual clinician level, and at the clinic level to assess quality.
The measure is available as a computer adaptive test, for reduced
patient burden, or a short form (static measure).

functional status (FS) for patients 14 years+ with elbow, wrist, or
hand impairments. The change in functional status (FS) is
assessed using the FOTO Elbow/Wrist/Hand FS patient-reported Patient-Reported
Functional Status Change for Patients with Elbow, outcome measure (PROM). The measure is adjusted to patient Communication and Care Outcome-Based
Wrist or Hand Impairments N/A N/A N/A 222 characteristics known to be associated with FS outcomes (risk Coordination Performance Functional Outcomes X -
Percentage of patients aged 18 years and older who were

Preventive Care and Screening: Tobacco Use: screened for tobacco use one or more times within the Community/Population Prevention and Treatment of
Screening and Cessation Intervention CMS138v10 0028e 0028 226 measurement period AND who received tobacco cessation Health Process Opioid and Substance Use - -
intervention on the date of the encounter or within the previous Disorders
12 months if identified as a tobacco user.
Percentage of patients 18-85 years of age who had a diagnosis of

essential hypertension starting before and continuing into, or
Controlling High Blood Pressure CMS165v10 N/A N/A 236 starting during the first six months of the measurement period, Effective Clinical Care Intermediate Management of Chronic X -
Outcome Conditions
and whose most recent blood pressure was adequately
controlled (<140/90mmHg) during the measurement period.
Percentage of patients 65 years of age and older who were

Use of High-Risk Medications in Older Adults CMS156v10 N/A 0022 238 ordered at least two high-risk medications from the same drug Patient Safety Process Medication Management X -
class.
Percentage of patients 3-17 years of age who had an outpatient

visit with a Primary Care Physician (PCP) or
Obstetrician/Gynecologist (OB/GYN) and who had evidence of
Weight Assessment and Counseling for Nutrition the following during the measurement period. Three rates are Community/Population
and Physical Activity for Children/Adolescents CMS155v10 N/A N/A 239 reported. Health Process Preventive Care - -
• Percentage of patients with height, weight, and body mass
index (BMI) percentile documentation
• Percentage of patients with counseling for nutrition
• Percentage of patients with counseling for physical activity.
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Quality
NQF (Q#) Use
Percentage of children 2 years of age who had four diphtheria,

tetanus and acellular pertussis (DTaP); three polio (IPV), one
measles, mumps and rubella (MMR); three or four H influenza
Childhood Immunization Status CMS117v10 N/A N/A 240 type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); Community/Population Process Preventive Care - -
four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two Health
or three rotavirus (RV); and two influenza (flu) vaccines by their
second birthday.
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
Cardiac Rehabilitation Patient Referral from an N/A N/A 0643 243 valve surgery, or cardiac transplantation, or who have chronic Communication and Care Process Preventive Care X -
Outpatient Setting stable angina (CSA) and have not already participated in an early Coordination
outpatient cardiac rehabilitation/secondary prevention (CR)
program for the qualifying event/diagnosis who were referred to
a CR program.
Percentage of esophageal biopsy reports that document the

Transfer of Health Information
Barrett’s Esophagus N/A N/A N/A 249 presence of Barrett’s mucosa that also include a statement about Effective Clinical Care Process and Interoperability - -
dysplasia.
Percentage of radical prostatectomy pathology reports that

Radical Prostatectomy Pathology Reporting N/A N/A N/A 250 include the pT category, the pN category, the Gleason score and a Effective Clinical Care Process Transfer of Health Information - -
statement about margin status. and Interoperability
Percentage of pregnant female patients aged 14 to 50 who

Ultrasound Determination of Pregnancy Location present to the emergency department (ED) with a chief
N/A N/A N/A 254 complaint of abdominal pain or vaginal bleeding who receive a Effective Clinical Care Process Preventive Care - -
for Pregnant Patients with Abdominal Pain trans-abdominal or trans-vaginal ultrasound to determine
pregnancy location.
Rate of Open Repair of Small or Moderate Non- Percent of patients undergoing open repair of small or moderate
Ruptured Infrarenal Abdominal Aortic Aneurysms N/A N/A N/A 258 sized non-ruptured infrarenal abdominal aortic aneurysms Patient Safety Outcome Appropriate Use of Healthcare X -
(AAA) without Major Complications (Discharged to (AAA) who do not experience a major complication (discharge to
Home by Post-Operative Day #7) home no later than post-operative day #7).
Rate of Endovascular Aneurysm Repair (EVAR) of Percent of patients undergoing endovascular repair of small or
Small or Moderate Non-Ruptured Infrarenal
Abdominal Aortic Aneurysms (AAA) without Major N/A N/A N/A 259 moderate non-ruptured infrarenal abdominal aortic aneurysms Patient Safety Outcome Appropriate Use of Healthcare X -
(AAA) that do not experience a major complication (discharged
Complications (Discharged to Home by Post- to home no later than post-operative day #2).
Operative Day #2)
Rate of Carotid Endarterectomy (CEA) for Percent of asymptomatic patients undergoing Carotid
Asymptomatic Patients, without Major Endarterectomy (CEA) who are discharged to home no later than
Complications (Discharged to Home by Post- N/A N/A N/A 260 Patient Safety Outcome Appropriate Use of Healthcare X -
Operative Day #2) post-operative day #2.
Percentage of patients aged birth and older referred to a

Referral for Otologic Evaluation for Patients with physician (preferably a physician specially trained in disorders Communication and Care Transfer of Health Information
Acute or Chronic Dizziness N/A N/A N/A 261 of the ear) for an otologic evaluation subsequent to an audiologic Coordination Process and Interoperability X -
evaluation after presenting with acute or chronic dizziness.
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Quality
NQF (Q#) Use
The percentage of clinically node negative (clinical stage

Sentinel Lymph Node Biopsy for Invasive Breast N/A N/A N/A 264 T1N0M0 or T2N0M0) breast cancer patients before or after Effective Clinical Care Process Appropriate Use of Healthcare - -
Cancer neoadjuvant systemic therapy, who undergo a sentinel lymph
node (SLN) procedure.
Percentage of new patients whose biopsy results have been

Biopsy Follow-Up N/A N/A N/A 265 reviewed and communicated to the primary care/referring Communication and Care Process Transfer of Health Information X -
Coordination and Interoperability
physician and patient.
Percentage of all patients of childbearing potential (12 years and

Epilepsy: Counseling for Women of Childbearing older) diagnosed with epilepsy who were counseled at least once Management of Chronic
Potential with Epilepsy N/A N/A N/A 268 a year about how epilepsy and its treatment may affect Effective Clinical Care Process Conditions - -
contraception and pregnancy.
Inflammatory Bowel Disease (IBD): Assessment of Percentage of patients with a diagnosis of inflammatory bowel
disease (IBD) who had Hepatitis B Virus (HBV) status assessed Management of Chronic
Hepatitis B Virus (HBV) Status Before Initiating N/A N/A N/A 275 and results interpreted prior to initiating anti-TNF (tumor Effective Clinical Care Process Conditions - -
Anti-TNF (Tumor Necrosis Factor) Therapy necrosis factor) therapy.

Sleep Apnea: Severity Assessment at Initial of obstructive sleep apnea who had an apnea hypopnea index Management of Chronic
Diagnosis N/A N/A N/A 277 (AHI) or a respiratory disturbance index (RDI) measured at the Effective Clinical Care Process Conditions - -
time of initial diagnosis.
Percentage of visits for patients aged 18 years and older with a

Sleep Apnea: Assessment of Adherence to Positive diagnosis of obstructive sleep apnea who were prescribed Management of Chronic
Airway Pressure Therapy N/A N/A N/A 279 positive airway pressure therapy who had documentation that Effective Clinical Care Process Conditions - -
adherence to positive airway pressure therapy was objectively
measured.
Percentage of patients, regardless of age, with a diagnosis of Prevention, Treatment, and

Dementia: Cognitive Assessment CMS149v10 2872e N/A 281 dementia for whom an assessment of cognition is performed and Effective Clinical Care Process Management of Mental Health - -
the results reviewed at least once within a 12-month period.
Percentage of patients with dementia for whom an assessment of

Dementia: Functional Status Assessment N/A N/A N/A 282 functional status was performed at least once in the last 12 Effective Clinical Care Process Prevention, Treatment, and - -
months. Management of Mental Health
Percentage of patients with dementia for whom there was a

Dementia Associated Behavioral and Psychiatric documented screening for behavioral and psychiatric symptoms,
including depression, and for whom, if symptoms screening was Prevention, Treatment, and
Symptoms Screening and Management N/A N/A N/A 283 positive, there was also documentation of recommendations for Effective Clinical Care Process Management of Mental Health - -
management in the last 12 months.
Percentage of patients with dementia or their caregiver(s) for

whom there was a documented safety concerns screening in two
domains of risk: 1) dangerousness to self or others and 2)
environmental risks; and if safety concerns screening was
Dementia: Safety Concern Screening and Follow-Up positive in the last 12 months, there was documentation of Prevention, Treatment, and
for Patients with Dementia N/A N/A N/A 286 mitigation recommendations, including but not limited to Patient Safety Process Management of Mental Health X -
referral to other resources.
2021 Measures List

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Quality
NQF (Q#) Use
Percentage of patients with dementia whose caregiver(s) were

Dementia: Education and Support of Caregivers for N/A N/A N/A 288 provided with education on dementia disease management and Communication and Care Process Prevention, Treatment, and X -
Patients with Dementia health behavior changes AND were referred to additional Coordination Management of Mental Health
resources for support in the last 12 months.
Percentage of all patients with a diagnosis of Parkinson’s Disease

essment of Mood Disorders and Psychosis for Patients with Parkinson’sN/A
Disease N/A N/A 290 [PD] who were assessed for depression, anxiety, apathy, AND Effective Clinical Care Process Prevention, Treatment, and - -
Management of Mental Health
psychosis once during the measurement period.
Percentage of all patients with a diagnosis of Parkinson’s Disease Prevention, Treatment, and
ment of Cognitive Impairment or Dysfunction for Patients with Parkinson’s
N/ADisease N/A N/A 291 [PD] who were assessed for cognitive impairment or dysfunction Effective Clinical Care Process Management of Mental Health - -
once during the measurement period.
Percentage of all patients with a diagnosis of Parkinson’s Disease

Rehabilitative Therapy Referral for Patients with N/A N/A N/A 293 who were referred to physical, occupational, speech, or Communication and Care Process Management of Chronic X -
Parkinson’s Disease recreational therapy once during the measurement period. Coordination Conditions
Cataracts: Improvement in Patient’s Visual Percentage of patients aged 18 years and older who had cataract Person and Caregiver- Patient-Reported
Function within 90 Days Following Cataract N/A N/A N/A 303 surgery and had improvement in visual function achieved within Centered Experience and Outcome-Based Functional Outcomes X -
Surgery 90 days following the cataract surgery, based on completing a Outcomes Performance
pre-operative and post-operative visual function survey. Measure
Percentage of patients aged 18 years and older who had cataract

surgery and were satisfied with their care within 90 days Person and Caregiver- Patient
Cataracts: Patient Satisfaction within 90 Days N/A N/A N/A 304 following the cataract surgery, based on completion of the Centered Experience and Engagement/Experi Functional Outcomes X -
Following Cataract Surgery Consumer Assessment of Healthcare Providers and Systems Outcomes ence
Surgical Care Survey.
Percentage of patients 13 years of age and older with a new

episode of alcohol or other drug abuse or (AOD) dependence who
received the following. Two rates are reported.
a. Percentage of patients who initiated treatment including either

an intervention or medication for the treatment of AOD abuse or
Initiation and Engagement of Alcohol and Other dependence within 14 days of the diagnosis. Prevention and Treatment of
Drug Dependence Treatment CMS137v10 N/A N/A 305 b. Percentage of patients who engaged in ongoing treatment Effective Clinical Care Process Opioid and Substance Use X -
Disorders
including two additional interventions or a medication for the
treatment of AOD abuse or dependence within 34 days of the
initiation visit. For patients who initiated treatment with a
medication, at least one of the two engagement events must be a
treatment intervention.
Percentage of women 21-64 years of age who were screened for

cervical cancer using either of the following criteria:
* Women age 21-64 who had cervical cytology performed within
Cervical Cancer Screening CMS124v10 N/A N/A 309 the last 3 years Effective Clinical Care Process Preventive Care - -
* Women age 30-64 who had cervical human papillomavirus
(HPV) testing performed within the last 5 years
Percentage of women 16-24 years of age who were identified as Community/Population

Chlamydia Screening for Women CMS153v10 N/A N/A 310 sexually active and who had at least one test for chlamydia Health Process Preventive Care - -
2021 Measures List

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Quality
NQF (Q#) Use
Percentage of patient visits for patients aged 18 years and older

Preventive Care and Screening: Screening for High seen during the measurement period who were screened for Community/Population
CMS22v10 N/A N/A 317 high blood pressure AND a recommended follow-up plan is Process Preventive Care - -
Blood Pressure and Follow-Up Documented documented, as indicated, if blood pressure is elevated or Health
hypertensive.
Falls: Screening for Future Fall Risk CMS139v10 N/A 0101 318 Percentage of patients 65 years of age and older who were Patient Safety Process Preventable Healthcare Harm X -
screened for future fall risk during the measurement period.
Percentage of patients aged 50 to 75 years of age receiving a

Appropriate Follow-Up Interval for Normal screening colonoscopy without biopsy or polypectomy who had a Communication and Care
Colonoscopy in Average Risk Patients N/A N/A 0658 320 recommended follow-up interval of at least 10 years for repeat Coordination Process Appropriate Use of Healthcare X X
colonoscopy documented in their colonoscopy report.
The Consumer Assessment of Healthcare Providers and Systems

(CAHPS) for MIPS Clinician/Group Survey is comprised of 10
Summary Survey Measures (SSMs) and measures patient
experience of care within a group practice. The NQF
endorsement status and endorsement id (if applicable) for each
SSM utilized in this measure are as follows:
•
Getting timely care, appointments, and information (Not Person and Caregiver- Patient
CAHPS for MIPs Clinician/Group Survey N/A N/A 0005 321 endorsed by NQF); Centered Experience and Engagement/Experi Functional Outcomes X -
• How well providers Communicate (Not endorsed by NQF); Outcomes ence
• Patient’s Rating of Provider (NQF endorsed #0005);
• Access to Specialists (Not endorsed by NQF);
• Health Promotion & Education (Not endorsed by NQF);
• Shared Decision Making (Not endorsed by NQF);
• Health Status/Functional Status (Not endorsed by NQF);
• Courteous and Helpful Office Staff (NQF endorsed #0005);
• Care Coordination (Not endorsed by NQF); and
• Stewardship of Patient Resources (Not endorsed by NQF).
Percentage of stress single-photon emission computed

Cardiac Stress Imaging Not Meeting Appropriate tomography (SPECT) myocardial perfusion imaging (MPI), stress
echocardiogram (ECHO), cardiac computed tomography
Use Criteria: Preoperative Evaluation in Low-Risk N/A N/A N/A 322 angiography (CCTA), or cardiac magnetic resonance (CMR) Efficiency and Cost Reduction Efficiency Appropriate Use of Healthcare X X
Surgery Patients performed in low-risk surgery patients 18 years or older for
preoperative evaluation during the 12-month submission period.
Percentage of all stress single-photon emission computed

tomography (SPECT) myocardial perfusion imaging (MPI), stress
Cardiac Stress Imaging Not Meeting Appropriate echocardiogram (ECHO), cardiac computed tomography
Use Criteria: Routine Testing After Percutaneous N/A N/A N/A 323 angiography (CCTA), and cardiovascular magnetic resonance Efficiency and Cost Reduction Efficiency Appropriate Use of Healthcare X X
Coronary Intervention (PCI) (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.
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Quality
NQF (Q#) Use
Percentage of all stress single-photon emission computed

tomography (SPECT) myocardial perfusion imaging (MPI), stress
Cardiac Stress Imaging Not Meeting Appropriate echocardiogram (ECHO), cardiac computed tomography
Use Criteria: Testing in Asymptomatic, Low-Risk N/A N/A N/A 324 angiography (CCTA), and cardiovascular magnetic resonance Efficiency and Cost Reduction Efficiency Appropriate Use of Healthcare X X
Patients (CMR) performed in asymptomatic, low coronary heart disease
(CHD) risk patients 18 years and older for initial detection and
risk assessment.
Percentage of patients aged 18 years and older with atrial

Atrial Fibrillation and Atrial Flutter: Chronic fibrillation (AF) or atrial flutter who were prescribed an FDA- Management of Chronic
Anticoagulation Therapy N/A N/A 1525 326 approved oral anticoagulant drug for the prevention of Effective Clinical Care Process Conditions - -
thromboembolism during the measurement period.
Adult Sinusitis: Antibiotic Prescribed for Acute Percentage of patients, aged 18 years and older, with a diagnosis
Viral Sinusitis (Overuse) N/A N/A N/A 331 of acute viral sinusitis who were prescribed an antibiotic within Efficiency and Cost Reduction Process Appropriate Use of Healthcare X X
10 days after onset of symptoms.
Adult Sinusitis: Appropriate Choice of Antibiotic: Percentage of patients aged 18 years and older with a diagnosis
Amoxicillin With or Without Clavulanate Prescribed N/A N/A N/A 332 of acute bacterial sinusitis that were prescribed amoxicillin, with Efficiency and Cost Reduction Process Appropriate Use of Healthcare X X
for Patients with Acute Bacterial Sinusitis or without clavulanate, as a first line antibiotic at the time of
(Appropriate Use) diagnosis.
Percentage of patients, regardless of age, who gave birth during a

Maternity Care: Elective Delivery (Without Medical 12-month period, delivered a live singleton at < 39 weeks of
Indication) at < 39 Weeks (Overuse) N/A N/A N/A 335 gestation, and had elective deliveries (without medical Patient Safety Outcome Appropriate Use of Healthcare X X
indication) by cesarean birth or induction of labor.
Percentage of patients, regardless of age, who gave birth during a

12-month period who were seen for postpartum care before or
at 12 weeks of giving birth and received the following at a
postpartum visit: breastfeeding evaluation and education,
Maternity Care: Postpartum Follow-Up and Care N/A N/A N/A 336 postpartum depression screening, postpartum glucose screening Communication and Care Process Prevention, Treatment, and X -
Coordination for gestational diabetes patients, family and contraceptive Coordination Management of Mental Health
planning counseling, tobacco use screening and cessation
education, healthy lifestyle behavioral advice, and an
immunization review and update.
The percentage of patients, regardless of age, with a diagnosis of

HIV Viral Load Suppression N/A N/A 2082 338 HIV with a HIV viral load less than 200 copies/mL at last HIV Effective Clinical Care Outcome Management of Chronic X -
viral load test during the measurement year. Conditions
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 Management of Chronic
HIV Medical Visit Frequency N/A N/A 2079 340 Efficiency and Cost Reduction Process X -
24 month measurement period, with a minimum of 60 days Conditions
between medical visits.
Rate of Carotid Artery Stenting (CAS) for

Asymptomatic Patients, Without Major N/A N/A N/A 344 Percent of asymptomatic patients undergoing CAS who are Effective Clinical Care Outcome Appropriate Use of Healthcare X -
Complications (Discharged to Home by Post- discharged to home no later than post-operative day #2.
Operative Day #2)
2021 Measures List

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Quality
NQF (Q#) Use
Percentage of patients regardless of age undergoing a total knee

Total Knee or Hip Replacement: Shared Decision- or total hip replacement with documented shared decision- Communication and Care Care is Personalized and
Making: Trial of Conservative (Non-surgical) N/A N/A N/A 350 making with discussion of conservative (non-surgical) therapy Process X -
Therapy (e.g., non-steroidal anti-inflammatory drug (NSAIDs), analgesics, Coordination Aligned with Patient’s Goals
weight loss, exercise, injections) prior to the procedure.
Percentage of patients regardless of age undergoing a total knee

Total Knee or Hip Replacement: Venous or total hip replacement who are evaluated for the presence or
Thromboembolic and Cardiovascular Risk absence of venous thromboembolic and cardiovascular risk
N/A N/A N/A 351 factors within 30 days prior to the procedure (e.g., History of Patient Safety Process Preventive Care X -
Evaluation Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE),
Myocardial Infarction (MI), Arrhythmia and Stroke).
Percentage of patients aged 18 years and older who required an

Anastomotic Leak Intervention N/A N/A N/A 354 anastomotic leak intervention following gastric bypass or Patient Safety Outcome Preventable Healthcare Harm X -
colectomy surgery.
Unplanned Reoperation within the 30 Day Percentage of patients aged 18 years and older who had any Admissions and Readmissions
Postoperative Period N/A N/A N/A 355 unplanned reoperation within the 30 day postoperative period. Patient Safety Outcome to Hospitals X -
Percentage of patients aged 18 years and older who had an

Unplanned Hospital Readmission within 30 Days of N/A N/A N/A 356 unplanned hospital readmission within 30 days of principal Effective Clinical Care Outcome Admissions and Readmissions X -
Principal Procedure procedure. to Hospitals
Surgical Site Infection (SSI) N/A N/A N/A 357 Percentage of patients aged 18 years and older who had a Effective Clinical Care Outcome Healthcare Associated X -
surgical site infection (SSI). Infections
Percentage of patients who underwent a non-emergency surgery

Patient-Centered Surgical Risk Assessment and who had their personalized risks of postoperative complications Person and Caregiver- Care is Personalized and
Communication N/A N/A N/A 358 assessed by their surgical team prior to surgery using a clinical Centered Experience and Process Aligned with Patient’s Goals X -
data-based, patient-specific risk calculator and who received Outcomes
personal discussion of those risks with the surgeon.
Percentage of computed tomography (CT) and cardiac nuclear

Optimizing Patient Exposure to Ionizing Radiation: medicine (myocardial perfusion studies) imaging reports for all
Count of Potential High Dose Radiation Imaging patients, regardless of age, that document a count of known Transfer of Health Information
Studies: Computed Tomography (CT) and Cardiac N/A N/A N/A 360 previous CT (any type of CT) and cardiac nuclear medicine Patient Safety Process and Interoperability X X
Nuclear Medicine Studies (myocardial perfusion) studies that the patient has received in
the 12-month period prior to the current study.
Percentage of final reports for CT imaging studies with a finding

of an incidental pulmonary nodule for patients aged 35 years and
Optimizing Patient Exposure to Ionizing Radiation: older that contain an impression or conclusion that includes a
Appropriateness: Follow-up CT Imaging for recommended interval and modality for follow-up (e.g., type of Communication and Care Transfer of Health Information
Incidentally Detected Pulmonary Nodules N/A N/A N/A 364 imaging or biopsy) or for no follow-up, and source of Coordination Process and Interoperability X X
According to Recommended Guidelines recommendations (e.g., guidelines such as Fleischner Society,
American Lung Association, American College of Chest
Physicians).
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Quality
NQF (Q#) Use
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
Follow-Up Care for Children Prescribed ADHD Initiation Phase. Prevention, Treatment, and
Medication (ADD) CMS136v11 N/A N/A 366 b. Percentage of children who remained on ADHD medication for Effective Clinical Care Process Management of Mental Health - -
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.
The percentage of adolescent patients 12 to 17 years of age and

adult patients 18 years of age or older with major depression or Prevention, Treatment, and
Depression Remission at Twelve Months CMS159v10 0710e 0710 370 dysthymia who reached remission 12 months (+/- 60 days) after Effective Clinical Care Outcome Management of Mental Health X -
an index event date.
Closing the Referral Loop: Receipt of Specialist Percentage of patients with referrals, regardless of age, for which Communication and Care Transfer of Health Information
Report CMS50v10 N/A N/A 374 the referring provider receives a report from the provider to Coordination Process and Interoperability X -
whom the patient was referred.
Percentage of patients 18 years of age and older who received an Person and Caregiver-
Functional Status Assessment for Total Knee CMS66v10 N/A N/A 375 elective primary total knee arthroplasty (TKA) and completed a Centered Experience and Process Functional Outcomes X -
Replacement functional status assessment within 90 days prior to the surgery
and in the 270-365 days after the surgery. Outcomes
Percentage of patients 18 years of age and older who received an

Functional Status Assessment for Total Hip elective primary total hip arthroplasty (THA) and completed a Person and Caregiver-
CMS56v10 N/A N/A 376 Centered Experience and Process Functional Outcomes X -
Replacement functional status assessment within 90 days prior to the surgery Outcomes
and in the 270-365 days after the surgery.
Percentage of patients 18 years of age and older with heart Person and Caregiver-
Functional Status Assessments for Heart Failure CMS90v11 N/A N/A 377 failure who completed initial and follow-up patient-reported Centered Experience and Process Functional Outcomes X -
functional status assessments. Outcomes
Percentage of children, 6 months - 20 years of age at the start of

the measurement period, who have had tooth decay or cavities Community/Population
Children Who Have Dental Decay or Cavities CMS75v10 N/A N/A 378 Health Outcome Preventive Care X -
Primary Caries Prevention Intervention as Offered CMS74v11 N/A N/A 379 Percentage of children, 6 months - 20 years of age, who received Effective Clinical Care Process Preventive Care - -
by Primary Care Providers, including Dentists a fluoride varnish application during the measurement period.
Percentage of patient visits for those patients aged 6 through 17

Child and Adolescent Major Depressive Disorder years with a diagnosis of major depressive disorder with an Prevention, Treatment, and
CMS177v10 1365e N/A 382 Patient Safety Process X -
(MDD): Suicide Risk Assessment assessment for suicide risk. Management of Mental Health
Percentage of individuals at least 18 years of age as of the

beginning of the performance period with schizophrenia or
Adherence to Antipsychotic Medications For schizoaffective disorder who had at least two prescriptions filled Intermediate Prevention, Treatment, and
Individuals with Schizophrenia N/A N/A 1879 383 for any antipsychotic medication and who had a Proportion of Patient Safety Outcome Management of Mental Health X -
Days Covered (PDC) of at least 0.8 for antipsychotic medications
during the performance period.
Adult Primary Rhegmatogenous Retinal Patients aged 18 years and older who had surgery for primary
Detachment Surgery: No Return to the Operating N/A N/A N/A 384 rhegmatogenous retinal detachment who did not require a Effective Clinical Care Outcome Preventable Healthcare Harm X -
Room Within 90 Days of Surgery return to the operating room within 90 days of surgery.
2021 Measures List

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Quality
NQF (Q#) Use
Adult Primary Rhegmatogenous Retinal Patients aged 18 years and older who had surgery for primary
Detachment Surgery: Visual Acuity Improvement N/A N/A N/A 385 rhegmatogenous retinal detachment and achieved an Effective Clinical Care Outcome Functional Outcomes X -
Within 90 Days of Surgery improvement in their visual acuity, from their preoperative level,
within 90 days of surgery in the operative eye.
Percentage of patients diagnosed with Amyotrophic Lateral

Amyotrophic Lateral Sclerosis (ALS) Patient Care Sclerosis (ALS) who were offered assistance in planning for end Person and Caregiver- End of Life Care According to
N/A N/A N/A 386 Centered Experience and Process X -
Preferences of life issues (e.g. advance directives, invasive ventilation, Outcomes Preferences
hospice) at least once annually.
Percentage of patients, regardless of age, who are active injection

Annual Hepatitis C Virus (HCV) Screening for N/A N/A N/A 387 drug users who received screening for HCV infection within the Effective Clinical Care Process Preventive Care - -
Patients who are Active Injection Drug Users 12-month reporting period.
Cataract Surgery: Difference Between Planned and Percentage of patients aged 18 years and older who had cataract
Final Refraction N/A N/A N/A 389 surgery performed and who achieved a final refraction within +/- Effective Clinical Care Outcome Functional Outcomes X -
1.0 diopters of their planned (target) refraction.
The percentage of discharges for patients 6 years of age and

older who were
hospitalized for treatment of selected mental illness or
intentional self-harm diagnoses and who had a follow-up visit
with a
Follow-Up After Hospitalization for Mental Illness N/A N/A 0576 391 mental health provider. Communication and Care Process Prevention, Treatment, and X -
(FUH) Coordination Management of Mental Health
Two rates are submitted:
• The percentage of discharges for which the patient received
follow-up within 30 days after discharge
• The percentage of discharges for which the patient received
follow-up within 7 days after discharge
Rate of cardiac tamponade and/or pericardiocentesis following

atrial fibrillation ablation. This measure is submitted as four
rates stratified by age and gender:
Cardiac Tamponade and/or Pericardiocentesis N/A N/A 2474 392 • Submission Age Criteria 1: Females 18-64 years of age Patient Safety Outcome Preventable Healthcare Harm X -
Following Atrial Fibrillation Ablation • Submission Age Criteria 2: Males 18-64 years of age
• Submission Age Criteria 3: Females 65 years of age and older
• Submission Age Criteria 4: Males 65 years of age and older
Infection within 180 Days of Cardiac Implantable Infection rate following CIED device implantation, replacement, Healthcare Associated
Electronic Device (CIED) Implantation, N/A N/A N/A 393 or revision. Patient Safety Outcome X -
Replacement, or Revision Infections
The percentage of adolescents 13 years of age who had one dose

of meningococcal vaccine (serogroups A, C, W, Y), one tetanus,
Immunizations for Adolescents N/A N/A N/A 394 diphtheria toxoids and acellular pertussis (Tdap) vaccine, and Community/Population Process Preventive Care - -
have completed the human papillomavirus (HPV) vaccine series Health
by their 13th birthday.
Pathology reports based on lung biopsy and/or cytology

specimens with a diagnosis of primary non-small cell lung cancer
Lung Cancer Reporting (Biopsy/Cytology classified into specific histologic type following the International Communication and Care Transfer of Health Information
N/A N/A N/A 395 Association for the Study of Lung Cancer (IASLC) guidance or Process X -
Specimens) classified as non-small cell lung cancer not otherwise specified Coordination and Interoperability
(NSCLC-NOS) with an explanation included in the pathology
report.
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Quality
NQF (Q#) Use
Pathology reports based on lung resection specimens with a

diagnosis of primary lung carcinoma that include the pT Communication and Care Transfer of Health Information
Lung Cancer Reporting (Resection Specimens) N/A N/A N/A 396 category, pN category and for non-small cell lung cancer Coordination Process and Interoperability X -
(NSCLC), histologic type.
Pathology reports for primary malignant cutaneous melanoma

Melanoma Reporting N/A N/A N/A 397 that include the pT category, thickness, ulceration and mitotic Communication and Care Process Transfer of Health Information X -
rate, peripheral and deep margin status and presence or absence Coordination and Interoperability
of microsatellitosis for invasive tumors.
Composite measure of the percentage of pediatric and adult

Optimal Asthma Control N/A N/A N/A 398 patients whose asthma is well-controlled as demonstrated by Effective Clinical Care Outcome Management of Chronic X -
one of three age appropriate patient reported outcome tools and Conditions
not at risk for exacerbation.
One-Time Screening for Hepatitis C Virus (HCV) for Percentage of patients age >= 18 years who received one-time
all Patients N/A N/A N/A 400 screening for hepatitis C virus (HCV) infection. Effective Clinical Care Process Preventive Care - -

of chronic hepatitis C cirrhosis who underwent imaging with
Hepatitis C: Screening for Hepatocellular N/A N/A N/A 401 either ultrasound, contrast enhanced CT or MRI for Effective Clinical Care Process Preventive Care - -
Carcinoma (HCC) in Patients with Cirrhosis hepatocellular carcinoma (HCC) at least once within the 12-
month submission period.
The percentage of adolescents 12 to 20 years of age with a

Tobacco Use and Help with Quitting Among primary care visit during the measurement year for whom Community/Population Prevention and Treatment of
Adolescents N/A N/A N/A 402 tobacco use status was documented and received help with Health Process Opioid and Substance Use - -
Disorders
quitting if identified as a tobacco user.
The percentage of current smokers who abstain from cigarettes Intermediate Prevention and Treatment of
Anesthesiology Smoking Abstinence N/A N/A N/A 404 prior to anesthesia on the day of elective surgery or procedure. Effective Clinical Care Outcome Opioid and Substance Use X -
Disorders
Percentage of final reports for imaging studies for patients aged

18 years and older with one or more of the following noted
incidentally with a specific recommendation for no follow‐up
imaging recommended based on radiological findings:
Appropriate Follow-up Imaging for Incidental • Cystic renal lesion that is simple appearing* (Bosniak I or II)
Abdominal Lesions N/A N/A N/A 405 • Adrenal lesion less than or equal to 1.0 cm Effective Clinical Care Process Appropriate Use of Healthcare X X
• Adrenal lesion greater than 1.0 cm but less than or equal to
4.0 cm classified as likely benign or diagnostic benign by
unenhanced CT, or washout protocol CT, or MRI with in- and
opposed-phase sequences or other equivalent institutional
imaging protocols
Percentage of final reports for computed tomography (CT), CT

angiography (CTA) or magnetic resonance imaging (MRI) or
Appropriate Follow-up Imaging for Incidental magnetic resonance angiogram (MRA) studies of the chest or
Thyroid Nodules in Patients N/A N/A N/A 406 neck for patients aged 18 years and older with no known thyroid Effective Clinical Care Process Appropriate Use of Healthcare X X
disease with a thyroid nodule < 1.0 cm noted incidentally with
follow-up imaging recommended
2021 Measures List

Page 46 of 119
Quality
NQF (Q#) Use
Clinical Outcome Post Endovascular Stroke Percentage of patients with a Modified Rankin Score (mRS) score Management of Chronic
Treatment N/A N/A N/A 409 of 0 to 2 at 90 days following endovascular stroke intervention. Effective Clinical Care Outcome Conditions X -
Percentage of psoriasis vulgaris patients receiving systemic

medication who meet minimal physician-or patient- reported
Psoriasis: Clinical Response to Systemic disease activity levels. It is implied that establishment and Person and Caregiver- Management of Chronic
N/A N/A N/A 410 maintenance of an established minimum level of disease control Centered Experience and Outcome X -
Medications as measured by physician-and/or patient-reported outcomes Outcomes Conditions
will increase patient satisfaction with and adherence to
treatment.
Door to Puncture Time for Endovascular Stroke Percentage of patients undergoing endovascular stroke Intermediate Patient Focused Episode of
N/A N/A N/A 413 treatment who have a door Effective Clinical Care X -
Treatment to puncture time of 90 minutes or less. Outcome Care
Emergency Medicine: Emergency Department Percentage of emergency department visits for patients aged 18
years and older who presented with a minor blunt head trauma
Utilization of CT for Minor Blunt Head Trauma for N/A N/A N/A 415 who had a head CT for trauma ordered by an emergency care Efficiency and Cost Reduction Efficiency Appropriate Use of Healthcare X -
Patients Aged 18 Years and Older provider who have an indication for a head CT.
Percentage of emergency department visits for patients aged 2

Emergency Medicine: Emergency Department through 17 years who presented with a minor blunt head trauma
Utilization of CT for Minor Blunt Head Trauma for N/A N/A N/A 416 who had a head CT for trauma ordered by an emergency care
provider who are classified as low risk according to the Pediatric Efficiency and Cost Reduction Efficiency Appropriate Use of Healthcare X X
Patients Aged 2 Through 17 Years Emergency Care Applied Research Network (PECARN)
prediction rules for traumatic brain injury.
The percentage of women 50–85 years of age who suffered a

Osteoporosis Management in Women Who Had a fracture and who had either a bone mineral density (BMD) test Management of Chronic
Fracture N/A N/A 0053 418 or prescription for a drug to treat osteoporosis in the six months Effective Clinical Care Process Conditions - -
after the fracture.
Percentage of patients for whom imaging of the head (CT or MRI)

Overuse of Imaging for the Evaluation of Primary N/A N/A N/A 419 is obtained for the evaluation of primary headache when clinical Efficiency and Cost Reduction Process Appropriate Use of Healthcare X X
Headache
indications are not present.
Percentage of patients treated for varicose veins (CEAP C2-S)

who are treated with saphenous ablation (with or without Patient-Reported
Varicose Vein Treatment with Saphenous Ablation: Outcome-Based
Outcome Survey N/A N/A N/A 420 adjunctive tributary treatment) that report an improvement on a Effective Clinical Care Performance Functional Outcomes X -
disease specific patient reported outcome survey instrument Measure
after treatment.
Percentage of patients in whom a retrievable IVC filter is placed

Appropriate Assessment of Retrievable Inferior who, within 3 months post-placement, have a documented
N/A N/A N/A 421 assessment for the appropriateness of continued filtration, Effective Clinical Care Process Preventable Healthcare Harm - -
Vena Cava (IVC) Filters for Removal device removal or the inability to contact the patient with at least
two attempts.
Performing Cystoscopy at the Time of Percentage of patients who undergo cystoscopy to evaluate for
Hysterectomy for Pelvic Organ Prolapse to Detect N/A N/A 2063 422 lower urinary tract injury at the time of hysterectomy for pelvic Patient Safety Process Preventable Healthcare Harm X -
Lower Urinary Tract Injury organ prolapse.
2021 Measures List

Page 47 of 119
Quality
NQF (Q#) Use
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
Perioperative Temperature Management N/A N/A N/A 424 temperature greater than or equal to 35.5 degrees Celsius (or Patient Safety Outcome Preventable Healthcare Harm X -
95.9 degrees Fahrenheit) was achieved within the 30 minutes
immediately before or the 15 minutes immediately after
anesthesia end time.
The rate of screening and surveillance colonoscopies for which Transfer of Health Information
Photodocumentation of Cecal Intubation N/A N/A N/A 425 photodocumentation of at least two landmarks of cecal Effective Clinical Care Process and Interoperability - -
intubation is performed to establish a complete examination.
Percentage of patients, aged 18 years and older, who undergo a

procedure under an inhalational general anesthetic, AND who
Prevention of Post-Operative Nausea and Vomiting N/A N/A N/A 430 have three or more risk factors for post-operative nausea and Patient Safety Process Preventive Care X -
(PONV) – Combination Therapy vomiting (PONV), who receive combination therapy consisting of
at least two prophylactic pharmacologic antiemetic agents of
different classes preoperatively and/or intraoperatively.
Percentage of patients aged 18 years and older who were

screened for unhealthy alcohol use using a systematic screening Prevention and Treatment of
Preventive Care and Screening: Unhealthy Alcohol N/A N/A 2152 431 method at least once within the last 12 months AND who Community/Population Process Opioid and Substance Use - -
Use: Screening & Brief Counseling received brief counseling if identified as an unhealthy alcohol Health Disorders
user.
Proportion of Patients Sustaining a Bladder Injury Percentage of patients undergoing pelvic organ prolapse repairs
N/A N/A N/A 432 who sustain an injury to the bladder recognized either during or Patient Safety Outcome Preventable Healthcare Harm X -
at the Time of any Pelvic Organ Prolapse Repair within 30 days after surgery.
Percentage of patients undergoing surgical repair of pelvic organ

Proportion of Patients Sustaining a Bowel Injury at N/A N/A N/A 433 prolapse that is complicated by a bowel injury at the time of Patient Safety Outcome Preventable Healthcare Harm X -
the time of any Pelvic Organ Prolapse Repair index surgery that is recognized intraoperatively or within 30
days after surgery.
Percentage of final reports for patients aged 18 years and older

undergoing computed tomography (CT) with documentation that
one or more of the following dose reduction techniques were
Radiation Consideration for Adult CT: Utilization of N/A N/A N/A 436 used: Effective Clinical Care Process Appropriate Use of Healthcare - -
Dose Lowering Techniques
• Automated exposure control.
• Adjustment of the mA and/or kV according to patient size.
• Use of iterative reconstruction technique.
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: *All patients who were
previously diagnosed with or currently have an active diagnosis
Statin Therapy for the Prevention and Treatment of of clinical atherosclerotic cardiovascular disease (ASCVD), Management of Chronic
Cardiovascular Disease CMS347v5 N/A N/A 438 including an ASCVD procedure; OR *Patients aged >=20 years Effective Clinical Care Process Conditions - -
who have ever had a low-density lipoprotein cholesterol (LDL-C)
level >=190 mg/dL or were previously diagnosed with or
currently have an active diagnosis of familial
hypercholesterolemia; OR *Patients aged 40-75 years with a
diagnosis of diabetes
The percentage of screening colonoscopies performed in patients

Age Appropriate Screening Colonoscopy N/A N/A N/A 439 greater than or equal to 86 years of age from January 1 to Efficiency and Cost Reduction Efficiency Appropriate Use of Healthcare X X
December 31.
2021 Measures List

Page 48 of 119
Quality
NQF (Q#) Use
Percentage of biopsies with a diagnosis of cutaneous Basal Cell

Carcinoma (BCC) and Squamous Cell Carcinoma (SCC), or
Skin Cancer: Biopsy Reporting Time – Pathologist N/A N/A N/A 440 melanoma (including in situ disease) in which the pathologist Communication and Care Process Transfer of Health Information X -
to Clinician communicates results to the clinician within 7 days from the time Coordination and Interoperability
when the tissue specimen was received by the pathologist.
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:
Ischemic Vascular Disease (IVD) All or None • Most recent blood pressure (BP) measurement is less than or Intermediate Management of Chronic
Outcome Measure (Optimal Control) N/A N/A N/A 441 Effective Clinical Care Outcome Conditions X -
equal to 140/90 mm Hg -- AND
• Most recent tobacco status is Tobacco Free -- AND
• Daily Aspirin or Other Antiplatelet Unless Contraindicated --
AND
• Statin Use Unless Contraindicated
Non-Recommended Cervical Cancer Screening in The percentage of adolescent females 16–20 years of age who
Adolescent Females N/A N/A N/A 443 were screened unnecessarily for cervical cancer. Patient Safety Process Appropriate Use of Healthcare X X
Percent of patients aged 18 years and older undergoing isolated

CABG who die, including both all deaths occurring during the
Risk-Adjusted Operative Mortality for Coronary N/A N/A 0119 445 hospitalization in which the CABG was performed, even if after Effective Clinical Care Outcome Risk Adjusted Mortality X -
Artery Bypass Graft (CABG)
30 days, and those deaths occurring after discharge from the
hospital, but within 30 days of the procedure.
Percentage of patients, aged 18 years and older, who undergo

Appropriate Workup Prior to Endometrial Ablation N/A N/A N/A 448 endometrial sampling or hysteroscopy with biopsy and results Communication and Care Process Appropriate Use of Healthcare X -
Coordination
are documented before undergoing an endometrial ablation.
Appropriate Treatment for Patients with Stage I Percentage of female patients aged 18 to 70 with stage I (T1c) –
(T1c) – III HER2 Positive Breast Cancer N/A N/A 1858 450 III HER2 positive breast cancer for whom appropriate treatment Effective Clinical Care Process Appropriate Use of Healthcare X X
is initiated.
RAS (KRAS and NRAS) Gene Mutation Testing Percentage of adult patients (aged 18 or over) with metastatic
Performed for Patients with Metastatic Colorectal colorectal cancer who receive anti-epidermal growth factor
Cancer who receive Anti-epidermal Growth Factor N/A N/A 1859 451 receptor monoclonal antibody therapy for whom RAS (KRAS and Effective Clinical Care Process Appropriate Use of Healthcare - -
Receptor (EGFR) Monoclonal Antibody Therapy NRAS) gene mutation testing was performed.
Patients with Metastatic Colorectal Cancer and RAS Percentage of adult patients (aged 18 or over) with metastatic
(KRAS or NRAS) Gene Mutation Spared Treatment
with Anti-epidermal Growth Factor Receptor N/A N/A 1860 452 colorectal cancer and RAS (KRAS or NRAS) gene mutation spared Patient Safety Process Appropriate Use of Healthcare X X
(EGFR) Monoclonal Antibodies treatment with anti-EGFR monoclonal antibodies.
Percentage of Patients Who Died from Cancer

Receiving Chemotherapy in the Last 14 Days of Life N/A N/A 0210 453 Percentage of patients who died from cancer receiving Effective Clinical Care Process Appropriate Use of Healthcare X X
chemotherapy in the last 14 days of life.
(lower score – better)
2021 Measures List

Page 49 of 119
Quality
NQF (Q#) Use
Percentage of Patients Who Died from Cancer Percentage of patients who died from cancer admitted to the ICU
Admitted to the Intensive Care Unit (ICU) in the N/A N/A 0213 455 in the last 30 days of life. Effective Clinical Care Outcome Appropriate Use of Healthcare X X
Last 30 Days of Life (lower score – better)
Percentage of Patients Who Died from Cancer Percentage of patients who died from cancer, and admitted to End of Life Care According to
Admitted to Hospice for Less than 3 days (lower N/A N/A 0216 457 hospice and spent less than 3 days there. Effective Clinical Care Outcome Preferences X X
score – better)
For patients 18 years of age or older who had a lumbar

discectomy/laminectomy procedure, back pain is rated by the Person and Caregiver- Patient-Reported
Outcome-Based
Back Pain After Lumbar Discectomy/Laminectomy N/A N/A N/A 459 patients as less than or equal to 3.0 OR an improvement of 5.0 Centered Experience and Performance Functional Outcomes X -
points or greater on the Visual Analog Scale (VAS) Pain scale at Outcomes Measure
three months (6 to 20 weeks) postoperatively.
For patients 18 years of age or older who had a lumbar fusion

procedure, back pain is rated by the patient as less than or equal Person and Caregiver- Patient-Reported
to 3.0 OR an improvement of 5.0 points or greater on the Visual Outcome-Based
Back Pain After Lumbar Fusion N/A N/A N/A 460 Analog Scale (VAS) Pain scale at one year (9 to 15 months) Centered Experience and Performance Functional Outcomes X -
postoperatively. Outcomes Measure
For patients 18 years of age or older who had a lumbar

discectomy/laminectomy procedure, leg pain is rated by the Person and Caregiver- Patient-Reported
Outcome-Based
Leg Pain After Lumbar Discectomy/Laminectomy N/A N/A N/A 461 patient as less than or equal to 3.0 OR an improvement of 5.0 Centered Experience and Performance Functional Outcomes X -
points or greater on the Visual Analog Scale (VAS) Pain scale at Outcomes Measure
three months (6 to 20 weeks) postoperatively.
Patients determined as having prostate cancer who are currently

Bone Density Evaluation for Patients with Prostate starting or undergoing androgen deprivation therapy (ADT), for
an anticipated period of 12 months or greater and who receive Management of Chronic
Cancer and Receiving Androgen Deprivation CMS645v5 N/A N/A 462 an initial bone density evaluation. The bone density evaluation Effective Clinical Care Process Conditions - -
Therapy
must be prior to the start of ADT or within 3 months of the start
of ADT.
Percentage of patients aged 3 through 17 years, who undergo a

procedure under general anesthesia in which an inhalational
anesthetic is used for maintenance AND who have two or more
Prevention of Post-Operative Vomiting (POV) – N/A N/A N/A 463 risk factors for post-operative vomiting (POV), who receive Patient Safety Process Preventive Care X -
Combination Therapy (Pediatrics) combination therapy consisting of at least two prophylactic
pharmacologic anti-emetic agents of different classes
preoperatively and/or intraoperatively.
Percentage of patients aged 2 months through 12 years with a

Otitis Media with Effusion: Systemic Antimicrobials N/A N/A 0657 464 diagnosis of OME who were not prescribed systemic Effective Clinical Care Process Appropriate Use of Healthcare X X
- Avoidance of Inappropriate Use
antimicrobials.
Uterine Artery Embolization Technique: The percentage of patients with documentation of angiographic
Documentation of Angiographic Endpoints and N/A N/A N/A 465 endpoints of embolization AND the documentation of Patient Safety Process Transfer of Health Information X -
embolization strategies in the presence of unilateral or bilateral and Interoperability
Interrogation of Ovarian Arteries absent uterine arteries.
Continuity of Pharmacotherapy for Opioid Use Percentage of adults aged 18 years and older with Prevention and Treatment of
Disorder (OUD) N/A N/A N/A 468 pharmacotherapy for opioid use disorder (OUD) who have at Effective Clinical Care Process Opioid and Substance Use X X
least 180 days of continuous treatment. Disorders
2021 Measures List

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Quality
NQF (Q#) Use
For patients 18 years of age and older who had a lumbar fusion
procedure, functional status is rated by the patient as less than or Person and Caregiver- Patient-Reported
Functional Status After Lumbar Fusion N/A N/A N/A 469 equal to 22 OR an improvement of 30 points or greater on the Centered Experience and Outcome-Based Functional Outcomes X -
Performance
Oswestry Disability Index (ODI version 2.1a) at one year (9 to 15 Outcomes Measure
months) postoperatively.
For patients age 18 and older who had a primary total knee Patient-Reported
replacement procedure, functional status is rated by the patient Person and Caregiver-
Functional Status After Primary Total Knee N/A N/A N/A 470 as greater than or equal to 37 on the Oxford Knee Score (OKS) or Centered Experience and Outcome-Based Functional Outcomes X -
Replacement a 71 or greater on the KOOS, JR tool at one year (9 to 15 months) Outcomes Performance
Measure
postoperatively.
For patients age 18 and older who had lumbar

discectomy/laminectomy procedure, functional status is rated by Person and Caregiver- Patient-Reported
Functional Status After Lumbar N/A N/A N/A 471 the patient as less than or equal to 22 OR an improvement of 30 Centered Experience and Outcome-Based Functional Outcomes X -
Discectomy/Laminectomy Performance
points or greater on the Oswestry Disability Index (ODI version Outcomes Measure
2.1a) at three months (6 to 20 weeks) postoperatively.
Percentage of female patients 50 to 64 years of age without

Appropriate Use of DXA Scans in Women Under 65 select risk factors for osteoporotic fracture who received an
Years Who Do Not Meet the Risk Factor Profile for CMS249v4 3475e N/A 472 order for a dual-energy x-ray absorptiometry (DXA) scan during Efficiency and Cost Reduction Process Appropriate Use of Healthcare X X
Osteoporotic Fracture
the measurement period.
For patients 18 years of age or older who had a lumbar fusion

procedure, leg pain is rated by the patient as less than or equal to Patient-Reported
3.0 OR an improvement of 5.0 points or greater on the Visual Person and Caregiver- Outcome-Based
Leg Pain After Lumbar Fusion N/A N/A N/A 473 Analog Scale (VAS) Pain scale at one year (9 to 15 months) Centered Experience and Performance Functional Outcomes X -
Outcomes
postoperatively. Measure
2021 Measures List

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Collection Type(s)
Medicare CMS Administrative MIPS Allergy/ Certified Nurse Chiropractic Clinical Social Diagnostic
Primary Measure Steward Part B Claims CSV eCQM Web Claims CQM Immunology Anesthesiology Audiology Cardiology Midwife Medicine Work Dentistry Dermatology Radiology
Interface
National Committee for Quality

Assurance X - X X - X - - - - - - - - - -
American Heart Association - - X - - X - - - X - - - - - -
American Heart Association - - - - - X - - - X - - - - - -
National Committee for Quality - - X - - - - - - - - - - - - -

Assurance
American Academy of
- - X - - - - - - - - - - - - -
Ophthalmology
American Academy of
Ophthalmology - - - - - X - - - - - - - - - -
American Academy of
Ophthalmology - - X - - X - - - - - - - - - -
2021 Measures List

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CMS
Primary Measure Steward Medicare CSV eCQM Web Administrative MIPS Allergy/ Anesthesiology Audiology Cardiology Certified Nurse Chiropractic Clinical Social Dentistry Dermatology Diagnostic
Part B Claims Interface Claims CQM Immunology Midwife Medicine Work Radiology
National Committee for Quality X - - - - X - - - - - - - - - -

Assurance
National Committee for Quality X - - - - X - - - - - - - - - -

Assurance
National Committee for Quality X - - - - X - - - X X - X - - -

Assurance
National Committee for Quality - - - - - X - - - - - - - - - -

Assurance

Assurance
American Thoracic Society - - - - - X - - - - - - - - - -
National Committee for Quality - - X - - X - - - - - - - - - -

Assurance

Assurance - - X - - X - - - - - - - - - -
American Society of
Anesthesiologists X - - - - X - X - - - - - - - -
American Academy of
Otolaryngology – Head and - - - - - X - - - - - - - - - -
Neck Surgery
Centers for Medicare &

Medicaid Services - - X - - X - - - - - - - - - -
2021 Measures List

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CMS
American Urological
Association Education and - - - - - X - - - - - - - - - -
Research
Mathematica - - X - - - - - - - - - - - - -
National Committee for Quality X - X X - X X - - X X - - - - -

Assurance

Assurance X - X - - X X - - X - - - - - -
National Committee for Quality X - X X - X - - - - - - - - - -

Assurance

Assurance X - X X - X - - - - - - - - - -

Assurance - - - - - X - - - - - - - - - -
National Committee for Quality X - X - - X - - - - - - - - - -

Assurance
National Committee for Quality - - X - - X - - - - - - - - - -

Assurance
American Podiatric Medical

Association - - - - - X - - - - - - - - - -
American Podiatric Medical

Association - - - - - X - - - - - - - - - -
2021 Measures List

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CMS

Medicaid Services X - X - - X - - - X - - - - - -

Medicaid Services X - X - - X X - X X X - X - X -
Centers for Medicare & X - X X - X - - X - - - X - - -

Medicaid Services
American Academy of
Dermatology - - - - - X - - - - - - - - X -
American Academy of - - - - - X - - - - - - - - X -
Dermatology
American Academy of X - - - - X - - - - - - - - - -
Ophthalmology
American Society of Clinical

Oncology - - X - - X - - - - - - - - - -

Oncology - - - - - X - - - - - - - - - -
American College of Radiology X - - - - X - - - - - - - - - X
2021 Measures List

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CMS
Society of Nuclear Medicine X - - - - X - - - - - - - - - X

and Molecular Imaging
National Committee for Quality X - - - - X - - X - - - - - - -

Assurance
Society of Thoracic Surgeons - - - - - X - - - - - - - - - -
American College of
Rheumatology - - - - - X - - - - - - - - X -
American College of - - - - - X - - - - - - - - - -
Rheumatology
American College of - - - - - X - - - - - - - - - -
Rheumatology
American College of
Rheumatology - - - - - X - - - - - - - - - -

Medicaid Services X - - - - X - - X - - - X - - -

Medicaid Services - - - - - X - - X - - X - - - -
American Gastroenterological
Association - - - - - X - - - - - - - - - -
American Heart Association - - - - - X - - - - - - - - - -
2021 Measures List

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CMS
American Academy of
- - X - - X - - - - - - - - - -
Ophthalmology
Health Resources and Services

Administration - - - - - X - - - - - - - - - -
FOTO Patient Outcomes - - - - - X - - - - - X - - - -
2021 Measures List

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CMS

Assurance X - X X - X X - X X X - X - X -
National Committee for Quality X - X X - X - - - X - - - - - -

Assurance
National Committee for Quality - - X - - X X - - X - - - - - -

Assurance

Assurance - - X - - - - - - - - - - - - -
2021 Measures List

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CMS
National Committee for Quality - - X - - - - - - - - - - - - -

Assurance
College of American
Pathologists X - - - - X - - - - - - - - - -
College of American X - - - - X - - - - - - - - - -
Pathologists
American College of Emergency - - - - - X - - - - - - - - - -

Physicians
Society for Vascular Surgeons - - - - - X - - - - - - - - - -
Audiology Quality Consortium X - - - - X - - X - - - - - - -
2021 Measures List

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CMS
American Society of Breast - - - - - X - - - - - - - - - -

Surgeons
Dermatology
American Academy of
Neurology - - - - - X - - - - - - - - - -
Association - - - - - X - - - - - - - - - -
American Academy of Sleep

Medicine - - - - - X - - - - - - - - - -
American Academy of Sleep

Medicine - - - - - X - - - - - - - - - -
American Academy of
Neurology - - X - - - - - - - - - X - - -
American Academy of
Neurology/American - - - - - X - - - - - - X - - -
Psychiatric Association
American Academy of
American Academy of
2021 Measures List

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CMS
American Academy of
American Academy of - - - - - X - - - - - - - - - -
Neurology
American Academy of
Neurology - - - - - X - - - - - - - - - -
Neurology
Ophthalmology
Ophthalmology

Assurance - - X - - - - - - - - - - - - -

Assurance - - X - - - - - - - - - - - - -

Assurance - - X - - - - - - - - - - - - -
2021 Measures List

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CMS

Medicaid Services X - X - - X X - - X - - - - X -
National Committee for Quality - - X X - - - - X - - - - - - -

Assurance
Association X - - - - X - - - - - - - - - -
Agency for Healthcare Research - X - - - - - - - - - - - - - -

& Quality
American College of Cardiology - - - - - X - - - X - - - - - -
2021 Measures List

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CMS
American Academy of
Otolaryngology – Head and - - - - - X X - - - - - - - - -
Neck Surgery Foundation
American Academy of
Otolaryngology – Head and - - - - - X X - - - - - - - - -

Medicaid Services - - - - - X - - - - X - - - - -
Centers for Medicare & - - - - - X - - - - X - - - - -

Medicaid Services
Health Resources and Services - - - - - X X - - - - - - - - -

Administration
Health Resources and Services

- - - - - X X - - - - - - - - -
Administration
Society for Vascular Surgeons - - - - - X - - - X - - - - - -
2021 Measures List

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CMS
American Association of Hip - - - - - X - - - - - - - - - -

and Knee Surgeons
American Association of Hip

and Knee Surgeons - - - - - X - - - - - - - - - -
American College of Surgeons - - - - - X - - - - - - - - - -
American College of Radiology - - - - - X - - - - - - - - - X
American College of Radiology - - - - - X - - - - - - - - - X
2021 Measures List

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CMS

Assurance - - X - - - - - - - - - - - - -
Minnesota Community
Measurement - - X X - X - - - - - - X - - -

Medicaid Services - - X - - X X - - X - - - - X -
Centers for Medicare & - - X - - - - - - - - - - - - -

Medicaid Services

Medicaid Services - - X - - - - - - - - - - - - -
Centers for Medicare & - - X - - - - - - - - - - - - -

Medicaid Services

Medicaid Services - - X - - - - - - - - - - X - -
Centers for Medicare & - - X - - - - - - - - - - X - -

Medicaid Services
Mathematica - - X - - - - - - - - - X - - -

Medicaid Services - - - - - X - - - - - - X - - -
American Academy of
Ophthalmology - - - - - X - - - - - - - - - -
2021 Measures List

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CMS
Ophthalmology
American Academy of
Neurology - - - - - X - - - - - - - - - -
American Gastroenterological - - - - - X - - - - - - - - - -
Association
American Academy of
Ophthalmology - - - - - X - - - - - - - - - -

Assurance
American College of Cardiology - - - - - X - - - - - - - - - -
American College of Cardiology - - - - - X - - - - - - - - - -

Assurance
Pathologists
2021 Measures List

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CMS
College of American
Pathologists X - - - - X - - - - - - - - - -
Pathologists
Minnesota Community - - - - - X X - - - - - - - - -
Measurement
Association - - - - - X - - - - - - - - - -
American Gastroenterological - - - - - X - - - - - - - - - -
Association

Assurance - - - - - X X - - X - - X - X -
American Society of
Anesthesiologists - - - - - X - X - - - - - - - -
2021 Measures List

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CMS
Society of Interventional
Radiology - - - - - X - - - - - - - - - -
Dermatology
Society of Interventional - - - - - X - - - - - - - - - -
Radiology
American College of Emergency

Physicians - - - - - X - - - - - - - - - -
American College of Emergency X - - - - X - - - - - - - - - -

Physicians

Assurance X - - - - X - - - - - - - - - -
Neurology
Society of Interventional
Radiology - - - - - X - - - - - - - - - -
Radiology
American Urogynecologic X - - - - X - - - - - - - - - -
Society
2021 Measures List

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CMS
American Society of - - - - - X - X - - - - - - - -
Anesthesiologists
American Society for

Gastrointestinal Endoscopy - - - - - X - - - - - - - - - -
Anesthesiologists
National Committee for Quality - - - - - X - - - X X - X - - -

Assurance
American Urogynecologic - - - - - X - - - - - - - - - -
Society
American Urogynecologic - - - - - X - - - - - - - - - -
Society
American College of Radiology/

American Medical Association/ X - - - - X - - - - - - - - - X
Assurance

Medicaid Services - - X X - X - - - X - - - - - -
Association - - - - - X - - - - - - - - - -
2021 Measures List

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CMS
Dermatology
Wisconsin Collaborative for

Healthcare Quality - - - - - X - - - X - - - - - -

Assurance - - - - - X - - - - - - - - - -
Centers for Medicare & - - - - - X - - - - - - - - - -

Medicaid Services

Oncology - - - - - X - - - - - - - - - -

Oncology - - - - - X - - - - - - - - - -

Oncology - - - - - X - - - - - - - - - -
American Society of Clinical - - - - - X - - - - - - - - - -

Oncology
2021 Measures List

Page 70 of 119
CMS

Oncology - - - - - X - - - - - - - - - -

Oncology - - - - - X - - - - - - - - - -
Minnesota Community
Measurement - - - - - X - - - - - - - - - -
Minnesota Community
Measurement - - - - - X - - - - - - - - - -
Minnesota Community
Measurement - - - - - X - - - - - - - - - -
Oregon Urology Institute - - X - - - - - - - - - - - - -
Anesthesiologists
American Academy of
Otolaryngology – Head and - - - - - X - - - - - - - - - -
Radiology
University of Southern
California - - - - - X - - - - - - - - - -
2021 Measures List

Page 71 of 119
CMS
Minnesota Community - - - - - X - - - - - - - - - -
Measurement
Measurement
Measurement

Medicaid Services - - X - - - - - - - - - - - - -
Minnesota Community
Measurement - - - - - X - - - - - - - - - -
2021 Measures List

Page 72 of 119
Specialty Measure Sets
Electro-
physiology Emergency Family Gastro- General Infectious Internal Interventional Mental/ Nutrition/
Cardiac Medicine Endocrinology Medicine enterology Surgery Geriatrics Hospitalists Disease Medicine Radiology Behavioral Nephrology Neurology Neurosurgical Dietician
Health
Specialist
- - X X - - - - - X - - X - - -
- - - X - - - X - X - - - - - -
- - - X - - - - - X - - - - - -
- - - X - - - - - X - - - - - -
- - - X - - - X - X - - - - - -
- - - X - - - - - X - X - - - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
2021 Measures List

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Electro- Mental/
physiology Emergency Endocrinology Family Gastro- General Geriatrics Hospitalists Infectious Internal Interventional Behavioral Nephrology Neurology Neurosurgical Nutrition/
Cardiac Medicine Medicine enterology Surgery Disease Medicine Radiology Health Dietician
Specialist
- - - X - - - - - X - - - - - -
- - X X - - X - - X - - - - - -
- - - X X X X X - X - - X X - -
- - - X - - X - - X - - - - - -
- - - X - - X - - X - - - - - -
- - - - - - - - - - - - - - - -
- - - X - - - - - - - - - - - -
- X - X - - - - - - - - - - - -
- - - - - - - X - - X - - - - -
- X - X - - - - - X - - - - - -
- - - - - - - - - - - - - - - -
2021 Measures List

Page 74 of 119
Electro- Mental/
Specialist
- - - - - - - - - - - - - - - -
- X - X - - - - - X - X - - - -
- - X X - - X - X X - - X - - -
- - X X - - X - X X - - X - - -
- - - X - - - - - - - - - - - -
- - - X - - - - - - - - - - - -
- X - X - - - - - X - - - - - -
- - X X - - - - - X - - - - - -
- - X - - - - - - - - - - - - -
- - X X - - - - - X - - X - - -
- - X X - - - - - X - - - - - X
- - - - - - - - - - - - - - - X
2021 Measures List

Page 75 of 119
Electro- Mental/
Specialist
- - X X X X - - - X - X - - - X
- - X X X X X X X X - X X X X X
- - X X - - - - - X - X - X - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - X - - - - -
2021 Measures List

Page 76 of 119
Electro- Mental/
Specialist
- - - - - - - - - - - - - - - -
- - - X - - X - - X - - - X - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
- - - X - - X - - X - X - X - X
- - - X - - - - - - - - X - - -
- - - - X - - - - - - - - - - -
- X - - - - - - - - - - - - X -
2021 Measures List

Page 77 of 119
Electro- Mental/
Specialist
- - - - - - - - - - - - - - - -
- - - - - - - - X - - - - - - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
2021 Measures List

Page 78 of 119
Electro- Mental/
Specialist
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
- - X X X X - - - X - X - X X -
- - X X - - - - - X - - - - - -
- - - X - - X - - X - - - - - -
- - - - - - - - - - - - - - - X
2021 Measures List

Page 79 of 119
Electro- Mental/
Specialist
- - - - - - - - - - - - - - - -
- - - X - - - - - X - - - - - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
- X - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - X -
- - - - - - - - - - - - - - - -
2021 Measures List

Page 80 of 119
Electro- Mental/
Specialist
- - - - - X - - - - - - - - - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - X - -
- - - - X - - - - - - - - - - -
- - - - - - - - - X - - - X - -
- - - - - - - - - X - - - X - -
- - - - - - X - - - - X - X - -
- - - - - - X - - - - X - X - -
- - - - - - X - - - - X - X - -
- - - - - - X - - - - X - X - -
2021 Measures List

Page 81 of 119
Electro- Mental/
Specialist
- - - - - - X - - - - X - X - -
- - - - - - - - - - - - - X - -
- - - - - - - - - - - - - X - -
- - - - - - - - - - - - - X - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
- - - X - - - - - X - - - - - -
- - - X - - - - - X - - - - - -
- - - - - - - - - - - - - - - -
2021 Measures List

Page 82 of 119
Electro- Mental/
Specialist
- X - X X X - - - X - X X X - -
- - - X - - - - - X - - X - - -
- - - - X - - - - - - - - - - -
- - - X - - - - - X - - - - - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
2021 Measures List

Page 83 of 119
Electro- Mental/
Specialist
- - - - - - - - - - - - - - - -
- - - X - - - - - X - - - - - -
- X - X - - - - - X - - - - - -
- X - X - - - - - X - - - - - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
- - - X - - - - X X - - - - - -
- - - - - - - - X - - - - - - -
- - - - - - - - - - - - - - X -
2021 Measures List

Page 84 of 119
Electro- Mental/
Specialist
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
- - - - - X - - - - - - - - - -
- - - - - X - - - - - - - - - -
- - - - - X - - - - - - - - - -
- - - - - X - - - - - - - - - -
- - - - - X - - - - - - - - - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
2021 Measures List

Page 85 of 119
Electro- Mental/
Specialist
- - - - - - - - - - - X - - - -
- - - X - - X - - X - X - - - -
- - X X X X - - - X X - - X - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
- - - X - - - - - X - - - - - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - X - - - -
- - - X - - - - - X - X - - - -
- - - - - - - - - - - - - - - -
2021 Measures List

Page 86 of 119
Electro- Mental/
Specialist
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - X - -
- - - X - - - - - X - - - - - -
- - - - - - - - - - - - - - - -
- - - - - - - - - X - X - - - -
X - - - - - - - - - - - - - - -
X - - - - - - - - - - - - - - -
- - - X - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
2021 Measures List

Page 87 of 119
Electro- Mental/
Specialist
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
- - - X - - - - - X - - - - - -
- - - X - - - - - X - - X - - -
- - - X X - - - - X - - - - - -
- - - X X X - - - X - X - X - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
2021 Measures List

Page 88 of 119
Electro- Mental/
Specialist
- - - - - - - - - - X - - - X -
- - - - - - - - - - - - - - - -
- - - - - - - - - - X - - - X -
- X - - - - - - - - - - - - - -
- X - - - - - - - - - - - - - -
- - X X - - - - - X - - - - - -
- - - - - - - - - - - - - X - -
- - - - - - - - - - X - - - - -
- - - - - - - - - - X - - - - -
- - - - - - - - - - - - - - - -
2021 Measures List

Page 89 of 119
Electro- Mental/
Specialist
- - - - - - - - - - - - - - - -
- - - - X - - - - - - - - - - -
- - - - - - - - - - - - - - - -
- - - X X - - - - X - X - X - X
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
- - X X - - - - - X - - - - - -
- - - - X - - - - - - - - - - -
2021 Measures List

Page 90 of 119
Electro- Mental/
Specialist
- - - - - - - - - - - - - - - -
- - - X - - - - - X - - - - - -
- - - X - - - - - X - - - - - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
2021 Measures List

Page 91 of 119
Electro- Mental/
Specialist
- - - - - - X - - - - - - - - -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - X -
- - - - - - - - - - - - - - X -
- - - - - - - - - - - - - - X -
- - X - - - - - - - - - - - - -
- - - - - - - - - - - - - - - -
- - - X - - - - - - - - - - - -
- - - - - - - - - - X - - - - -
- - - X - - - - - X - X - - - -
2021 Measures List

Page 92 of 119
Electro- Mental/
Specialist
- - - - - - - - - - - - - - X -
- - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - X -
- - - X - - - - - X - - - - - -
- - - - - - - - - - - - - - X -
2021 Measures List

Page 93 of 119
Physical
Obstetrics/ Oncology/ Orthopedic Physical Therapy/ Plastic Preventive Radiation
Gynecology Hematology Ophthalmology Surgery Otolaryngology Pathology Pediatrics Medicine Occupational Surgery Podiatry Medicine Pulmonology Oncology
Therapy
- - - - - - - - - - - X - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
- - X - - - - - - - - - - -
- - X - - - - - - - - - - -
- - X - - - - - - - - - - -
2021 Measures List

Page 94 of 119
Physical
Obstetrics/ Oncology/ Ophthalmology Orthopedic Otolaryngology Pathology Pediatrics Physical Therapy/ Plastic Podiatry Preventive Pulmonology Radiation
Gynecology Hematology Surgery Medicine Occupational Surgery Medicine Oncology
Therapy
- - - X - - - - - - - X - -
- - - - - - - - - - - X - -
X X - X X - - X - - - X X -
X - - - - - - - - - - X - -
X - - - - - - - X - - - - -
- - - - - - - - - - - - X -
- - - - X - X - - - - - - -
- - - - - - X - - - - - - -
- - - - - - - - - - - - - -
- - - - X - X - - - - - - -
- X - - - - - - - - - - - X
2021 Measures List

Page 95 of 119
Physical
Therapy
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
X X - - X - X - - - - X X -
X X - - X - - - - - - X X -
X - - - - - - - - - - X - -
- - - - - - - - - - - X - -
- - - - - - X - - - - X - -
- - X - - - - - - - - - - -
- - - - - - - - - - - - - -
- - - - - - - - - - - X - -
- - - - - - - - X - X X - -
- - - - - - - - X - X - - -
2021 Measures List

Page 96 of 119
Physical
Therapy
X - - X X - - X X X X X X -
X X X X X - - X X X - X X -
- - - X - - X - X - - X - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
- - X - - - - - - - - - - -
- X - - - - - - - - - - - X
- X - - - - - - - - - - - X
- - - - - - - - - - - - - -
2021 Measures List

Page 97 of 119
Physical
Therapy
- - - - - - - - - - - - - -
- - - X X - - X X - X X - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
- - - X - - - - - - - - - -
- - - X - - - - - - - - - -
- - - - - - - - X - - - - -
- - - X - - - X X - - X - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
2021 Measures List

Page 98 of 119
Physical
Therapy
- - X - - - - - - - - - - -
- - - - - - X - - - - - - -
- - - X - - - - X - - - - -
- - - X - - - - X - - - - -
- - - X - - - - X - - - - -
- - - X - - - - X - - - - -
2021 Measures List

Page 99 of 119
Physical
Therapy
- - - X - - - - X - - - - -
- - - X - - - - X - - - - -
X X X X X - - X X X X X X -
X - - - - - - - - - - - X -
- - X - - - - - - - - - X -
- - - - - - X - - - - - - -
2021 Measures List

Page 100 of 119
Physical
Therapy
- - - - - - X - - - - - - -
- - - - - - - - - - - - - -
- - - - - X - - - - - - - -
- X - - - X - - - - - - - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
2021 Measures List

Page 101 of 119
Physical
Therapy
- - - - - - - - - - - - - -
X - - - X - - - - - - - - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
- - - - X - - - - - - - X -
- - - - X - - - - - - - X -
- - - - - - - - X - - - - -
- - - - - - - - - - - - - -
- - - - - - - - X - - - - -
- - - - - - - - X - - - - -
2021 Measures List

Page 102 of 119
Physical
Therapy
- - - - - - - - X - - - - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
- - X - - - - - - - - - - -
- - X - - - - - - - - - - -
- - - - - - X - - - - - - -
X - - - - - - - - - - - - -
X - - - - - X - - - - - - -
2021 Measures List

Page 103 of 119
Physical
Therapy
X X - X X - - X - X - X - -
- - - X X - - - X - X - - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
2021 Measures List

Page 104 of 119
Physical
Therapy
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
- - - - X - - - - - - - - -
- - - - X - - - - - - - - -
X - - - - - - - - - - - - -
X - - - - - - - - - - - - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
2021 Measures List

Page 105 of 119
Physical
Therapy
- - - X - - - - - - - - - -
- - - X - - - - - - - - - -
- - - - - - - - - - - - - -
- - - - - - - - - X - - - -
- - - - - - - - - X - - - -
- - - - X - - - - X - - - -
- - - X X - - - - X - - - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
2021 Measures List

Page 106 of 119
Physical
Therapy
- - - - - - X - - - - - - -
- - - - - - X - - - - - - -
X X X X X - - X - - - X X -
- - - X - - - - - - - - - -
- - - X - - - - - - - - - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
- - - - - - X - - - - - - -
- - - - - - X - - - - - - -
- - - - - - - - - - - - - -
- - X - - - - - - - - - - -
2021 Measures List

Page 107 of 119
Physical
Therapy
- - X - - - - - - - - - - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
- - X - - - - - - - - - - -
- - - - - - X - - - - - - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
- - - - - - X - - - - - - -
- - - - - X - - - - - - - -
2021 Measures List

Page 108 of 119
Physical
Therapy
- - - - - X - - - - - - - -
- - - - - X - - - - - - - -
- - - - X - X - - - - - X -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
X X - X X - X X - - - X - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
2021 Measures List

Page 109 of 119
Physical
Therapy
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
X - - X - - - - - - - - - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
X - - - - - - - - - - - - -
2021 Measures List

Page 110 of 119
Physical
Therapy
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
- - - - - - - - - - - - - -
X X - - X - - X - - - X X -
X - - - - - - - - - - - - -
X - - - - - - - - - - - - -
- - - - - - - - - - - - - -
- - - - - - - - - - - X - -
- - - - - - - - - - - - - -
2021 Measures List

Page 111 of 119
Physical
Therapy
- - - - - X - - - - - - - -
- - - - - - - - - - - - - -
X - - - - - - - - - - - - -
- - - - - - - - - - - - - -
X - - - - - - - - - - - - -
- X - - - - - - - - - - - -
- X - - - - - - - - - - - -
- X - - - - - - - - - - - -
- X - - - - - - - - - - - -
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Physical
Therapy
- X - - - - - - - - - - - -
- X - - - - - - - - - - - -
- - - X - - - - - - - - - -
- - - X - - - - - - - - - -
- - - X - - - - - - - - - -
- X - - - - - - - - - - - -
- - - - - - - - - - - - - -
- - - - X - X - - - - - - -
- - - - - - - - - - - - - -
- - - - - - - X - - - - - -
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Page 113 of 119
Physical
Therapy
- - - X - - - - - - - - - -
- - - X - - - - - - - - - -
- - - X - - - - - - - - - -
X - - - - - - - - - - - - -
- - - X - - - - - - - - - -
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Appendix I - Measure Steward/Contact Information
Full Name Contact

Agency for Healthcare Research & Quality Email questions and comments to mipscahps@hcqis.org
American Academy of Dermatology Email questions and comments to scarter@aad.org

American Academy of Neurology Email questions and comments to Elee@aan.com & Abennett@aan.com
American Academy of Ophthalmology Email questions and comments to irisregistry@aao.org
American Academy of Otolaryngology - Head and Email questions and comments to echavarria@etnet.org
Neck Surgery
American Academy of Sleep Medicine Email questions and comments to dgray@aasm.org
American Association of Hip and Knee Surgeons Email questions and comments to jkerr@aahks.org
American Board of Family Medicine Email questions and comments to DPavletic@theabfm.org
American College of Cardiology Email questions and comments to Joseph Allen at jallen@acc.org and Jarrot Mayfield at jmayfield@acc.org
American College of Emergency Physicians Email questions and comments to agupta@acep.org
American College of Radiology Email questions and comments to info@acr.org or jburleson@acr.org
American College of Rheumatology Email questions and comments to tjohansson@rheumatology.org

American College of Surgeons Email questions to ulangenscheidt@facs.org
American Gastroenterological Association Email questions and comments to cfremont@gastro.org; dgodzina@gastro.org
American Heart Association Email questions and comments to melanie.shahriary@heart.org or sana.gokak@heart.org
American Podiatric Medical Association Email questions and comments to dtower@apma.org

American Psychiatric Association Email questions and comments to BYowell@psych.org
American Society for Gastrointestinal Endoscopy Email questions and comments to eessex@asge.org
American Society of Anesthesiologists Email questions and comments to c.ostarello@asahq.org
American Society of Breast Surgeons Email questions and comments to sgrutman@breastsurgeons.org

American Society of Clinical Oncology Email questions and comments to Caitlin.Drumheller@asco.org
American Thoracic Society Email questions and comments to atsinfo@thoracic.org or jruminjo@thoracic.org

American Urogynecologic Society Email questions and comments to karen@augs.org
American Urological Association Education and Email questions and comments to Kejohnson@auanet.org
Research
Audiology Quality Consortium Email questions and comments to SWarren@asha.org or pfarrell@asha.org

Centers for Medicare & Medicaid Services Email questions and comments to QPP@cms.hhs.gov
College of American Pathologists Email questions and comments to cskau@cap.org
FOTO Patient Outcomes Email questions and comments to deannahayes@fotoinc.com
Health Resources and Services Administration Email questions and comments to tmatthews@hrsa.gov
Mathematica Email questions and comments to DClayman@mathematica-mpr.com
Minnesota Community Measurement Email questions and comments to info@mncm.org
National Committee for Quality Assurance Submit questions and comments to https://my.ncqa.org/
Oregon Urology Institute/Large Urology Practice Email questions and comments to colleen@oregonurology.com
Association
Appendix I - Measure Steward/Contact Information
Full Name Contact

Society for Nuclear Medicine and Molecular Email questions and comments to DBurrichter@snmmi.org
Imaging
Society for Vascular Surgeons Visit vascularweb.org and select "Contact Us"
Society of Interventional Radiology Email questions and comments to cstrain@sirweb.org

Society of Thoracic Surgeons Email questions and comments to dmcdonald@sts.org
University of Michigan Email questions and comments jmsto@med.umich.edu and parrotte@med.umich.edu
University of Southern California Email questions and comments to Mattke@usc.edu
Wisconsin Collaborative for Healthcare Quality Email questions and comments to mgordon@wchq.org
Other Contacts
aburns@aad.org; lvera@aad.org; jraad@aad.org

BSchierman@aan.com; klundgren@aan.com
mpeltzman@aao.org; flum@aao.org
ndhepyasuwan@entnet.org
suzannebpope@gmail.com
jshuemaker@theabfm.org; rebecca.etz@vcuhealth.org
pgoyal@acep.org; bmalcom@acep.org; dsharma@acep.org; avithalani@acep.org
zsmith@acr.org; kcampos@acr.org;
sshugarman@acr.org
jmartin@rheumatology.org
tshippen@facs.org
christine.rutan@heart.org, rebecca.diekemper@heart.org
jrchristina@apma.org
m.popovich@asahq.org; c.ostarello@asahq.org; qra@asahq.org
stephanie.jones@asco.org;hiral.dudhwala@asco.org
mfarquhar@auanet.org
Ecalvert@auanet.org
Kross@auanet.org
mips@cap.org and italave@cap.org

Jessica Zeff jessica.zeff@nethealth.com
mmatosky@hrsa.gov
PDiMilia@mathematica-mpr.com
cole@mncm.org; donovan@mncm.org
wade@ncqa.org; rehm@ncqa.org
Other Contacts
BClarke@snmmi.org
Maureen Malek at Mmalek@vascularsociety.org; Reva Bhushan <rbhushan@vascularsociety.org>
byagci@sts.org; dsteck@sts.org
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Updated file to Performance Period 2022
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2022 MIPS Quality Measures List

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2022 MIPS Quality Measures List

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2022 Merit-based Incentive Payment System (MIPS)

Quality Measures List

1. Search by measure number

1. Search by measure number

2. Search by NQS Domain

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Diabetes: Hemoglobin A1c (HbA1c) Poor Control

Percentage of patients aged 18 years and older with a diagnosis

Percentage of patients aged 18 years and older with a diagnosis

3. Search by Collection Type

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4. Search using Keywords

This is an image of the Measure Title header

Percentage of patients whose providers are ensuring active tuberculosis

Percentage of patients, regardless of age, with a current diagnosis of

AAHKS is a small specialty society

Percentage of patients regardless of age undergoing a total knee replacement Non-Endorsed/

Percentage of patients regardless of age or gender undergoing total knee

Epilepsy: Documentation of Etiology of Epilepsy or Non-Endorsed/

Epilepsy: Counseling for Women of Childbearing Time limited Full

Percentage of patients aged 18 years and older with a diagnosis of

Percentage of patients aged 18 years and older with a diagnosis of

Percentage of patients aged 18 years and older with a diagnosis of

Percentage of patients aged 18 years and older with a diagnosis of heart

Percentage of calendar months within a 12-month period during which a

Urinary Incontinence: Assessment of Presence or Non-Endorsed/

Measure replaced by measure NQF #2152: Preventive Care and Screening:

Percentage of patients aged 18 years and older with a diagnosis of rheumatoid

Percentage of patients aged 18 years and older with a diagnosis of rheumatoid

Percentage of surgical patients aged 18 years and older undergoing

Percentage of surgical patients aged 18 years and older undergoing

Percentage of non-cardiac surgical patients aged 18 years and older

Percentage of surgical patients aged 18 years and older undergoing

Percentage of patients aged 18 years and older with a diagnosis of chronic

Percentage of patients aged 18 years and older with a diagnosis of chronic

Percentage of patients aged 18 years and older with a diagnosis of chronic

Percentage of patients aged 18 years and older with a diagnosis of heart

Percentage of patients aged 18 years and older with a diagnosis of heart

Percentage of patients aged 18 years and older with a diagnosis of coronary

Percentage of patients aged 18 years and older with a diagnosis of coronary

Percentage of patients aged 6 months and older with a diagnosis of HIV/AIDS

Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS

Percentage of patients aged 5 through 64 years with a diagnosis of asthma Non-Endorsed/

Percentage of patients aged 5 through 64 years with a diagnosis of asthma (or

Percentage of patients aged 5 through 64 years with a diagnosis of asthma

Percentage of patients, regardless of age, with a diagnosis of dementia whose Non-Endorsed/

Percentage of patients, regardless of age, with a diagnosis of dementia for Non-Endorsed/

Percentage of patients, regardless of age, with a diagnosis of dementia for Non-Endorsed/

Percentage of patients, regardless of age, with a diagnosis of dementia who Non-Endorsed/

Percentage of patients, regardless of age, with a diagnosis of dementia or their Non-Endorsed/

Percentage of patients, regardless of age, with a diagnosis of dementia or their Non-Endorsed/

Percentage of patients, regardless of age, with a diagnosis of dementia whose

Percentage of patients aged 18 years and older with a diagnosis of

Percentage of patients aged 18 years and older with a diagnosis of

Percentage of patients, regardless of patient age, with a diagnosis of cancer

Percentage of visits for patients, regardless of age, with a diagnosis of cancer

Percentage of patients, regardless of age, with a diagnosis of cancer who are

Percentage of computed tomography (CT) imaging reports for all patients,

Percentage of computed tomography (CT) and cardiac nuclear medicine

Percentage of final reports for computed tomography (CT) studies performed

Percentage of final reports of computed tomography (CT) studies performed

Percentage of patients aged 18 years and older with a diagnosis of primary