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MIPSwizard Registry Reporting includes the Quality, Promoting Interoperability and Improvement Activities Categories
$
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PURCHASE FOR AN INDIVIDUAL CLINICIAN
PURCHASE GROUP REPORT (GPRO) ONLINE
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QUALITY ID | MEASURE NAME | High Priority | SPECIALTY MEASURE SET | |||||||
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1 | Diabetes: Hemoglobin A1c Poor Control | Yes |
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5 | Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) | No |
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6 | Coronary Artery Disease (CAD): Antiplatelet Therapy | No |
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7 | Coronary Artery Disease (CAD): Beta-Blocker Therapy - Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%) | No |
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8 | Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) | No |
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12 | Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation | No |
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14 | Age-Related Macular Degeneration (AMD): Dilated Macular Examination | No |
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19 | Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care | Yes |
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21 | Perioperative Care: Selection of Prophylactic Antibiotic - First OR Second Generation Cephalosporin | Yes |
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23 | Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) | Yes |
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24 | Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older | Yes |
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39 | Screening for Osteoporosis for Women Aged 65-85 Years of Age | No |
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43 | Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery | No |
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44 | Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery | No |
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46 | Medication Reconciliation Post-Discharge | Yes |
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47 | Care Plan | Yes |
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48 | Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older | No |
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50 | Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older | Yes |
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51 | Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation | No |
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52 | Chronic Obstructive Pulmonary Disease (COPD): Inhaled Bronchodilator Therapy | No |
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65 | Appropriate Treatment for Children with Upper Respiratory Infection (URI) | Yes |
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66 | Appropriate Testing for Children with Pharyngitis | Yes |
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67 | Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow | No |
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68 | Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy | No |
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69 | Hematology: Multiple Myeloma: Treatment with Bisphosphonates | No |
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70 | Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry | No |
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76 | Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections | Yes |
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91 | Acute Otitis Externa (AOE): Topical Therapy | Yes |
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93 | Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy - Avoidance of Inappropriate Use | Yes |
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99 | Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade | No |
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100 | Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade | No |
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102 | Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients | Yes |
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104 | Prostate Cancer: Adjuvant Hormonal Therapy for High Risk or Very High Risk Prostate Cancer | No |
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109 | Osteoarthritis (OA): Function and Pain Assessment | Yes |
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110 | Preventive Care and Screening: Influenza Immunization | No |
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111 | Pneumonia Vaccination Status for Older Adults | No |
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112 | Breast Cancer Screening | No |
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113 | Colorectal Cancer Screening | No |
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116 | Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis | Yes |
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117 | Diabetes: Eye Exam | No |
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118 | Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%) | No |
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119 | Diabetes: Medical Attention for Nephropathy | No |
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122 | Adult Kidney Disease: Blood Pressure Management | Yes |
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126 | Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy - Neurological Evaluation | No |
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127 | Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention - Evaluation of Footwear | No |
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128 | Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan | No |
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130 | Documentation of Current Medications in the Medical Record | Yes |
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131 | Pain Assessment and Follow-Up | Yes |
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134 | Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan | No |
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137 | Melanoma: Continuity of Care - Recall System | Yes |
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138 | Melanoma: Coordination of Care | Yes |
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140 | Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement | No |
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141 | Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care | Yes |
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143 | Oncology: Medical and Radiation - Pain Intensity Quantified | Yes |
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144 | Oncology: Medical and Radiation - Plan of Care for Pain | Yes |
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145 | Radiology: Exposure Time Reported for Procedures Using Fluoroscopy | Yes |
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146 | Radiology: Inappropriate Use of "Probably Benign" Assessment Category in Screening Mammograms | Yes |
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147 | Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy | Yes |
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154 | Falls: Risk Assessment | Yes |
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155 | Falls: Plan of Care | Yes |
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156 | Oncology: Radiation Dose Limits to Normal Tissues | Yes |
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164 | Coronary Artery Bypass Graft (CABG): Prolonged Intubation | Yes |
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165 | Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate -National Quality Strategy Domain: Effective Clinical Care | Yes |
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166 | Coronary Artery Bypass Graft (CABG): Stroke- National Quality Strategy Domain: Effective Clinical Care | Yes |
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167 | Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure - National Quality Strategy Domain: Effective Clinical Care | Yes |
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168 | Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration - National Quality Strategy Domain: Effective Clinical Care | Yes |
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176 | Rheumatoid Arthritis (RA): Tuberculosis Screening - National Quality Strategy Domain: Effective Clinical Care | No |
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177 | Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity - National Quality Strategy Domain: Effective Clinical Care Measure | No |
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178 | Rheumatoid Arthritis (RA): Functional Status Assessment | No |
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179 | Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis - National Quality Strategy Domain: Effective Clinical Care | No |
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180 | Rheumatoid Arthritis (RA): Glucocorticoid Management | No |
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181 | Elder Maltreatment Screen and Follow-Up Plan | Yes |
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182 | Functional Outcome Assessment | Yes |
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185 | Colonoscopy Interval for Patients with a History of Adenomatous Polyps - Avoidance of Inappropriate Use | Yes |
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187 | Stroke and Stroke Rehabilitation: Thrombolytic Therapy | No |
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191 | Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery | Yes |
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192 | Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures | Yes |
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195 | Radiology: Stenosis Measurement in Carotid Imaging Reports | No |
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204 | Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic | No |
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205 | HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis | No |
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217 | Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Knee Impairments | Yes |
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218 | Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Hip Impairments | Yes |
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219 | Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Lower Leg, Foot or Ankle Impairments | Yes |
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220 | Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Lumbar Spine Impairments | Yes |
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221 | Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Shoulder Impairments | Yes |
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222 | Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Elbow, Wrist or Hand Impairments | Yes |
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223 | Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Neck, Cranium, Mandible, Thoracic Spine, Ribs, or Other General Orthopedic Impairments | Yes |
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224 | Melanoma: Overutilization of Imaging Studies in Melanoma | Yes |
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225 | Radiology: Reminder System for Screening Mammograms | Yes |
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226 | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | No |
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236 | Controlling High Blood Pressure | Yes |
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238 | Use of High-Risk Medications in the Elderly | Yes |
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243 | Cardiac Rehabilitation Patient Referral from an Outpatient Setting | Yes |
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249 | Barrett's Esophagus | No |
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250 | Radical Prostatectomy Pathology Reporting | No |
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251 | Quantitative Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) for Breast Cancer Patients | No |
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254 | Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain | No |
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255 | Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure | No |
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257 | Statin Therapy at Discharge after Lower Extremity Bypass (LEB) | No |
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258 | Rate of Open Repair of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7) | Yes |
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259 | Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post Operative Day #2) | Yes |
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260 | Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2) | Yes |
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261 | Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness | Yes |
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262 | Image Confirmation of Successful Excision of Image-Localized Breast Lesion | Yes |
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263 | Preoperative Diagnosis of Breast Cancer | No |
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264 | Sentinel Lymph Node Biopsy for Invasive Breast Cancer | No |
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265 | Biopsy Follow-Up | Yes |
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268 | Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy | No |
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271 | Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury - Bone Loss Assessment | No |
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275 | Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy | No |
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276 | Sleep Apnea: Assessment of Sleep Symptoms | No |
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277 | Sleep Apnea: Severity Assessment at Initial Diagnosis | No |
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278 | Sleep Apnea: Positive Airway Pressure Therapy Prescribed | No |
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279 | Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy | No |
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282 | Dementia: Functional Status Assessment - National Quality Strategy Domain: Effective Clinical Care | No |
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283 | Dementia: Neuropsychiatric Symptom Assessment - National Quality Strategy Domain: Effective Clinical Care | No |
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286 | Dementia: Counseling Regarding Safety Concerns - National Quality Strategy Domain: Patient Safety | Yes |
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288 | Dementia: Caregiver Education and Support - National Quality Strategy Domain: Communication and Care Coordination | Yes |
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290 | Parkinson's Disease: Psychiatric Symptoms Assessment for Patients with Parkinson's Disease - National Quality Strategy Domain: Effective Clinical Care | No |
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291 | Parkinson's Disease: Cognitive Impairment or Dysfunction Assessment - National Quality Strategy Domain: Effective Clinical Care | No |
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293 | Parkinson's Disease: Rehabilitative Therapy Options - National Quality Strategy Domain: Communication and Care Coordination | Yes |
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303 | Cataracts: Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery | Yes |
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304 | Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery | Yes |
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317 | Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | No |
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320 | Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients | Yes |
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322 | Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients | Yes |
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323 | Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI) | Yes |
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324 | Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients | Yes |
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325 | Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions | Yes |
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326 | Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy | No |
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327 | Pediatric Kidney Disease: Adequacy of Volume Management | No |
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328 | Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level < 10 g/dL (NQF 1667) | Yes |
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329 | Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis | Yes |
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330 | Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days | Yes |
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331 | Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse) | Yes |
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332 | Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use) | Yes |
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333 | Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse) | Yes |
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334 | Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse) | Yes |
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335 | Maternity Care: Elective Delivery or Early Induction Without Medical Indication at > 37 and < 39 Weeks | Yes |
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336 | Maternity Care: Post-Partum Follow-Up and Care Coordination | Yes |
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337 | Tuberculosis Prevention for Psoriasis,Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier | No |
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338 | HIV Viral Load Suppression -- National Quality Strategy Domain:Effective Clinical Care | Yes |
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340 | HIV Medical Visit Frequency - National Quality Strategy Domain: Efficiency And Cost Reduction | Yes |
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342 | Pain Brought Under Control Within 48 Hours | Yes |
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343 | Screening Colonoscopy Adenoma Detection Rate | Yes |
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344 | Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2) | Yes |
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345 | Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS) | Yes |
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346 | Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Endarterectomy (CEA) | Yes |
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347 | Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) Who Die While in Hospital | Yes |
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348 | HRS-3 Implantable Cardioverter-Defibrillator (ICD) Complications Rate | Yes |
View Details
|
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|
||||||||||
+
|
350 | Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy | Yes |
View Details
|
||||||
|
||||||||||
+
|
351 | Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation | Yes |
View Details
|
||||||
|
||||||||||
+
|
352 | Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet | Yes |
View Details
|
||||||
|
||||||||||
+
|
353 | Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report | Yes |
View Details
|
||||||
|
||||||||||
+
|
354 | Anastomotic Leak Intervention - National Quality Strategy Domain: Patient Safety | Yes |
View Details
|
||||||
|
||||||||||
+
|
355 | Unplanned Reoperation within the 30 Day Postoperative Period | Yes |
View Details
|
||||||
|
||||||||||
+
|
356 | Unplanned Hospital Readmission within 30 Days of Principal Procedure | Yes |
View Details
|
||||||
|
||||||||||
+
|
357 | Surgical Site Infection (SSI) | Yes |
View Details
|
||||||
|
||||||||||
+
|
358 | Patient-centered Surgical Risk Assessment and Communication | Yes |
View Details
|
||||||
|
||||||||||
+
|
359 | Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging Description | Yes |
View Details
|
||||||
|
||||||||||
+
|
360 | Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry | Yes |
View Details
|
||||||
|
||||||||||
+
|
361 | Optimizing Patient Exposure to Ionizing Radiation: | Yes |
View Details
|
||||||
|
||||||||||
+
|
362 | Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison Purposes | Yes |
View Details
|
||||||
|
||||||||||
+
|
363 | Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Studies Through a Secure, Authorized, Media-Free, Shared Archive | Yes |
View Details
|
||||||
|
||||||||||
+
|
364 | Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines - National Quality Strategy Domain: Communication And Care Coordination | Yes |
View Details
|
||||||
|
||||||||||
+
|
370 | Depression Remission at Twelve Months | Yes |
View Details
|
||||||
|
||||||||||
+
|
374 | Closing the Referral Loop: Receipt of Specialist Report | Yes |
View Details
|
||||||
|
||||||||||
+
|
383 | Adherence to Antipsychotic Medications for Individuals with Schizophrenia | Yes |
View Details
|
||||||
|
||||||||||
+
|
384 | Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery | Yes |
View Details
|
||||||
|
||||||||||
+
|
385 | Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery | Yes |
View Details
|
||||||
|
||||||||||
+
|
386 | Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences | Yes |
View Details
|
||||||
|
||||||||||
+
|
387 | Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users | No |
View Details
|
||||||
|
||||||||||
+
|
388 | Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy) | Yes |
View Details
|
||||||
|
||||||||||
+
|
389 | Cataract Surgery: Difference Between Planned and Final Refraction | Yes |
View Details
|
||||||
|
||||||||||
+
|
390 | Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options | Yes |
View Details
|
||||||
|
||||||||||
+
|
391 | Follow-up After Hospitalization for Mental Illness (FUH) | Yes |
View Details
|
||||||
|
||||||||||
+
|
392 | HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation | Yes |
View Details
|
||||||
|
||||||||||
+
|
393 | HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision | Yes |
View Details
|
||||||
|
||||||||||
+
|
394 | Immunizations for Adolescents | No |
View Details
|
||||||
|
||||||||||
+
|
395 | Lung Cancer Reporting (Biopsy/Cytology Specimens) | Yes |
View Details
|
||||||
|
||||||||||
+
|
396 | Lung Cancer Reporting (Resection Specimens) | Yes |
View Details
|
||||||
|
||||||||||
+
|
397 | Melanoma Reporting | Yes |
View Details
|
||||||
|
||||||||||
+
|
398 | Optimal Asthma Control | Yes |
View Details
|
||||||
|
||||||||||
+
|
400 | One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk | No |
View Details
|
||||||
|
||||||||||
+
|
401 | Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis | No |
View Details
|
||||||
|
||||||||||
+
|
402 | Tobacco Use and Help with Quitting Among Adolescents | No |
View Details
|
||||||
|
||||||||||
+
|
403 | Adult Kidney Disease: Referral to Hospice | Yes |
View Details
|
||||||
|
||||||||||
+
|
404 | Anesthesiology Smoking Abstinence | Yes |
View Details
|
||||||
|
||||||||||
+
|
405 | Appropriate Follow-up Imaging for Incidental Abdominal Lesions | Yes |
View Details
|
||||||
|
||||||||||
+
|
406 | Appropriate Follow-Up Imaging for Incidental Thyroid Nodules in Patients | Yes |
View Details
|
||||||
|
||||||||||
+
|
407 | Appropriate Treatment of Meticillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia | Yes |
View Details
|
||||||
|
||||||||||
+
|
408 | Opioid Therapy Follow-up Evaluation | Yes |
View Details
|
||||||
|
||||||||||
+
|
409 | Clinical Outcome Post Endovascular Stroke Treatment | Yes |
View Details
|
||||||
|
||||||||||
+
|
410 | Psoriasis: Clinical Response to Oral Systemic or Biologic Medications | Yes |
View Details
|
||||||
|
||||||||||
+
|
411 | Depression Remission at Six Months | Yes |
View Details
|
||||||
|
||||||||||
+
|
412 | Documentation of Signed Opioid Treatment Agreement | Yes |
View Details
|
||||||
|
||||||||||
+
|
413 | Door to Puncture Time for Endovascular Stroke Treatment | Yes |
View Details
|
||||||
|
||||||||||
+
|
414 | Evaluation or Interview for Risk of Opioid Misuse | Yes |
View Details
|
||||||
|
||||||||||
+
|
415 | Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older | Yes |
View Details
|
||||||
|
||||||||||
+
|
416 | Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 through 17 Years | Yes |
View Details
|
||||||
|
||||||||||
+
|
417 | Rate of Open Repair of Small or Moderate Abdominal Aortic Aneurysms (AAA) Where Patients Are Discharged Alive - National Quality Strategy Domain: Patient Safety | Yes |
View Details
|
||||||
|
||||||||||
+
|
418 | Osteoporosis Management in Women Who Had a Fracture | No |
View Details
|
||||||
|
||||||||||
+
|
419 | Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination | Yes |
View Details
|
||||||
|
||||||||||
+
|
420 | Varicose Vein Treatment with Saphenous Ablation: Outcome Survey | Yes |
View Details
|
||||||
|
||||||||||
+
|
421 | Appropriate Assessment of Retrievable Inferior Vena Cava Filters for Removal | No |
View Details
|
||||||
|
||||||||||
+
|
422 | Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury | Yes |
View Details
|
||||||
|
||||||||||
+
|
423 | Perioperative Anti-platelet Therapy for Patients Undergoing Carotid Endarterectomy | No |
View Details
|
||||||
|
||||||||||
+
|
424 | Perioperative Temperature Management | Yes |
View Details
|
||||||
|
||||||||||
+
|
425 | Photodocumentation of Cecal Intubation | No |
View Details
|
||||||
|
||||||||||
+
|
426 | Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU) | Yes |
View Details
|
||||||
|
||||||||||
+
|
427 | Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU) | Yes |
View Details
|
||||||
|
||||||||||
+
|
428 | Pelvic Organ Prolapse: Preoperative Assessment of Occult Stress Urinary Incontinence | No |
View Details
|
||||||
|
||||||||||
+
|
429 | Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy | Yes |
View Details
|
||||||
|
||||||||||
+
|
430 | Prevention of Post-Operative Nausea and Vomiting (PONV) - Combination Therapy | Yes |
View Details
|
||||||
|
||||||||||
+
|
431 | Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling | No |
View Details
|
||||||
|
||||||||||
+
|
432 | Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair | Yes |
View Details
|
||||||
|
||||||||||
+
|
433 | Proportion of Patients Sustaining a Major Viscus Injury at the Time of Any Pelvic Organ Prolapse Repair | Yes |
View Details
|
||||||
|
||||||||||
+
|
434 | Proportion of Patients Sustaining A Ureter Injury at the Time of any Pelvic Organ Prolapse Repair | Yes |
View Details
|
||||||
|
||||||||||
+
|
435 | Quality Of Life Assessment For Patients With Primary Headache Disorders | Yes |
View Details
|
||||||
|
||||||||||
+
|
436 | Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques | No |
View Details
|
||||||
|
||||||||||
+
|
437 | Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure | Yes |
View Details
|
||||||
|
||||||||||
+
|
438 | Statin Therapy for the Prevention and Treatment of Cardiovascular Disease | No |
View Details
|
||||||
|
||||||||||
+
|
439 | Age Appropriate Screening Colonoscopy | Yes |
View Details
|
||||||
|
||||||||||
+
|
440 | Basal Cell Carcinoma (BCC)/Squamous Cell Carcinoma: Biopsy Reporting Time - Pathologist to Clinician - National Quality Strategy Domain: Communication and Care Coordination | Yes |
View Details
|
||||||
|
||||||||||
+
|
441 | Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control) | Yes |
View Details
|
||||||
|
||||||||||
+
|
442 | Persistence of Beta-Blocker Treatment After a Heart Attack - National Quality Strategy Domain: Effective Clinical Care | No |
View Details
|
||||||
|
||||||||||
+
|
443 | Non-Recommended Cervical Cancer Screening in Adolescent Females - National Quality Strategy Domain: Patient Safety | Yes |
View Details
|
||||||
|
||||||||||
+
|
444 | Medication Management for People with Asthma - National Quality Strategy Domain: Efficiency and Cost Reduction | Yes |
View Details
|
||||||
|
||||||||||
+
|
445 | Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG) - National Quality Strategy Domain: Effective Clinical Care | Yes |
View Details
|
||||||
|
||||||||||
+
|
446 | Operative Mortality Stratified by the Five STS-EACTS Mortality Categories | Yes |
View Details
|
||||||
|
||||||||||
+
|
447 | Chlamydia Screening and Follow Up - National Quality Strategy Domain: Community/Population Health | No |
View Details
|
||||||
|
||||||||||
+
|
448 | Appropriate Workup Prior to Endometrial Ablation- National Quality Strategy Domain: Communication and Care Coordination | Yes |
View Details
|
||||||
|
||||||||||
+
|
449 | HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment with HER2-Targeted Therapies - National Quality Strategy Domain: Efficiency and Cost Reduction | Yes |
View Details
|
||||||
|
||||||||||
+
|
450 | Trastuzumab Received By Patients With AJCC Stage I (T1c) - III And HER2 Positive Breast Cancer Receiving Adjuvant Chemotherapy- National Quality Strategy Domain: Effective Clinical Care | Yes |
View Details
|
||||||
|
||||||||||
+
|
451 | KRAS Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy | No |
View Details
|
||||||
|
||||||||||
+
|
452 | Patients with Metastatic Colorectal Cancer and KRAS Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies | Yes |
View Details
|
||||||
|
||||||||||
+
|
453 | Proportion Receiving Chemotherapy in the Last 14 Days of Life | Yes |
View Details
|
||||||
|
||||||||||
+
|
454 | Proportion of Patients who Died from Cancer with more than One Emergency Department Visit in the Last 30 Days of Life | Yes |
View Details
|
||||||
|
||||||||||
+
|
455 | Proportion Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life | Yes |
View Details
|
||||||
|
||||||||||
+
|
456 | Proportion Not Admitted to Hospice | Yes |
View Details
|
||||||
|
||||||||||
+
|
457 | Proportion Admitted to Hospice for less than 3 days | Yes |
View Details
|
||||||
|
||||||||||
+
|
459 | Average Change in Back Pain Following Lumbar Discectomy/Laminotomy | Yes |
View Details
|
||||||
|
||||||||||
+
|
460 | Average Change in Back Pain following Lumbar Fusion | Yes |
View Details
|
||||||
|
||||||||||
+
|
461 | Average Change in Leg Pain Following Lumbar Discectomy and/or Laminotomy | Yes |
View Details
|
||||||
|
||||||||||
+
|
463 | Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics) | Yes |
View Details
|
||||||
|
||||||||||
+
|
464 | Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use | Yes |
View Details
|
||||||
|
||||||||||
+
|
465 | Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian Arteries | Yes |
View Details
|
||||||
|
||||||||||
+
|
467 | Developmental Screening in the First Three Years of Life | No |
View Details
|
||||||
|
MEASURE NAME | ID | OBJECTIVE NAME | REQUIRED FOR BASE SCORE | ||||||||||
+ |
Clinical Data Registry Reporting | PI_PHCDRR_5 | Clinical Data Registry Reporting | Yes | View Details |
||||||||
|
|||||||||||||
+ |
Clinical Information Reconciliation | PI_HIE_3 | Clinical Information Reconciliation | Yes | View Details |
||||||||
|
|||||||||||||
+ |
e-Prescribing | PI_EP_1 | e-Prescribing | Yes | View Details |
||||||||
|
|||||||||||||
+ |
E-Prescribing Exclusion | PI_LVPP_1 | E-Prescribing Exclusion | Yes | View Details |
||||||||
|
|||||||||||||
+ |
Electronic Case Reporting | PI_PHCDRR_3 | Electronic Case Reporting | Yes | View Details |
||||||||
|
|||||||||||||
+ |
Immunization Registry Reporting | PI_PHCDRR_1 | Immunization Registry Reporting | Yes | View Details |
||||||||
|
|||||||||||||
+ |
ONC Direct Review Attestation | PI_ONCDIR_1 | ONC Direct Review Attestation | Yes | View Details |
||||||||
|
|||||||||||||
+ |
ONC-ACB Surveillance Attestation (Optional) | PI_ONCACB_1 | ONC-ACB Surveillance Attestation (Optional) | Yes | View Details |
||||||||
|
|||||||||||||
+ |
Patient-Generated Health Data | PI_CCTPE_3 | Patient-Generated Health Data | Yes | View Details |
||||||||
|
|||||||||||||
+ |
Patient-Specific Education | PI_PEA_2 | Patient-Specific Education | Yes | View Details |
||||||||
|
|||||||||||||
+ |
PI bonus for submission of eligible Improvement Activities using CEHRT | PI_IACEHRT_1 | PI bonus for submission of eligible Improvement Activities using CEHRT | Yes | View Details |
||||||||
|
|||||||||||||
+ |
Prevention of Information Blocking Attestation | PI_INFBLO_1 | Prevention of Information Blocking Attestation | Yes | View Details |
||||||||
|
|||||||||||||
+ |
Provide Patient Access | PI_PEA_1 | Provide Patient Access | Yes | View Details |
||||||||
|
|||||||||||||
+ |
Public Health Registry Reporting | PI_PHCDRR_4 | Public Health Registry Reporting | Yes | View Details |
||||||||
|
|||||||||||||
+ |
Request/Accept Summary of Care | PI_HIE_2 | Request/Accept Summary of Care | Yes | View Details |
||||||||
|
|||||||||||||
+ |
Secure Messaging | PI_CCTPE_2 | Secure Messaging | Yes | View Details |
||||||||
|
|||||||||||||
+ |
Security Risk Analysis | PI_PPHI_1 | Security Risk Analysis | Yes | View Details |
||||||||
|
|||||||||||||
+ |
Send a Summary of Care | PI_HIE_1 | Send a Summary of Care | Yes | View Details |
||||||||
|
|||||||||||||
+ |
Send a Summary of Care Exclusion | PI_LVOTC_1 | Send a Summary of Care Exclusion | Yes | View Details |
||||||||
|
|||||||||||||
+ |
Syndromic Surveillance Reporting | PI_PHCDRR_2 | Syndromic Surveillance Reporting | Yes | View Details |
||||||||
|
|||||||||||||
+ |
View, Download and Transmit (VDT) | PI_CCTPE_1 | View, Download and Transmit (VDT) | Yes | View Details |
||||||||
|
MEASURE NAME | ID | OBJECTIVE NAME | REQUIRED FOR BASE SCORE | ||||||||||||
+ |
e-Prescribing | PI_TRANS_EP_1 | e-Prescribing | Yes | View Details |
||||||||||
|
|||||||||||||||
+ |
E-Prescribing Exclusion | PI_TRANS_EP_1 | E-Prescribing Exclusion | Yes | View Details |
||||||||||
|
|||||||||||||||
+ |
Health Information Exchange | PI_TRANS_HIE_1 | Health Information Exchange | Yes | View Details |
||||||||||
|
|||||||||||||||
+ |
Immunization Registry Reporting | PI_TRANS_PHCDRR_1 | Immunization Registry Reporting | Yes | View Details |
||||||||||
|
|||||||||||||||
+ |
Medication Reconciliation | PI_TRANS_MR_1 | Medication Reconciliation | Yes | View Details |
||||||||||
|
|||||||||||||||
+ |
Patient-Specific Education | PI_TRANS_PSE_1 | Patient-Specific Education | Yes | View Details |
||||||||||
|
|||||||||||||||
+ |
Provide Patient Access | PI_TRANS_PEA_1 | Provide Patient Access | Yes | View Details |
||||||||||
|
|||||||||||||||
+ |
Secure Messaging | PI_TRANS_SM_1 | Secure Messaging | Yes | View Details |
||||||||||
|
|||||||||||||||
+ |
Security Risk Analysis | PI_TRANS_PPHI_1 | Security Risk Analysis | Yes | View Details |
||||||||||
|
|||||||||||||||
+ |
Specialized Registry Reporting | PI_TRANS_PHCDRR_3 | Specialized Registry Reporting | Yes | View Details |
||||||||||
|
|||||||||||||||
+ |
Syndromic Surveillance Reporting | PI_TRANS_PHCDRR_2 | Syndromic Surveillance Reporting | Yes | View Details |
||||||||||
|
|||||||||||||||
+ |
View, Download, or Transmit (VDT) | PI_TRANS_PEA_2 | View, Download, or Transmit (VDT) | Yes | View Details |
||||||||||
|
ACTIVITY NAME | ID | SUBCATEGORY | WIEGHTING | ||||||||||
Provide 24/7 access to eligible clinicians or groups who have real-time access to patient's medical record | IA_EPA_1 | Expanded Practice Access | High | ||||||||||
Provide 24/7 access to eligible clinicians or groups who have real-time access to patient's medical record
|
|||||||||||||
Use of telehealth services that expand practice access | IA_EPA_2 | Expanded Practice Access | Medium | ||||||||||
Use of telehealth services that expand practice access
|
|||||||||||||
Collection and use of patient experience and satisfaction data on access | IA_EPA_3 | Expanded Practice Access | Medium | ||||||||||
Collection and use of patient experience and satisfaction data on access
|
|||||||||||||
Additional improvements in access as a result of QIN/QIO TA | IA_EPA_4 | Expanded Practice Access | Medium | ||||||||||
Additional improvements in access as a result of QIN/QIO TA
|
|||||||||||||
Participation in User Testing of the Quality Payment Program Website (https://qpp.cms.gov/) | IA_EPA_5 | Expanded Practice Access | Medium | ||||||||||
Participation in User Testing of the Quality Payment Program Website (https://qpp.cms.gov/)
|
|||||||||||||
Participation in an AHRQ-listed patient safety organization. | IA_PSPA_1 | Patient Safety & Practice Assessment | Medium | ||||||||||
Participation in an AHRQ-listed patient safety organization.
|
|||||||||||||
Participation in MOC Part IV | IA_PSPA_2 | Patient Safety & Practice Assessment | Medium | ||||||||||
Participation in MOC Part IV
|
|||||||||||||
Participate in IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS(R) or other similar activity. | IA_PSPA_3 | Patient Safety & Practice Assessment | Medium | ||||||||||
Participate in IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS(R) or other similar activity.
|
|||||||||||||
Administration of the AHRQ Survey of Patient Safety Culture | IA_PSPA_4 | Patient Safety & Practice Assessment | Medium | ||||||||||
Administration of the AHRQ Survey of Patient Safety Culture
|
|||||||||||||
Annual registration in the Prescription Drug Monitoring Program | IA_PSPA_5 | Patient Safety & Practice Assessment | Medium | ||||||||||
Annual registration in the Prescription Drug Monitoring Program
|
|||||||||||||
Consultation of the Prescription Drug Monitoring program | IA_PSPA_6 | Patient Safety & Practice Assessment | High | ||||||||||
Consultation of the Prescription Drug Monitoring program
|
|||||||||||||
Use of QCDR data for ongoing practice assessment and improvements | IA_PSPA_7 | Patient Safety & Practice Assessment | Medium | ||||||||||
Use of QCDR data for ongoing practice assessment and improvements
|
|||||||||||||
Use of patient safety tools | IA_PSPA_8 | Patient Safety & Practice Assessment | Medium | ||||||||||
Use of patient safety tools
|
|||||||||||||
Completion of the AMA STEPS Forward program | IA_PSPA_9 | Patient Safety & Practice Assessment | Medium | ||||||||||
Completion of the AMA STEPS Forward program
|
|||||||||||||
Completion of training and receipt of approved waiver for provision opioid medication-assisted treatments | IA_PSPA_10 | Patient Safety & Practice Assessment | Medium | ||||||||||
Completion of training and receipt of approved waiver for provision opioid medication-assisted treatments
|
|||||||||||||
Participation in CAHPS or other supplemental questionnaire | IA_PSPA_11 | Patient Safety & Practice Assessment | High | ||||||||||
Participation in CAHPS or other supplemental questionnaire
|
|||||||||||||
Participation in private payer CPIA | IA_PSPA_12 | Patient Safety & Practice Assessment | Medium | ||||||||||
Participation in private payer CPIA
|
|||||||||||||
Participation in Joint Commission Evaluation Initiative | IA_PSPA_13 | Patient Safety & Practice Assessment | Medium | ||||||||||
Participation in Joint Commission Evaluation Initiative
|
|||||||||||||
Participation in Bridges to Excellence or other similar program | IA_PSPA_14 | Patient Safety & Practice Assessment | Medium | ||||||||||
Participation in Bridges to Excellence or other similar program
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Measurement and improvement at the practice and panel level | IA_PSPA_18 | Patient Safety & Practice Assessment | Medium | ||||||||||
Measurement and improvement at the practice and panel level
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Implementation of antibiotic stewardship program | IA_PSPA_15 | Patient Safety & Practice Assessment | Medium | ||||||||||
Implementation of antibiotic stewardship program
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Use of decision support and standardized treatment protocols | IA_PSPA_16 | Patient Safety & Practice Assessment | Medium | ||||||||||
Use of decision support and standardized treatment protocols
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Implementation of analytic capabilities to manage total cost of care for practice population | IA_PSPA_17 | Patient Safety & Practice Assessment | Medium | ||||||||||
Implementation of analytic capabilities to manage total cost of care for practice population
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Implementation of formal quality improvement methods, practice changes or other practice improvement processes | IA_PSPA_19 | Patient Safety & Practice Assessment | Medium | ||||||||||
Implementation of formal quality improvement methods, practice changes or other practice improvement processes
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Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes | IA_PSPA_20 | Patient Safety & Practice Assessment | Medium | ||||||||||
Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes
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Implementation of fall screening and assessment programs | IA_PSPA_21 | Patient Safety & Practice Assessment | Medium | ||||||||||
Implementation of fall screening and assessment programs
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CDC Training on CDC's Guideline for Prescribing Opioids for Chronic Pain | IA_PSPA_22 | Patient Safety & Practice Assessment | High | ||||||||||
CDC Training on CDC's Guideline for Prescribing Opioids for Chronic Pain
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Completion of CDC Training on Antibiotic Stewardship | IA_PSPA_23 | Patient Safety & Practice Assessment | High | ||||||||||
Completion of CDC Training on Antibiotic Stewardship
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Initiate CDC Training on Antibiotic Stewardship | IA_PSPA_24 | Patient Safety & Practice Assessment | Medium | ||||||||||
Initiate CDC Training on Antibiotic Stewardship
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Cost Display for Laboratory and Radiographic Orders | IA_PSPA_25 | Patient Safety & Practice Assessment | Medium | ||||||||||
Cost Display for Laboratory and Radiographic Orders
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Communication of Unscheduled Visit for Adverse Drug Event and Nature of Event | IA_PSPA_26 | Patient Safety & Practice Assessment | Medium | ||||||||||
Communication of Unscheduled Visit for Adverse Drug Event and Nature of Event
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Invasive Procedure or Surgery Anticoagulation Medication Management | IA_PSPA_27 | Patient Safety & Practice Assessment | Medium | ||||||||||
Invasive Procedure or Surgery Anticoagulation Medication Management
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Completion of an Accredited Safety or Quality Improvement Program | IA_PSPA_28 | Patient Safety & Practice Assessment | Medium | ||||||||||
Completion of an Accredited Safety or Quality Improvement Program
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Consulting Appropriate Use Criteria (AUC) Using Clinical Decision Support when Ordering Advanced Diagnostic Imaging | IA_PSPA_29 | Patient Safety & Practice Assessment | High | ||||||||||
Consulting Appropriate Use Criteria (AUC) Using Clinical Decision Support when Ordering Advanced Diagnostic Imaging
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PCI Bleeding Campaign | IA_PSPA_30 | Patient Safety & Practice Assessment | High | ||||||||||
PCI Bleeding Campaign
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Implementation of use of specialist reports back to referring clinician or group to close referral loop | IA_CC_1 | Care Coordination | Medium | ||||||||||
Implementation of use of specialist reports back to referring clinician or group to close referral loop
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Implementation of improvements that contribute to more timely communication of test results | IA_CC_2 | Care Coordination | Medium | ||||||||||
Implementation of improvements that contribute to more timely communication of test results
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Implementation of additional activity as a result of TA for improving care coordination | IA_CC_3 | Care Coordination | Medium | ||||||||||
Implementation of additional activity as a result of TA for improving care coordination
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TCPI participation | IA_CC_4 | Care Coordination | Medium | ||||||||||
TCPI participation
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CMS partner in Patients Hospital Improvement Innovation Networks | IA_CC_5 | Care Coordination | Medium | ||||||||||
CMS partner in Patients Hospital Improvement Innovation Networks
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Use of QCDR to promote standard practices, tools and processes in practice for improvement in care coordination | IA_CC_6 | Care Coordination | Medium | ||||||||||
Use of QCDR to promote standard practices, tools and processes in practice for improvement in care coordination
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Regular training in care coordination | IA_CC_7 | Care Coordination | Medium | ||||||||||
Regular training in care coordination
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Implementation of documentation improvements for practice/process improvements | IA_CC_8 | Care Coordination | Medium | ||||||||||
Implementation of documentation improvements for practice/process improvements
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Implementation of practices/processes for developing regular individual care plans | IA_CC_9 | Care Coordination | Medium | ||||||||||
Implementation of practices/processes for developing regular individual care plans
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Care transition documentation practice improvements | IA_CC_10 | Care Coordination | Medium | ||||||||||
Care transition documentation practice improvements
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Care transition standard operational improvements | IA_CC_11 | Care Coordination | Medium | ||||||||||
Care transition standard operational improvements
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Care coordination agreements that promote improvements in patient tracking across settings | IA_CC_12 | Care Coordination | Medium | ||||||||||
Care coordination agreements that promote improvements in patient tracking across settings
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Practice improvements for bilateral exchange of patient information | IA_CC_13 | Care Coordination | Medium | ||||||||||
Practice improvements for bilateral exchange of patient information
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Practice improvements that engage community resources to support patient health goals | IA_CC_14 | Care Coordination | Medium | ||||||||||
Practice improvements that engage community resources to support patient health goals
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PSH Care Coordination | IA_CC_15 | Care Coordination | Medium | ||||||||||
PSH Care Coordination
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Primary Care Physician and Behavioral Health Bilateral Electronic Exchange of Information for Shared Patients | IA_CC_16 | Care Coordination | Medium | ||||||||||
Primary Care Physician and Behavioral Health Bilateral Electronic Exchange of Information for Shared Patients
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