[ { "category": "ia", "measureId": "IA_AHW_1", "title": "Chronic Care and Preventative Care Management for Empaneled Patients", "description": "In order to receive credit for this activity, a MIPS eligible clinician must manage chronic and preventive care for empaneled patients (that is, patients assigned to care teams for the purpose of population health management), which could include one or more of the following actions:\n• Provide patients annually with an opportunity for development and/or adjustment of an individualized plan of care as appropriate to age and health status, including health risk appraisal; gender, age and condition-specific preventive care services; and plan of care for chronic conditions;\n• Use evidence based, condition-specific pathways for care of chronic conditions (for example, hypertension, diabetes, depression, asthma, and heart failure). These might include, but are not limited to, the NCQA Diabetes Recognition Program (DRP) and the NCQA Heart/Stroke Recognition Program (HSRP);\n• Use pre-visit planning, that is, preparations for conversations or actions to propose with patient before an in-office visit to optimize preventive care and team management of patients with chronic conditions;\n• Use panel support tools, (that is, registry functionality) or other technology that can use clinical data to identify trends or data points in patient records to identify services due;\n• Use predictive analytical models to predict risk, onset and progression of chronic diseases; and/or\n• Use reminders and outreach (e.g., phone calls, emails, postcards, patient portals, and community health workers where available) to alert and educate patients about services due; and/or routine medication reconciliation.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "advancingHealthAndWellness", "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "G0055", "M0002", "M0005", "M1370", "M1420", "M1424" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_1", "title": "Use of certified EHR to capture patient reported outcomes", "description": "To improve patient access, perform activities beyond routine care that enable capture of patient reported outcomes (for example, related to functional status, symptoms and symptom burden, health behaviors, or patient experience) or patient activation measures (that is, measures of patient involvement in their care) through use of certified electronic health record technology, and record these outcomes data for clinician review.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_3", "title": "Engagement with QIN-QIO to implement self-management training programs", "description": "Engagement with a Quality Innovation Network-Quality Improvement Organization, which may include participation in self-management training programs such as diabetes.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_4", "title": "Engagement of Patients through Implementation of New Patient Portal", "description": "To receive credit for this activity, MIPS eligible clinicians must implement and provide access to a new patient/caregiver portal that allows users (patients or caregivers and their clinicians) to engage in bidirectional information exchange. The primary use of this portal should be clinical and not administrative. Examples of the use of such a portal include, but are not limited to, the following: brief patient reevaluation by messaging; communication about test results and follow up; communication about medication adherence, side effects, and refills; blood pressure management for a patient with hypertension; blood sugar management for a patient with diabetes; and/or any relevant acute or chronic disease management.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0057", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1420", "M1421", "M1422", "M1499", "M1500", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_5", "title": "Enhancements/regular updates to practice websites/tools that also include considerations for patients with cognitive disabilities", "description": "Enhancements and ongoing regular updates and use of websites/tools that include consideration for compliance with section 508 of the Rehabilitation Act of 1973 or for improved design for patients with cognitive disabilities. Refer to the CMS website on Section 508 of the Rehabilitation Act https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/Section508/index.html?redirect=/InfoTechGenInfo/07_Section508.asp that requires that institutions receiving federal funds solicit, procure, maintain and use all electronic and information technology (EIT) so that equal or alternate/comparable access is given to members of the public with and without disabilities. For example, this includes designing a patient portal or website that is compliant with section 508 of the Rehabilitation Act of 1973.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_6", "title": "Regularly Assess Patient Experience of Care and Follow Up on Findings", "description": "Collect and follow up on patient experience and satisfaction data. This activity also requires follow-up on findings of assessments, including the development and implementation of improvement plans. To fulfill the requirements of this activity, MIPS eligible clinicians can use surveys (e.g., Consumer Assessment of Healthcare Providers and Systems Survey), advisory councils, or other mechanisms. MIPS eligible clinicians may consider implementing patient surveys in multiple languages, based on the needs of their patient population.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1370", "M1420", "M1421", "M1423", "M1498", "M1501", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_12", "title": "Use evidence-based decision aids to support shared decision-making.", "description": "Use evidence-based decision aids to support shared decision-making.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "G0058", "M0005", "M1369", "M1425", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_14", "title": "Engage Patients and Families to Guide Improvement in the System of Care", "description": "Engage patients and families to guide improvement in the system of care by leveraging digital tools for ongoing guidance and assessments outside the encounter, including the collection and use of patient data for return-to-work and patient quality of life improvement. Platforms and devices that collect patient-generated health data (PGHD) must do so with an active feedback loop, either providing PGHD in real or near-real time to the care team, or generating clinically endorsed real or near-real time automated feedback to the patient, including patient reported outcomes (PROs). Examples include patient engagement and outcomes tracking platforms, cellular or web-enabled bi-directional systems, and other devices that transmit clinically valid objective and subjective data back to care teams. Because many consumer-grade devices capture PGHD (for example, wellness devices), platforms or devices eligible for this improvement activity must be, at a minimum, endorsed and offered clinically by care teams to patients to automatically send ongoing guidance (one way). Platforms and devices that additionally collect PGHD must do so with an active feedback loop, either providing PGHD in real or near-real time to the care team, or generating clinically endorsed real or near-real time automated feedback to the patient (e.g. automated patient-facing instructions based on glucometer readings). Therefore, unlike passive platforms or devices that may collect but do not transmit PGHD in real or near-real time to clinical care teams, active devices and platforms can inform the patient or the clinical care team in a timely manner of important parameters regarding a patient’s status, adherence, comprehension, and indicators of clinical concern.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M0002", "M1500" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_15", "title": "Engagement of Patients, Family, and Caregivers in Developing a Plan of Care", "description": "Engage patients, family, and caregivers in developing a plan of care and prioritizing their goals for action, documented in the electronic health record (EHR) technology.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0055", "M0001", "M0002", "M1367", "M1368", "M1370", "M1421", "M1423", "M1500", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_16", "title": "Promote Self-management in Usual Care", "description": "To help patients self-manage their care, incorporate culturally and linguistically tailored evidence-based techniques for promoting self-management into usual care, and provide patients with tools and resources for self-management. Examples of evidence-based techniques to use in usual care include: goal setting with structured follow-up, Teach-back methods, action planning, assessment of need for self-management (for example, the Patient Activation Measure), and motivational interviewing. Examples of tools and resources to provide patients directly or through community organizations include: peer-led support for self-management, condition-specific chronic disease or substance use disorder self-management programs, and self-management materials.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M0002", "M0004", "M1366", "M1369", "M1370", "M1500" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_19", "title": "Use group visits for common chronic conditions (e.g., diabetes).", "description": "Use group visits for common chronic conditions (e.g., diabetes).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_22", "title": "Improved Practices that Engage Patients Pre-Visit", "description": "Implementation of workflow changes that engage patients prior to the visit, such as a pre-visit development of a shared visit agenda with the patient, or targeted pre-visit laboratory testing that will be resulted and available to the MIPS eligible clinician to review and discuss during the patient’s appointment.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0059", "M1500" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_23", "title": "Integration of patient coaching practices between visits", "description": "Provide coaching between visits with follow-up on care plan and goals.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M1369", "M1424" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_24", "title": "Financial Navigation Program", "description": "In order to receive credit for this activity, MIPS eligible clinicians must attest that their practice provides financial counseling to patients or their caregiver about costs of care and an exploration of different payment options. The MIPS eligible clinician may accomplish this by working with other members of their practice (for example, financial counselor or patient navigator) as part of a team-based care approach in which members of the patient care team collaborate to support patient- centered goals. For example, a financial counselor could provide patients with resources with further information or support options, or facilitate a conversation with a patient or caregiver that could address concerns. This activity may occur during diagnosis stage, before treatment, during treatment, and/or during survivorship planning, as appropriate.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "M0001", "M0004" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_25", "title": "Drug Cost Transparency", "description": "Provide counseling to patients and/or their caregivers regarding: costs of medications using a real time benefit tool (RTBT) which provides to the prescriber real-time patient-specific formulary and benefit information for drugs, including cost-sharing for a beneficiary.", "metricType": "boolean", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0055", "M1420" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_26", "title": "Promote Use of Patient-Reported Outcome Tools", "description": "Demonstrate performance of activities for employing patient-reported outcome (PRO) tools and corresponding collection of PRO data such as the use of PHQ-2 or PHQ-9, PROMIS instruments, patient reported Wound-Quality of Life (QoL), patient reported Wound Outcome, and patient reported Nutritional Screening.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0058", "M0002", "M0004", "M0005", "M1366", "M1367", "M1369", "M1370", "M1422", "M1423", "M1424", "M1425", "M1499", "M1501", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BE_27", "title": "Comprehensive Eye Exams", "description": "To receive credit for this activity, MIPS eligible clinicians must promote the importance of a comprehensive eye exam, which may be accomplished by any one or more of the following:\n • providing literature,\n • facilitating a conversation about this topic using resources such as the \"Think About Your Eyes\" campaign,\n • referring patients to resources providing no-cost eye exams, such as the American Academy of Ophthalmology’s EyeCare America and the American Optometric Association’s VISION USA, or\n • promoting access to vision rehabilitation services as appropriate for individuals with chronic vision impairment.This activity is intended for:\n • Non-ophthalmologists / optometrists who refer patients to an ophthalmologist/optometrist;\n • Ophthalmologists/optometrists caring for underserved patients at no cost; or\n • Any clinician providing literature and/or resources on this topic.This activity must be targeted at underserved and/or high-risk populations that would benefit from engagement regarding their eye health with the aim of improving their access to comprehensive eye exams or vision rehabilitation services.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "subcategoryId": "beneficiaryEngagement", "allowedPrograms": [ "mips", "app1", "appPlus" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BMH_1", "title": "Antipsychotic-Medication-Associated Physical Health Condition Assessment and Monitoring", "description": "MIPS eligible clinicians must implement at least one process improvement during treatment of patients taking anti-psychotic medication related to one or more component(s) of appropriate antipsychotic medication assessment and monitoring. Components include: \n• Personal and family history of obesity, diabetes, dyslipidemia, hypertension, or cardiovascular disease; \n• Body Mass Index (BMI); \n• Waist circumference; \n• Blood pressure; \n• Fasting plasma glucose; \n• Fasting lipid profile; \n• Clinical assessment of abnormal movements, such as through the Abnormal Involuntary Movement Scale (AIMS). \n\nProcess improvements must include at least one of the following types of activities: \n• Establishing and disseminating educational materials (for example, online or in-person training sessions) to educate clinical teams about physical health monitoring and protocols for monitoring (for example, AIMS assessment for medication-induced movement disorders); \n• Creating and implementing monitoring templates and protocols (for example, EHR-integrated flags), to standardize collection and documentation of one or more components of physical health monitoring; or\n• Establishing collaborative service agreements with an enhanced monitoring service, (for example, pharmacist-led monitoring clinic) to monitor for antipsychotic associated physical health condition and either adjust medications (for example, diabetes medications) based on laboratory results or refer patients for further \nassessments (for example, AIMS).”", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "appPlus" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BMH_2", "title": "Tobacco use", "description": "Tobacco use: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including tobacco use screening and cessation interventions (refer to NQF #0028) for patients with co-occurring conditions of behavioral or mental health and at risk factors for tobacco dependence.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0059", "M1369" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BMH_4", "title": "Depression screening", "description": "Depression screening and follow-up plan: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including depression screening and follow-up plan (refer to NQF #0418) for patients with co-occurring conditions of behavioral or mental health conditions.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "appPlus", "M0004" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BMH_5", "title": "MDD prevention and treatment interventions", "description": "Major depressive disorder: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including suicide risk assessment (refer to NQF #0104) for mental health patients with co-occurring conditions of behavioral or mental health conditions.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "appPlus", "M1369" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BMH_7", "title": "Implementation of Integrated Patient Centered Behavioral Health Model", "description": "Offer integrated behavioral health services to support patients with behavioral health needs who also have conditions such as dementia or other poorly controlled chronic illnesses. The services could include one or more of the following: • Use evidence-based treatment protocols and treatment to goal where appropriate;• Use evidence-based screening and case finding strategies to identify individuals at risk and in need of services;• Ensure regular communication and coordinated workflows between MIPS eligible clinicians in primary care and behavioral health;• Conduct regular case reviews for at-risk or unstable patients and those who are not responding to treatment;• Use of a registry or health information technology functionality to support active care management and outreach to patients in treatment;• Integrate behavioral health and medical care plans and facilitate integration through co-location of services when feasible; and/or• Participate in the National Partnership to Improve Dementia Care Initiative, which promotes a multidimensional approach that includes public reporting, state-based coalitions, research, training, and revised surveyor guidance.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "appPlus", "M1369", "M1500" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BMH_9", "title": "Unhealthy Alcohol Use for Patients with Co-occurring Conditions of Mental Health and Substance Abuse and Ambulatory Care Patients", "description": "Individual MIPS eligible clinicians or groups must regularly engage in integrated prevention and treatment interventions, including screening and brief counseling (for example: NQF #2152) for patients with co-occurring conditions of mental health and substance abuse. MIPS eligible clinicians would attest that 60 percent for the CY 2018 Quality Payment Program performance period, and 75 percent beginning in the 2019 performance period, of their ambulatory care patients are screened for unhealthy alcohol use.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "appPlus" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BMH_10", "title": "Completion of Collaborative Care Management Training Program", "description": "To receive credit for this activity, MIPS eligible clinicians must complete a collaborative care management training program, such as the American Psychiatric Association (APA) Collaborative Care Model training program available to the public, in order to implement a collaborative care management approach that provides comprehensive training in the integration of behavioral health into the primary care practice.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "appPlus" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BMH_11", "title": "Implementation of a Trauma-Informed Care (TIC) Approach to Clinical Practice", "description": "Create and implement a plan for trauma-informed care (TIC) that recognizes the potential impact of trauma experiences on patients and takes steps to mitigate the effects of adverse events in order to avoid re-traumatizing or triggering past trauma. Actions in this plan may include, but are not limited to, the following:•\tIncorporate trauma-informed training into new employee orientation •\tOffer annual refreshers and/or trainings for all staff •\tRecommend and supply TIC materials to third party partners, including care management companies and billing services•\tIdentify patients using a screening methodology•\tFlag charts for patients with one or more adverse events that might have caused trauma•\tUse ICD-10 diagnosis codes for adverse events when appropriateTIC is a strengths-based healthcare delivery approach that emphasizes physical, psychological, and emotional safety for both trauma survivors and their providers. Core components of a TIC approach are: awareness of the prevalence of trauma; understanding of the impact of past trauma on services utilization and engagement; and a commitment and plan to incorporate that understanding into training, policy, procedure, and practice.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "appPlus", "M1366" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BMH_12", "title": "Promoting Clinician Well-Being", "description": "Develop and implement programs to support clinician well-being and resilience—for example, through relationship-building opportunities, leadership development plans, or creation of a team within a practice to address clinician well-being—using one of the following approaches:•\tCompletion of clinician survey on clinician well-being with subsequent implementation of an improvement plan based on the results of the survey.•\tCompletion of training regarding clinician well-being with subsequent implementation of a plan for improvement.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "appPlus", "G0057", "M0001", "M1370", "M1498", "M1499", "M1501", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BMH_14", "title": "Behavioral/Mental Health and Substance Use Screening & Referral for Pregnant and Postpartum Women", "description": "Screen for perinatal mood and anxiety disorders (PMADs) and substance use disorder (SUD) in pregnant and postpartum women, and screen and refer to treatment and/or refer to appropriate social services, and document this in patient care plans.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "appPlus", "M1366", "M1369" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_BMH_15", "title": "Behavioral/Mental Health and Substance Use Screening & Referral for Older Adults", "description": "Complete age-appropriate screening for mental health and substance use in older adults, as well as screening and referral to treatment and/or referral to appropriate social services, and document this in-patient care plans.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": "behavioralAndMentalHealth", "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "M1369", "M1370" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_7", "title": "Regular training in care coordination", "description": "Implementation of regular care coordination training.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0058", "M1422", "M1423", "M1498", "M1499" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_8", "title": "Implementation of documentation improvements for practice/process improvements", "description": "Implementation of practices/processes that document care coordination activities (e.g., a documented care coordination encounter that tracks all clinical staff involved and communications from date patient is scheduled for outpatient procedure through day of procedure).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "M1370", "M1498", "M1499" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_9", "title": "Implementation of practices/processes for developing regular individual care plans", "description": "Implementation of practices/processes, including a discussion on care, to develop regularly updated individual care plans for at-risk patients that are shared with the beneficiary or caregiver(s). Individual care plans should include consideration of a patient’s goals and priorities, as well as desired outcomes of care.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "G0058", "M1366", "M1420", "M1422", "M1424", "M1499", "M1500", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_10", "title": "Care transition documentation practice improvements", "description": "In order to receive credit for this activity, a MIPS eligible clinician must document practices/processes for care transition with documentation of how a MIPS eligible clinician or group carried out an action plan for the patient with the patient’s preferences in mind (that is, a “patient-centered” plan) during the first 30 days following a discharge. Examples of these practices/processes for care transition include: staff involved in the care transition; phone calls conducted in support of transition; accompaniments of patients to appointments or other navigation actions; home visits; patient information access to their medical records; real time communication between PCP and consulting clinicians; PCP included on specialist follow-up or transition communications.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "M1420", "M1422" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_11", "title": "Care transition standard operational improvements", "description": "Establish standard operations to manage transitions of care that could include one or more of the following: • Establish formalized lines of communication with local settings in which empaneled patients receive care to ensure documented flow of information and seamless transitions in care; and/or• Partner with community or hospital-based transitional care services.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_12", "title": "Care coordination agreements that promote improvements in patient tracking across settings", "description": "Establish effective care coordination and active referral management that could include one or more of the following:• Establish care coordination agreements with frequently used consultants that set expectations for documented flow of information and MIPS eligible clinician or MIPS eligible clinician group expectations between settings. Provide patients with information that sets their expectations consistently with the care coordination agreements; • Track patients referred to specialist through the entire process; and/or• Systematically integrate information from referrals into the plan of care.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "M1370", "M1498", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_13", "title": "Practice Improvements to Align with OpenNotes Principles", "description": "Adherence to the principles described in the OpenNotes initiative (https://www.opennotes.org) to ensure that patients have full access to their patient information to guide patient care.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "G0058", "M0001", "M0002", "M0005", "M1367", "M1420", "M1422", "M1423" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_15", "title": "PSH Care Coordination", "description": "Participation in a Perioperative Surgical Home (PSH) that provides a patient-centered, physician-led, interdisciplinary, and team-based system of coordinated patient care, which coordinates care from pre-procedure assessment through the acute care episode, recovery, and post-acute care. This activity allows for reporting of strategies and processes related to care coordination of patients receiving surgical or procedural care within a PSH. The clinician must perform one or more of the following care coordination activities:• Coordinate with care managers/navigators in preoperative clinic to plan and implementation comprehensive post discharge plan of care;• Deploy perioperative clinic and care processes to reduce post-operative visits to emergency rooms;• Implement evidence-informed practices and standardize care across the entire spectrum of surgical patients; or• Implement processes to ensure effective communications and education of patients’ post-discharge instructions.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0058", "G0059", "M1425", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_16", "title": "Primary Care Physician and Behavioral Health Bilateral Electronic Exchange of Information for Shared Patients", "description": "The primary care and behavioral health practices use the same electronic health record system for shared patients or have an established bidirectional flow of primary care and behavioral health records.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_17", "title": "Patient Navigator Program", "description": "Implement a Patient Navigator Program that offers evidence-based resources and tools to reduce avoidable hospital readmissions, utilizing a patient-centered and team-based approach, leveraging evidence-based best practices to improve care for patients by making hospitalizations less stressful, and the recovery period more supportive by implementing quality improvement strategies.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "M0001", "M1423", "M1425", "M1499" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_18", "title": "Relationship-Centered Communication", "description": "In order to receive credit for this activity, MIPS eligible clinicians must participate in a minimum of eight hours of training on relationship-centered care tenets such as making effective open-ended inquiries; eliciting patient stories and perspectives; listening and responding with empathy; using the ART (ask, respond, tell) communication technique to engage patients, and developing a shared care plan. The training may be conducted in formats such as, but not limited to: interactive simulations practicing the skills above, or didactic instructions on how to implement improvement action plans, monitor progress, and promote stability around improved clinician communication.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "M1425" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_CC_19", "title": "Tracking of clinician’s relationship to and responsibility for a patient by reporting MACRA patient relationship codes.", "description": "To receive credit for this improvement activity, a MIPS eligible clinician must attest that they reported MACRA patient relationship codes (PRC) using the applicable HCPCS modifiers on 50 percent or more of their Medicare claims for a minimum of a continuous 90-day period within the performance period. Reporting the PRC modifiers enables the identification of a clinician’s relationship with, and responsibility for, a patient at the time of furnishing an item or service. See the CY 2018 PFS final rule (82 FR 53232 through 53234) for more details on these codes.", "metricType": "boolean", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "subcategoryId": "careCoordination", "allowedPrograms": [ "mips", "app1", "appPlus", "G0059", "M1498", "M1499", "M1501", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_EPA_2", "title": "Use of telehealth services that expand practice access", "description": "Create and implement a standardized process for providing telehealth services to expand access to care.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "M0001", "M0004", "M1366", "M1369", "M1370", "M1421", "M1423", "M1424", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_EPA_3", "title": "Collection and use of patient experience and satisfaction data on access", "description": "Collection of patient experience and satisfaction data on access to care and development of an improvement plan, such as outlining steps for improving communications with patients to help understanding of urgent access needs.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "appPlus", "M1370", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_EPA_4", "title": "Additional improvements in access as a result of QIN/QIO TA", "description": "As a result of Quality Innovation Network-Quality Improvement Organization technical assistance, performance of additional activities that improve access to services or improve care coordination (for example, investment of on-site diabetes educator).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "appPlus" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_EPA_5", "title": "Participation in User Testing of the Quality Payment Program Website (https://qpp.cms.gov/)", "description": "User participation in the Quality Payment Program website testing is an activity for eligible clinicians who have worked with CMS to provide substantive, timely, and responsive input to improve the CMS Quality Payment Program website through product user-testing that enhances system and program accessibility, readability and responsiveness as well as providing feedback for developing tools and guidance thereby allowing for a more user-friendly and accessible clinician and practice Quality Payment Program website experience.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "appPlus" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_EPA_6", "title": "Create and Implement a Language Access Plan", "description": "Create and implement a language access plan to address communication barriers for individuals with limited English proficiency. The language access plan must align with standards for communication and language assistance defined in the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care (https://thinkculturalhealth.hhs.gov/clas).", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "appPlus" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_EPA_7", "title": "Enhance Engagement of Medicaid and Other Underserved Populations", "description": "To improve responsiveness of care for Medicaid and other underserved patients: use time-to-treat data (i.e., data measuring the time between clinician identifying a need for an appointment and the patient having a scheduled appointment) to identify patterns by which care or engagement with Medicaid patients or other groups of underserved patients has not achieved standard practice guidelines; and with this information, create, implement, and monitor an approach for improvement. This approach may include screening for patient barriers to treatment, especially transportation barriers, and providing resources to improve engagement (e.g., state Medicaid non-emergency medical transportation benefit).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "appPlus", "M1366", "M1368", "M1369", "M1420", "M1421", "M1500", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_EPA_8", "title": "Provide Education Opportunities for New Clinicians", "description": "MIPS eligible clinicians acting as a preceptor for clinicians-in-training (such as medical residents/fellows, medical students, physician assistants, nurse practitioners, or clinical nurse specialists) and accepting such clinicians for clinical rotations in community practices in small, underserved, or rural areas.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "expandedPracticeAccess", "allowedPrograms": [ "mips", "app1", "appPlus", "M1370", "M1421", "M1422", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_ERP_1", "title": "Participation on Disaster Medical Assistance Team, registered for 6 months.", "description": "Participation in Disaster Medical Assistance Teams, or Community Emergency Responder Teams. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and MIPS eligible clinician groups must be registered for a minimum of 6 months as a volunteer for disaster or emergency response.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "emergencyResponseAndPreparedness", "allowedPrograms": [ "mips", "app1", "appPlus" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_ERP_2", "title": "Participation in a 60-day or greater effort to support domestic or international humanitarian needs.", "description": "Participation in domestic or international humanitarian volunteer work. Activities that simply involve registration are not sufficient. MIPS eligible clinicians and groups attest to domestic or international humanitarian volunteer work for a period of a continuous 60 days or greater.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "emergencyResponseAndPreparedness", "allowedPrograms": [ "mips", "app1", "appPlus" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_MVP", "title": "Practice-Wide Quality Improvement in MIPS Value Pathways", "description": "Create a quality improvement initiative within your practice and create a culture in which all staff actively participates. Clinicians must be participating in MIPS Value Pathways (MVPs) to attest to this activity.\n\nCreate a quality improvement plan that involves a minimum of three of the measures within a specific MVP and that is characterized by the following:\n• Train all staff in quality improvement methods, particularly as related to other quality initiatives currently underway in the practice;\n• Promote transparency and accelerate improvement by sharing practice-level and panel-level quality of care and patient experience and utilization data with staff;\n• Integrate practice change/quality improvement into all staff duties, including communication and education regarding all current quality initiatives;\n• Designate regular team meetings to review data and plan improvement cycles with defined, iterative goals as appropriate; and/or\n• Promote transparency and engage patients and families by sharing practice-level quality of care and patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data.\n\nIn addition, clinicians may consider:\n• Creation of specific plans for recognition of individual or groups of clinicians and staff when they meet certain practice-defined quality goals. Examples include recognition for achieving success in measure reporting and/or a high level of effort directed to quality improvement and practice standardization; or\n• Participation in the American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PCMH", "title": "Electronic submission of Patient Centered Medical Home accreditation", "description": "I attest that I am a Patient Centered Medical Home (PCMH) or Comparable Specialty Practice that has achieved certification from a national program, regional or state program, private payer, or other body that administers patient-centered medical home accreditation and should receive full credit for the Improvement Activities performance category.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": null, "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_2", "title": "Anticoagulant Management Improvements", "description": "Individual MIPS eligible clinicians and groups who prescribe anti-coagulation medications (including, but not limited to oral Vitamin K antagonist therapy, including warfarin or other coagulation cascade inhibitors) must attest that for 75 percent of their ambulatory care patients receiving these medications are being managed with support from one or more of the following improvement activities:• Participation in a systematic anticoagulation program (coagulation clinic, patient self-reporting program, or patient self-management program);• Patients are being managed by an anticoagulant management service, that involves systematic and coordinated care, incorporating comprehensive patient education, systematic prothrombin time (PT-INR) testing, tracking, follow-up, and patient communication of results and dosing decisions;• Patients are being managed according to validated electronic decision support and clinical management tools that involve systematic and coordinated care, incorporating comprehensive patient education, systematic PT-INR testing, tracking, follow-up, and patient communication of results and dosing decisions;• For rural or remote patients, patients are managed using remote monitoring or telehealth options that involve systematic and coordinated care, incorporating comprehensive patient education, systematic PT-INR testing, tracking, follow-up, and patient communication of results and dosing decisions; or• For patients who demonstrate motivation, competency, and adherence, patients are managed using either a patient self-testing (PST) or patient-self-management (PSM) program.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_3", "title": "RHC, IHS or FQHC quality improvement activities", "description": "Participating in a Rural Health Clinic (RHC), Indian Health Service Medium Management (IHS), or Federally Qualified Health Center in ongoing engagement activities that contribute to more formal quality reporting, and that include receiving quality data back for broader quality improvement and benchmarking improvement which will ultimately benefit patients. Participation in Indian Health Service, as an improvement activity, requires MIPS eligible clinicians and groups to deliver care to federally recognized American Indian and Alaska Native populations in the U.S. and in the course of that care implement continuous clinical practice improvement including reporting data on quality of services being provided and receiving feedback to make improvements over time.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_4", "title": "Glycemic management services", "description": "For outpatient Medicare beneficiaries with diabetes and who are prescribed antidiabetic agents (e.g., insulin, sulfonylureas), MIPS eligible clinicians and groups must attest to having: For the first performance year, at least 60 percent of medical records with documentation of an individualized glycemic treatment goal that: a) Takes into account patient-specific factors, including, at least 1) age, 2) comorbidities, and 3) risk for hypoglycemia, andb) Is reassessed at least annually.The performance threshold will increase to 75 percent for the second performance year and onward.Clinician would attest that, 60 percent for first year, or 75 percent for the second year, of their medical records that document individualized glycemic treatment represent patients who are being treated for at least 90 days during the performance period.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_5", "title": "Engagement of community for health status improvement", "description": "Take steps to improve health status of communities, such as collaborating with key partners and stakeholders to implement evidenced-based practices to improve a specific chronic condition. Refer to the local Quality Improvement Organization (QIO) for additional steps to take for improving health status of communities as there are many steps to select from for satisfying this activity. QIOs work under the direction of CMS to assist MIPS eligible clinicians and groups with quality improvement, and review quality concerns for the protection of beneficiaries and the Medicare Trust Fund.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_11", "title": "Regular review practices in place on targeted patient population needs", "description": "Implement regular reviews of targeted patient population needs, such as structured clinical case reviews, which include access to reports that show unique characteristics of MIPS eligible clinician's patient population, identification of underserved patients, and how clinical treatment needs are being tailored, if necessary, to address unique needs and what resources in the community have been identified as additional resources. The review should consider how structural inequities, such as racism, are influencing patterns of care and consider changes to acknowledge and address them. Reviews should stratify patient data by demographic characteristics and health related social needs to appropriately identify differences among unique populations and assess the drivers of gaps and disparities and identify interventions appropriate for the needs of the sub-populations.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M0002", "M0004", "M0005", "M1368", "M1425", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_14", "title": "Implementation of methodologies for improvements in longitudinal care management for high risk patients", "description": "Provide longitudinal care management to patients at high risk for adverse health outcome or harm that could include one or more of the following: • Use a consistent method to assign and adjust global risk status for all empaneled patients to allow risk stratification into actionable risk cohorts. Monitor the risk-stratification method and refine as necessary to improve accuracy of risk status identification; • Use a personalized plan of care for patients at high risk for adverse health outcome or harm, integrating patient goals, values and priorities; and/or• Use on-site practice-based or shared care managers to proactively monitor and coordinate care for the highest risk cohort of patients.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "M0001", "M1368", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_15", "title": "Implementation of episodic care management practice improvements", "description": "Provide episodic care management, including management across transitions and referrals that could include one or more of the following:• Routine and timely follow-up to hospitalizations, ED visits and stays in other institutional settings, including symptom and disease management, and medication reconciliation and management; and/or• Managing care intensively through new diagnoses, injuries and exacerbations of illness.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "M0001", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_16", "title": "Implementation of medication management practice improvements", "description": "Manage medications to maximize efficiency, effectiveness and safety that could include one or more of the following: • Reconcile and coordinate medications and provide medication management across transitions of care settings and eligible clinicians or groups; • Integrate a pharmacist into the care team; and/or• Conduct periodic, structured medication reviews.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "M0001", "M0002", "M0004", "M0005", "M1367", "M1420", "M1421", "M1424", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_17", "title": "Participation in Population Health Research", "description": "Participation in federally and/or privately funded research that identifies interventions, tools, or processes that can improve a targeted patient population.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M1423", "M1499" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_18", "title": "Provide Clinical-Community Linkages", "description": "Engaging community health workers to provide a comprehensive link to community resources through family-based services focusing on success in health, education, and self-sufficiency. This activity supports individual MIPS eligible clinicians or groups that coordinate with primary care and other clinicians, engage and support patients, use of health information technology, and employ quality measurement and improvement processes. An example of this community based program is the NCQA Patient-Centered Connected Care (PCCC) Recognition Program or other such programs that meet these criteria.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_19", "title": "Glycemic Screening Services", "description": "For at-risk outpatient Medicare beneficiaries, individual MIPS eligible clinicians and groups must attest to implementation of systematic preventive approaches in clinical practice for at least 60 percent for the 2018 performance period and 75 percent in future years, of electronic medical records with documentation of screening patients for abnormal blood glucose according to current US Preventive Services Task Force (USPSTF) and/or American Diabetes Association (ADA) guidelines.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_20", "title": "Glycemic Referring Services", "description": "For at-risk outpatient Medicare beneficiaries, individual MIPS eligible clinicians and groups must attest to implementation of systematic preventive approaches in clinical practice for at least 60 percent for the CY 2018 performance period and 75 percent in future years, of medical records with documentation of referring eligible patients with prediabetes to a CDC-recognized diabetes prevention program operating under the framework of the National Diabetes Prevention Program.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_21", "title": "Advance Care Planning", "description": "Implementation of practices/processes to develop advance care planning that includes: documenting the advance care plan or living will within the medical record, educating clinicians about advance care planning motivating them to address advance care planning needs of their patients, and how these needs can translate into quality improvement, educating clinicians on approaches and barriers to talking to patients about end-of-life and palliative care needs and ways to manage its documentation, as well as informing clinicians of the healthcare policy side of advance care planning.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M0001", "M0004", "M1423", "M1500", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_22", "title": "Improving Practice Capacity for Human Immunodeficiency Virus (HIV) Prevention Services", "description": "Establish policies and procedures to improve practice capacity to increase HIV prevention screening, improve HIV prevention education and awareness, and reduce disparities in pre-exposure prophylaxis (PrEP) uptake. Use one or more of the following activities:\n• Implement electronic health record (EHR) prompts or clinical decision support tools to increase appropriate HIV prevention screening; \n• Require that providers and designated clinical staff take part in at least one educational opportunity that includes components on the importance and application of HIV prevention screening and PrEP initiation in clinical practice; and/or \n• Assess and refine current policies for HIV prevention screening, including integrated sexually transmitted infection (STI)/HIV testing processes, universal HIV screening, and PrEP initiation.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M0005", "M1368" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_23", "title": "Use of Computable Guidelines and Clinical Decision Support to Improve Adherence for Cervical Cancer Screening and Management Guidelines", "description": "Incorporate the Cervical Cancer Screening and Management (CCSM) Clinical Decision Support (CDS) tool within the electronic health record (EHR) system to provide clinicians with ready access to and assisted interpretation of the most up-to-date clinical practice guidelines in CCSM to ensure adequate screening, timely follow-up, and optimal patient care.\n\nThe CCSM CDS helps ensure that patient populations receive adequate screening and management, according to evidence-based recommendations in the United States Preventive Services Task Force (USPSTF) screening and American Society for Colposcopy and Cervical Pathology (ASCCP) management guidelines for cervical cancer. The CDS integrates into the clinical workflow a clinician-facing dashboard to support the clinician’s awareness and adoption of and preventive care for cervical cancer, including screening and any necessary follow-up treatment.\n\nThe CCSM CDS is fully conformant with the HL7 Fast Healthcare Interoperability Resources (FHIR) standard, so it can be used with any certified EHR platform. The CDS Hooks and SMART-on-FHIR interoperability interface standards provide two ways to integrate with the clinical workflow in a way that complements existing displays and information pre-visit, during visit, and for post-visit follow-up. CCSM CDS helps the clinician evaluate the patient’s clinical data against existing guidance and displays patient-specific recommendations.", "metricType": "boolean", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M0005", "M1366" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_24", "title": "Implementation of Protocols and Provision of Resources to Increase Lung Cancer Screening Uptake", "description": "Establish a process or procedure to increase rates of lung cancer screening through one or more of the following interventions:\n•Implementation of protocols that support enhanced documentation methods to identify eligible patients for lung cancer screening. \n++ Example: A practice could embed electronic health record (EHR) prompts to flag insufficient patient smoking history (for example, total pack-years) and increase practice awareness around patient eligibility for screening\n++ Example: A practice could implement documentation processes or procedures (for example, retrospective chart review, lung cancer screening eligibility questionnaire) to improve patient lung cancer screening eligibility data in the medical record\n•Development of a patient outreach and activation plan consisting of educational materials and resources for patients at high-risk of lung cancer for improved patient engagement and decision-making. \n++ Example: Providers or clinic staff could provide culturally and linguistically appropriate patient-directed educational or care navigation materials related to lung cancer screening, eligibility criteria for low-dose computed tomography (LDCT), and the purpose and benefits of screening\n++ Example: Providers or clinic staff could provide tools to prepare patients for shared decision-making (SDM) clinical encounters and promote patient/provider communication on lung cancer screening decision-making\n•Establishment of a navigation program to improve uptake and adherence of lung cancer screening and increase rates of LDCT referral completion. \n++ Example: A practice could designate and train existing clinic staff or hire an additional staff member to counsel patients on the importance of lung cancer screening and refer them to existing resources (for example, transportation assistance, translator, financial services, appointment scheduling) to support ability to obtain LDCT\n++ Example: A practice could create a process to follow up with referred patients via telephone reminders or virtual notifications (for example, email, patient charts)", "metricType": "boolean", "firstPerformanceYear": 2025, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_25", "title": "Save a Million Hearts: Standardization of Approach to Screening and Treatment for Cardiovascular Disease Risk", "description": "Implement standardized, evidence-based cardiovascular disease risk assessment and care management for a defined population in the clinician’s practice.\nThe clinician or clinician group will apply standardized risk assessment and care management to a broad, clinician-defined patient population in the practice. The population can be defined by 1) patient age and/or atherosclerotic cardiovascular disease (ASCVD) risk factors; or 2) the constraints of the risk assessment tool (for example, the American College of Cardiology (ACC)/American Heart Association (AHA) ASCVD Risk Calculator is validated for patients over age 40).\nThe results of screening and the plan for treatment and follow up will be documented using a standardized method in the patient’s medical record. Care management plan and follow up intervals will be influenced by the degree of patient risk.\nCardiovascular care management should be defined by risk assessment and lead to the development of individualized care plans with specific goals. Shared decision making should be part of the development of every patient care plan.", "metricType": "boolean", "firstPerformanceYear": 2025, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus", "M0005" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_27", "title": "Improving Detection of Cognitive Impairment in Primary Care", "description": "To increase the detection rate of cognitive impairment, particularly in early stages, the MIPS eligible primary care clinician must perform the following activities:\n• Determine his/her baseline detection rates for mild cognitive impairment (MCI), dementia, and cognitive impairment at either stage using the tool provided for this Improvement Activity\n• If any of the three rates are below 1.0:\n o Increase the uptake of the Annual Wellness Visit\n o Ensure that each Annual Wellness Visit contains a structured cognitive assessment\n o Include a question about subjective memory concerns to the collection of vital signs during intake for patients 65+, and conduct a structured cognitive assessment in those with concerns\n• Remeasure detection rates for MCI, dementia, and cognitive impairment at either stage quarterly\nThis Improvement Activity should only focus on Medicare patients aged 65 and older, given the strong correlation of cognitive impairment with age.", "metricType": "boolean", "firstPerformanceYear": 2026, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PM_28", "title": "Integrating Oral Health Care in Primary Care", "description": "MIPS eligible clinicians that practice primary care will include an oral health risk assessment and intraoral screening as part of a patient's primary care management. The MIPS eligible clinician will provide education and counseling to the patient to include the importance of oral health and the impact of oral health on systemic diseases. For patients without a dental home and/or those with oral health needs, a dental referral will be provided. \n\nTo receive credit for this activity, a MIPS eligible clinician must complete two Smiles for Life (https://www.smilesforlifeoralhealth.org) trainings: (“The Oral Examination” and “Geriatric Oral Health”). These are one-time, free, online training 60-minute certification courses. Smiles for Life oral health education has been adopted by Medicaid in several states to improve oral health access, outcomes, and referrals for children through educating medical providers. \n\nThe MIPS eligible clinician must include one or more of the following activities in addition to completing the training: \n \n• Create a dental referral network list by specialty and accepted insurances. \n• Include applicable oral health screening questions in the patient health intake forms (dentist of record, date of the last dental exam, and personal oral hygiene routine). \n• Identify an applicable caries risk assessment tool to be used. \n• Include intraoral health screening and referral to dental provider as part of a patient's primary care management. \n• Provide education and counseling to patients about the importance of oral health and impact on systemic disease. \n• Refer patients without a dental home and/or those who have untreated dental disease indicated by health history, caries risk assessment, Intraoral health screening, medications and/or concerns reported by patient. \n• Include a description of the findings found in all dental referrals. \n o Documents with appropriate procedure and diagnostic codes to track services provided and referrals to validate performance of the improvement activity.", "metricType": "boolean", "firstPerformanceYear": 2026, "lastPerformanceYear": null, "subcategoryId": "populationManagement", "allowedPrograms": [ "mips", "app1", "appPlus" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_1", "title": "Participation in an AHRQ-listed patient safety organization.", "description": "Participation in an AHRQ-listed patient safety organization.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0057", "G0059", "M1498", "M1499", "M1501", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_2", "title": "Participation in MOC Part IV", "description": "In order to receive credit for this activity, a MIPS eligible clinician must participate in Maintenance of Certification (MOC) Part IV. Maintenance of Certification (MOC) Part IV requires clinicians to perform monthly activities across practice to regularly assess performance by reviewing outcomes addressing identified areas for improvement and evaluating the results. Some examples of activities that can be completed to receive MOC Part IV credit are: the American Board of Internal Medicine (ABIM) Approved Quality Improvement (AQI) Program, National Cardiovascular Data Registry (NCDR) Clinical Quality Coach, Quality Practice Initiative Certification Program, American Board of Medical Specialties Practice Performance Improvement Module or American Society of Anesthesiologists (ASA) Simulation Education Network, for improving professional practice including participation in a local, regional or national outcomes registry or quality assessment program; specialty- specific activities including Safety Certification in Outpatient Practice Excellence (SCOPE); American Psychiatric Association (APA) Performance in Practice modules.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "M1498", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_3", "title": "Participate in IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS® or Other Similar Activity", "description": "For MIPS eligible clinicians not participating in Maintenance of Certification (MOC) Part IV, new engagement for MOC Part IV, such as the Institute for Healthcare Improvement (IHI) Training/Forum Event; National Academy of Medicine, Agency for Healthcare Research and Quality (AHRQ) Team STEPPS®, or the American Board of Family Medicine (ABFM) Performance in Practice Modules.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_4", "title": "Administration of the AHRQ Survey of Patient Safety Culture", "description": "Administration of the AHRQ Survey of Patient Safety Culture and submission of data to the comparative database (refer to AHRQ Survey of Patient Safety Culture website http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/index.html). Note: This activity may be selected once every 4 years, to avoid duplicative information given that some of the modules may change on a year by year basis but over 4 years there would be a reasonable expectation for the set of modules to have undergone substantive change, for the improvement activities performance category score.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_7", "title": "Use of QCDR data for ongoing practice assessment and improvements", "description": "Participation in a Qualified Clinical Data Registry (QCDR) and use of QCDR data for ongoing practice assessment and improvements in patient safety, including:\n• Performance of activities that promote use of standard practices, tools, and processes for quality improvement (for example, documented preventive health efforts, like screening and vaccinations) that can be shared across MIPS eligible clinicians or groups);\n• Use of standard questionnaires for assessing improvements in health disparities related to functional health status (for example, use of Seattle Angina Questionnaire, MD Anderson Symptom Inventory, and/or SF-12/VR-12 functional health status assessment);\n• Use of standardized processes for screening for drivers of health, such as food security, housing stability, and transportation accessibility;\n• Generation and use of regular feedback reports that summarize local practice patterns and treatment outcomes, including for populations that are disadvantaged and/or underserved by the healthcare system;\n• Use of processes and tools that engage patients to improve adherence to treatment plans;\n• Implementation of patient self-action plans;\n• Implementation of shared clinical decision-making capabilities;\n• Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement;\n• Promotion of collaborative learning network opportunities that are interactive;\n• Use of supporting QCDR modules that can be incorporated into the certified EHR technology; or\n• Use of QCDR data for quality improvement, such as comparative analysis across specific patient populations of adverse outcomes after an outpatient surgical procedure and corrective steps to address these outcomes.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0055", "G0057", "G0058", "G0059", "M1367", "M1420", "M1423", "M1425", "M1498", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_8", "title": "Use of Patient Safety Tools", "description": "In order to receive credit for this activity, a MIPS eligible clinician must use tools that assist specialty practices in tracking specific measures that are meaningful to their practice.Some examples of tools that could satisfy this activity are: a surgical risk calculator; evidence based protocols, such as Enhanced Recovery After Surgery (ERAS) protocols; the Centers for Disease Control (CDC) Guide for Infection Prevention for Outpatient Settings predictive algorithms; and the opiate risk tool (ORT) or similar tool.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "M1421", "M1425" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_9", "title": "Completion of the AMA STEPS Forward program", "description": "Completion of the American Medical Association’s STEPS Forward program.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_12", "title": "Participation in private payer CPIA", "description": "Participation in designated private payer clinical practice improvement activities.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "M1423", "M1498", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_13", "title": "Participation in Joint Commission Evaluation Initiative", "description": "Participation in Joint Commission Ongoing Professional Practice Evaluation initiative.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "M0001", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_15", "title": "Implementation of an ASP", "description": "Leadership of an Antimicrobial Stewardship Program (ASP) that includes implementation of an ASP that measures the appropriate use of antibiotics for several different conditions (such as but not limited to upper respiratory infection treatment in children, diagnosis of pharyngitis, bronchitis treatment in adults) according to clinical guidelines for diagnostics and therapeutics. Specific activities may include: • Develop facility-specific antibiogram and prepare report of findings with specific action plan that aligns with overall facility or practice strategic plan.• Lead the development, implementation, and monitoring of patient care and patient safety protocols for the delivery of ASP including protocols pertaining to the most appropriate setting for such services (i.e., outpatient or inpatient). • Assist in improving ASP service line efficiency and effectiveness by evaluating and recommending improvements in the management structure and workflow of ASP processes.• Manage compliance of the ASP policies and assist with implementation of corrective actions in accordance with facility or clinic compliance policies and hospital medical staff by-laws. • Lead the education and training of professional support staff for the purpose of maintaining an efficient and effective ASP.• Coordinate communications between ASP management and facility or practice personnel regarding activities, services, and operational/clinical protocols to achieve overall compliance and understanding of the ASP.• Assist, at the request of the facility or practice, in preparing for and responding to third-party requests, including but not limited to payer audits, governmental inquiries, and professional inquiries that pertain to the ASP service line. • Implementing and tracking an evidence-based policy or practice aimed at improving antibiotic prescribing practices for high-priority conditions. • Developing and implementing evidence-based protocols and decision-support for diagnosis and treatment of common infections.• Implementing evidence-based protocols that align with recommendations in the Centers for Disease Control and Prevention’s Core Elements of Outpatient Antibiotic Stewardship guidance.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0057" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_16", "title": "Use decision support—ideally platform-agnostic, interoperable clinical decision support (CDS) tools —and standardized treatment protocols to manage workflow on the care team to meet patient needs.", "description": "Use decision support - ideally platform-agnostic, interoperable clinician decision support (CDS) tools - and standardized treatment protocols to manage workflow on the care team to meet patient needs. Clinicians should focus on utilizing open-source, freely available, interoperable CDS in completing the requirements of this activity.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0059", "M0001", "M0002", "M1370" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_17", "title": "Implementation of analytic capabilities to manage total cost of care for practice population", "description": "In order to receive credit for this activity, a MIPS eligible clinician must conduct or build the capacity to conduct analytic activities to manage total cost of care for the practice population. Examples of these activities could include:1.) Train appropriate staff on interpretation of cost and utilization information;2.) Use available data regularly to analyze opportunities to reduce cost through improved care. An example of a platform with the necessary analytic capability to do this is the American Society for Gastrointestinal (GI) Endoscopy’s GI Operations Benchmarking Platform.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_18", "title": "Measurement and improvement at the practice and panel level", "description": "Measure and improve quality at the practice and panel level, such as the American Board of Orthopaedic Surgery (ABOS) Physician Scorecards that could include one or more of the following:•\tRegularly review measures of quality, utilization, patient satisfaction and other measures; and/or•\tUse relevant data sources to create benchmarks and goals for performance at the practice or panel levels.MIPS eligible clinicians can apply the measurement and quality improvement to address inequities in quality and outcomes for underserved populations, including racial, ethnic, and/or gender minorities.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0058", "M1499", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_19", "title": "Implementation of formal quality improvement methods, practice changes, or other practice improvement processes", "description": "Adopt a formal model for quality improvement and create a culture in which all staff, including leadership, actively participates in improvement activities that could include one or more of the following, such as:\n• Participation in multisource feedback; \n• Train all staff in quality improvement methods;\n• Integrate practice change/quality improvement into staff duties;\n• Engage all staff in identifying and testing practices changes;\n• Designate regular team meetings to review data and plan improvement cycles;\n• Promote transparency and accelerate improvement by sharing practice level and panel level quality of care, patient experience and utilization data with staff;\n• Promote transparency and engage patients and families by sharing practice level quality of care, patient experience and utilization data with patients and families, including activities in which clinicians act upon patient experience data;\n• Participation in Bridges to Excellence;\n• Participation in American Board of Medical Specialties (ABMS) Multi-Specialty Portfolio Program.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_21", "title": "Implementation of fall screening and assessment programs", "description": "Implementation of fall screening and assessment programs to identify patients at risk for falls and address modifiable risk factors (e.g., Clinical decision support/prompts in the electronic health record that help manage the use of medications, such as benzodiazepines, that increase fall risk).", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "M0004", "M1370", "M1423" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_22", "title": "CDC Training on CDC’s Guideline for Prescribing Opioids for Chronic Pain", "description": "Completion of all the modules of the Centers for Disease Control and Prevention (CDC) course “Applying CDC’s Guideline for Prescribing Opioids” that reviews the 2016 “Guideline for Prescribing Opioids for Chronic Pain.” Note: This activity may be selected once every 4 years, to avoid duplicative information given that some of the modules may change on a year by year basis but over 4 years there would be a reasonable expectation for the set of modules to have undergone substantive change, for the improvement activities performance category score.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_23", "title": "Completion of CDC Training on Antibiotic Stewardship", "description": "Completion of all modules of the Centers for Disease Control and Prevention antibiotic stewardship course. Note: This activity may be selected once every 4 years, to avoid duplicative information given that some of the modules may change on a year by year basis but over 4 years there would be a reasonable expectation for the set of modules to have undergone substantive change, for the improvement activities performance category score.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "M1368", "M1502" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_25", "title": "Cost Display for Laboratory and Radiographic Orders", "description": "Implementation of a cost display for laboratory and radiographic orders, such as costs that can be obtained through the Medicare clinical laboratory fee schedule.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "M1499" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_26", "title": "Communication of Unscheduled Visit for Adverse Drug Event and Nature of Event", "description": "A MIPS eligible clinician providing unscheduled care (such as an emergency room, urgent care, or other unplanned encounter) attests that, for greater than 75 percent of case visits that result from a clinically significant adverse drug event, the MIPS eligible clinician provides information, including through the use of health IT to the patient’s primary care clinician regarding both the unscheduled visit and the nature of the adverse drug event within 48 hours. A clinically significant adverse event is defined as a medication-related harm or injury such as side-effects, supratherapeutic effects, allergic reactions, laboratory abnormalities, or medication errors requiring urgent/emergent evaluation, treatment, or hospitalization.", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_28", "title": "Completion of an Accredited Safety or Quality Improvement Program", "description": "Completion of an accredited performance improvement continuing medical education (CME) program that addresses performance or quality improvement according to the following criteria:• The activity must address a quality or safety gap that is supported by a needs assessment or problem analysis, or must support the completion of such a needs assessment as part of the activity;• The activity must have specific, measurable aim(s) for improvement;• The activity must include interventions intended to result in improvement;• The activity must include data collection and analysis of performance data to assess the impact of the interventions; and• The accredited program must define meaningful clinician participation in their activity, describe the mechanism for identifying clinicians who meet the requirements, and provide participant completion information.An example of an activity that could satisfy this improvement activity is completion of an accredited continuing medical education program related to opioid analgesic risk and evaluation strategy (REMS) to address pain control (that is, acute and chronic pain).", "metricType": "boolean", "firstPerformanceYear": 2018, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "M0001" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_31", "title": "Patient Medication Risk Education", "description": "In order to receive credit for this activity, MIPS eligible clinicians must provide both written and verbal education regarding the risks of concurrent opioid and benzodiazepine use for patients who are prescribed both benzodiazepines and opioids. Education must be completed for at least 75% of qualifying patients and occur: (1) at the time of initial co-prescribing and again following greater than 6 months of co- prescribing of benzodiazepines and opioids, or (2) at least once per MIPS performance period for patients taking concurrent opioid and benzodiazepine therapy.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_32", "title": "Use of CDC Guideline for Clinical Decision Support to Prescribe Opioids for Chronic Pain via Clinical Decision Support", "description": "In order to receive credit for this activity, MIPS eligible clinicians must utilize the Centers for Disease Control (CDC) Guideline for Prescribing Opioids for Chronic Pain via clinical decision support (CDS). For CDS to be most effective, it needs to be built directly into the clinician workflow and support decision making on a specific patient at the point of care. Specific examples of how the guideline could be incorporated into a CDS workflow include, but are not limited to: electronic health record (EHR)-based prescribing prompts, order sets that require review of guidelines before prescriptions can be entered, and prompts requiring review of guidelines before a subsequent action can be taken in the record.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "M1368", "M1369" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_33", "title": "Application of CDC’s Training for Healthcare Providers on Lyme Disease", "description": "Apply the Centers for Disease Control and Prevention’s (CDC) Training for Healthcare Providers on Lyme Disease using clinical decision support (CDS). CDS for Lyme disease should be built directly into the clinician workflow and support decision making for a specific patient at the point of care. Specific examples of how the guideline could be incorporated into a CDS workflow include but are not limited to: electronic health record (EHR) based prescribing prompts, order sets that require review of guidelines before prescriptions can be entered, and prompts requiring review of guidelines before a subsequent action can be taken in the record.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_34", "title": "Patient Safety in Use of Artificial Intelligence (AI)", "description": "Develop a new data-collection field within patient safety reporting systems for AI-attributable events, which would include both actual harm as well as near misses. When an event is identified, a process to identify the cause and plan for future mitigation is documented. AI-attributable events are defined broadly to include not only automated or semi-automated devices, but any electronic tool that is being used to support clinical decision making.", "metricType": "boolean", "firstPerformanceYear": 2026, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "ia", "measureId": "IA_PSPA_35", "title": "Adopt Certified Health Information Technology for Security Tags for Electronic Health Record Data", "description": "Use security labeling services available in certified Health Information Technology (IT) for electronic health record (EHR) data to facilitate data segmentation. Certification criteria for security tags may be found in the ONC Health IT Certification Program at 45 CFR 170.315(b)(7) and (b)(8).", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "subcategoryId": "patientSafetyAndPracticeAssessment", "allowedPrograms": [ "mips", "app1", "appPlus", "M1501" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_EP_1", "title": "e-Prescribing", "description": "At least one permissible prescription written by the MIPS eligible clinician is transmitted electronically using CEHRT.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVPP_1" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_EP_2", "title": "Query of the Prescription Drug Monitoring Program (PDMP)", "description": "For at least one Schedule II opioid or Schedule III or IV drug electronically prescribed using CEHRT during the performance period, the MIPS eligible clinician uses data from CEHRT to conduct a query of a PDMP for prescription drug history.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_EP_2_EX_1", "PI_EP_2_EX_2" ], "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_EP_2_EX_1", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician who is unable to electronically prescribe Schedule II opioids and Schedule III and IV drugs in accordance with applicable law during the performance period.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_EP_2_EX_2", "title": "Query of the Prescription Drug Monitoring Program (PDMP) Exclusion", "description": "Any MIPS eligible clinician who does not electronically prescribe any Schedule II opioids or Schedule III or IV drugs during the performance period.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Query-of-PDMP-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_EP_2_EX_1" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_HIE_1", "title": "Support Electronic Referral Loops By Sending Health Information", "description": "For at least one transition of care or referral, the MIPS eligible clinician that transitions or refers their patient to another setting of care or health care provider (1) creates a summary of care record using certified electronic health record technology (CEHRT); and (2) electronically exchanges the summary of care record.", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVOTC_1" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_HIE_4", "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information", "description": "For at least one electronic summary of care record received for patient encounters during the performance period for which a MIPS eligible clinician was the receiving party of a transition of care or referral, or for patient encounters during the performance period in which the MIPS eligible clinician has never before encountered the patient, the MIPS eligible clinician conducts clinical information reconciliation for medication, medication allergy, and current problem list.", "metricType": "proportion", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": [ "PI_LVITC_2" ], "substitutes": [ "PI_HIE_5", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_HIE_5", "title": "Health Information Exchange\n(HIE) Bi-Directional Exchange", "description": "The MIPS eligible clinician or group must establish the technical capacity and workflows to engage in bi-directional exchange via an HIE for all patients seen by the eligible clinician and for any patient record stored or maintained in their EHR.\nThe MIPS eligible clinician or group must attest that they engage in bi-directional exchange with an HIE to support transitions of care.", "metricType": "boolean", "firstPerformanceYear": 2021, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-HIE-Bi-Directional-Exchange-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_6" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_HIE_6", "title": "Enabling Exchange Under the Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "MIPS eligible clinicians would attest to the following: • Participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordination for Health Information Technology (ASTP/ONC’s ) website) in good standing (that is, not suspended) and enabling secure, bi-directional exchange of information to occur, in production, for every patient encounter, transition or referral, and record stored or maintained in the EHR during the performance period, in accordance with applicable law and policy. • Using the functions of CEHRT to support bi-directional exchange of patient information, in production, under this Framework Agreement.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Enabling-Exchange-Under-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_HIE_1", "PI_HIE_4", "PI_HIE_5" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_INFBLO_1", "title": "Actions to Limit or Restrict the Compatibility of CEHRT", "description": "I attest to CMS that I did not knowingly and willfully take action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Actions-to-Limit-Restrict-CEHRT-Attestation-Fact Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_LVITC_2", "title": "Support Electronic Referral Loops By Receiving and Reconciling Health Information Exclusion", "description": "Any MIPS eligible clinician who receives transitions of care or referrals or has patient encounters in which the MIPS eligible clinician has never before encountered the patient fewer than 100 times during the performance period.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Receiving-Reconciling-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_LVOTC_1", "title": "Support Electronic Referral Loops By Sending Health Information Exclusion", "description": "Any MIPS eligible clinician who transfers a patient to another setting or refers a patient fewer than 100 times during the performance period.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "healthInformationExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-E-Referral-Loops-by-Sending-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_LVPP_1", "title": "e-Prescribing Exclusion", "description": "Any MIPS eligible clinician who writes fewer than 100 permissible prescriptions during the performance period.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "electronicPrescribing", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-e-Prescribing-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_ONCACB_1", "title": "ONC-ACB Surveillance Attestation", "description": "I have (1) Acknowledged the option to cooperate in good faith with ONC-ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC-ACB surveillance is received; and (2) If requested, cooperated in good faith with ONC-ACB surveillance of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "attestation", "isBonus": false, "reportingCategory": null, "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-ACB-Surveillance-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_ONCDIR_1", "title": "ONC Direct Review Attestation", "description": "I attest that I - (1) Acknowledge the requirement to cooperate in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program if a request to assist in ONC direct review is received; and (2) If requested, cooperated in good faith with ONC direct review of his or her health information technology certified under the ONC Health IT Certification Program as authorized by 45 CFR part 170, subpart E, to the extent that such technology meets (or can be used to meet) the definition of CEHRT, including by permitting timely access to such technology and demonstrating its capabilities as implemented and used by the MIPS eligible clinician in the field.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "attestation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-ONC-Direct-Review-Attestation-Fact-Sheet.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PEA_1", "title": "Provide Patients Electronic Access to Their Health Information", "description": "For at least one unique patient seen by the MIPS eligible clinician: (1) The patient (or the patient-authorized representative) is provided timely access to view online, download, and transmit his or her health information; and (2) The MIPS eligible clinician ensures the patient's health information is available for the patient (or patient-authorized representative) to access using any application of their choice that is configured to meet the technical specifications of the Application Programming Interface (API) in the MIPS eligible clinician's certified electronic health record technology (CEHRT).", "metricType": "proportion", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "providerToPatientExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Provide-Patients-E-Access-to-Their-Health-Info-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1", "title": "Immunization Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency (PHA) to submit immunization data and receive immunization forecasts and histories from a public health immunization 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"category": "pi", "measureId": "PI_PHCDRR_1_EX_1", "title": "Immunization Registry Reporting Exclusion", "description": "Any MIPS eligible clinician who does not administer any immunizations to any of the populations for which data is collected by its jurisdiction's immunization registry or immunization information system during the performance period.", "metricType": "boolean", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_2", "PI_PHCDRR_1_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", 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2019, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "exclusion", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Immunization-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_1_EX_1", "PI_PHCDRR_1_EX_2" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_1_PRE", "title": "Immunization Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production 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Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. 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Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. 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"M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_2_PROD", "title": "Syndromic Surveillance Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Syndromic-Surveillance-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_2_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", 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"measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_EX_2", "PI_PHCDRR_3_EX_3" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3_EX_2", "title": "Electronic Case Reporting Exclusion", "description": "Any MIPS eligible clinician who operates in a jurisdiction for which no public health agency is capable of receiving electronic case reporting data in the specific standards required to meet the CEHRT definition 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Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_3_PROD", "title": "Electronic Case Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Electronic-Case-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_3_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4", "title": "Public Health Registry Reporting", "description": "The MIPS eligible clinician is in active engagement with a public health agency to submit data to public health registries.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_4_PRE", "PI_PHCDRR_4_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4_PRE", "title": "Public Health Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_4_PROD", "title": "Public Health Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_4_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5", "title": "Clinical Data Registry Reporting", "description": "The MIPS eligible clinician is in active engagement to submit data to a clinical data registry.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [ "PI_PHCDRR_5_PRE", "PI_PHCDRR_5_PROD" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5_PRE", "title": "Clinical Data Registry Reporting Active Engagement Level 1", "description": "Option 1 – Pre-Production and Validation: The MIPS eligible clinician must first register to submit data with the PHA or, where applicable, the clinical data registry (CDR) to which the information is being submitted. Registration must be completed within 60 days after the start of the performance period, while awaiting an invitation from the PHA or CDR to begin testing and validation. Upon completion of the initial registration, the MIPS eligible clinician must begin the process of testing and validation of the electronic submission of data. The MIPS eligible clinician must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within a performance period would result in the MIPS eligible clinician not meeting the measure.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PROD" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_5_PROD", "title": "Clinical Data Registry Reporting Active Engagement Level 2", "description": "Option 2 – Validated Data Production: The MIPS eligible clinician has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.", "metricType": "boolean", "firstPerformanceYear": 2023, "lastPerformanceYear": null, "isRequired": true, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Clinical-Data-Registry-Reporting-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [ "PI_PHCDRR_5_PRE" ], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PHCDRR_6", "title": "Public Health Reporting Using Trusted Exchange Framework and Common AgreementTM (TEFCATM)", "description": "The MIPS eligible clinician is (1) participating as a signatory to a Framework Agreement (as that term is defined by the Common Agreement for Nationwide Health Information Interoperability as published in the Federal Register and on the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC’s) website); (2) isn’t suspended from participating in TEFCATM Exchange; (3) submits health information using TEFCATM to a public health agency (PHA) consistent with one or more of the measures under the Public Health and Clinical Data Exchange objective; (4) is in active engagement Option 2 (validated data production) with a PHA to transfer health information for one or more of the measures under the Public Health and Clinical Data Exchange objective; and (5) uses the functions of CEHRT to exchange with the public health agency (PHA).", "metricType": "boolean", "firstPerformanceYear": 2026, "lastPerformanceYear": null, "isRequired": false, "objective": "publicHealthAndClinicalDataExchange", "isBonus": true, "reportingCategory": "bonus", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Public-Health-Reporting-Using-TEFCA-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "mips", "app1", "appPlus", "ssp", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_1", "title": "Security Risk Analysis", "description": "First, conduct or review a security risk analysis; and second, conduct security risk management activities, in accordance with the requirements under 45 CFR 164.308(a)(1)(ii)(A) and (B). Security risk analysis and management activities include addressing the security of data created or maintained by CEHRT (to include encryption), in accordance with 45 CFR 164.312(a)(2)(iv) and 45 CFR 164.306(d)(3). The encryption implementation specified at 45 CFR 164.312(a)(2)(iv) must be implemented if it is reasonable and appropriate; if encryption is not reasonable and appropriate, then the MIPS eligible clinician would adopt an equivalent alternative measure if it is reasonable and appropriate to do so.", "metricType": "boolean", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-Security-Risk-Analysis-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "pi", "measureId": "PI_PPHI_2", "title": "High Priority Practices Safety Assurance Factors for EHR Resilience (SAFER) Guide", "description": "Conduct an annual self-assessment using the 2025 High Priority Practices SAFER Guide at any point during the calendar year in which the performance period occurs.", "metricType": "boolean", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isRequired": true, "objective": "protectPatientHealthInformation", "isBonus": false, "reportingCategory": "required", "measureSpecification": { "default": "https://qpp.cms.gov/docs/pi_specifications/Measure Specifications/2026-MIPS-Promoting-Interoperability-High-Priority-Practices-SAFER-Guide-Measure.pdf" }, "measureSets": [], "exclusion": null, "substitutes": [], "allowedPrograms": [ "ssp", "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "preprod": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "001", "title": "Diabetes: Glycemic Status Assessment Greater Than 9%", "description": "Percentage of patients 18-75 years of age with diabetes who had a glycemic status assessment (hemoglobin A1c [HbA1c] or glucose management indicator [GMI]) > 9.0% during the measurement period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS122v14", "eMeasureUuid": "9700a8b9-9f65-41a8-8464-1da26cda857b", "nqfEMeasureId": null, "nqfId": "0059", "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [ "001SSP" ], "allowedPrograms": [ "mips", "app1", "appPlus", "M0002", "M0005", "M1503" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [ "endocrinology", "familyMedicine", "internalMedicine", "nephrology", "nutritionDietician", "preventiveMedicine" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0122v14", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_001_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_001_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients whose most recent glycemic status assessment (HbA1c or GMI) (performed during the measurement period) is >9.0% or is missing, or was not performed during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "51D8CA9A-E511-4793-8AD4-EFAE90F3ABA4", "denominatorUuid": "EA65F958-962E-433B-A9A3-CC2EA7B76E26", "numeratorUuid": "10C65EBE-685C-48F8-8B24-351C6F3481E9", "denominatorExclusionUuid": "CA386077-1F7A-4C23-85D7-33A4FCED0803" } } ] }, { "category": "quality", "measureId": "001SSP", "title": "Diabetes: Glycemic Status Assessment Greater Than 9%", "description": "Percentage of patients 18-75 years of age with diabetes who had a glycemic status assessment (hemoglobin A1c [HbA1c] or glucose management indicator [GMI]) > 9.0% during the measurement period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [ "001" ], "allowedPrograms": [ "appPlus" ], "submissionMethods": [ "registry" ], "measureSets": [ "endocrinology", "familyMedicine", "internalMedicine", "nephrology", "nutritionDietician", "preventiveMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_001SSP_MedicareCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "005", "title": "Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)", "description": "Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) ≤ 40% who were prescribed ACE inhibitor or ARB or ARNI therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS135v14", "eMeasureUuid": "c41e2269-718d-40d9-bda2-a6cc80b44763", "nqfEMeasureId": "0081e", "nqfId": "0081", "measureType": "process", "isHighPriority": false, "primarySteward": "American Heart Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0055" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "cardiology", "familyMedicine", "hospitalists", "internalMedicine" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0135v14", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_005_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients who were prescribed or already taking ACE inhibitor or ARB or ARNI therapy during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "387A9670-3826-437F-99C6-436D51ECA38B", "denominatorUuid": "7F599BDC-FDC8-4139-BE0C-9DE81B1FA01B", "numeratorUuid": "19BD56A6-3838-4888-9780-1B284DFE6C45", "denominatorExceptionUuid": "D3887622-BD0C-4965-B2E4-3C58A3F2550F", "denominatorExclusionUuid": "F2B96014-C3D2-4F0B-BA16-8B93747A04E8" } } ] }, { "category": "quality", "measureId": "006", "title": "Coronary Artery Disease (CAD): Antiplatelet Therapy", "description": "Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12-month period who were prescribed aspirin or clopidogrel.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0067", "measureType": "process", "isHighPriority": false, "primarySteward": "American Heart Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0055" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "skilledNursingFacility" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_006_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "007", "title": "Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%)", "description": "Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12-month period who also have a prior MI or a current or prior LVEF ≤ 40% who were prescribed beta-blocker therapy.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS145v14", "eMeasureUuid": "5f7dd8a7-07b4-4271-81ff-3e0ab486cae7", "nqfEMeasureId": "0070e", "nqfId": "0070", "measureType": "process", "isHighPriority": false, "primarySteward": "American Heart Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0055" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "skilledNursingFacility" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0145v14", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_007_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients with left ventricular systolic dysfunction (LVEF <=40%) - Population 2: Patients with a prior (within the past 3 years) myocardial infarction For the purposes of this measure, a single performance rate can be calculated as follows: Performance Rate = (Numerator 1 + Numerator 2)/ [(Denominator 1 - Denominator Exceptions 1) + (Denominator 2 - Denominator Exceptions 2)]", "eMeasureUuids": { "initialPopulationUuid": "A8E96013-BA2C-445F-8084-5610925F378A", "denominatorUuid": "412A6DD3-1582-43EE-9E7E-BA55261D5485", "numeratorUuid": "1A0759C1-708C-4DC9-B3F4-5D8EAC1BA579", "denominatorExceptionUuid": "A25F0F00-D7D5-44AA-A335-36E844CB96AD" } } ] }, { "category": "quality", "measureId": "008", "title": "Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)", "description": "Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) ≤ 40% who were prescribed beta-blocker therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS144v14", "eMeasureUuid": "36fb771e-e488-4e62-9a46-fe4cd390c801", "nqfEMeasureId": "0083e", "nqfId": "0083", "measureType": "process", "isHighPriority": false, "primarySteward": "American Heart Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0055" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "cardiology", "familyMedicine", "hospitalists", "internalMedicine", "skilledNursingFacility" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0144v14", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_008_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients who were prescribed or already taking beta-blocker therapy during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "EF7BEF3F-81C2-475F-96C7-2FC7F741FB4D", "denominatorUuid": "2C681E01-0A30-437E-A0C3-953EF766E5E7", "numeratorUuid": "AC0D26F8-7DE1-42F6-9CD9-2B96D8383E51", "denominatorExceptionUuid": "E3081257-80AD-420A-98D4-EA2629C32C0E", "denominatorExclusionUuid": "686A54E2-2D9C-423B-B3C5-31C9AECCFA73" } } ] }, { "category": "quality", "measureId": "009", "title": "Antidepressant Medication Management", "description": "Percentage of patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported. a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks). b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months).", "metricType": "multiPerformanceRate", "overallAlgorithm": "simpleAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS128v14", "eMeasureUuid": "ee910ec9-e9e4-4fd2-8f04-68b2cf545719", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1369" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "familyMedicine", "internalMedicine", "mentalBehavioralHealth" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0128v14" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks).", "eMeasureUuids": { "initialPopulationUuid": "FB7963B0-4087-4620-831A-011F11461F1D", "denominatorUuid": "6377FF0F-DF03-46C5-9269-4047935DEF0D", "numeratorUuid": "2F9BA0BC-A3A0-4F25-AF9E-FD3BB4DEA05A", "denominatorExclusionUuid": "CEE186A0-C49C-48C1-B6A2-9D3DBDCAB754" }, "name": "84Days" }, { "description": "Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months).", "eMeasureUuids": { "initialPopulationUuid": "6E7B2368-CCCA-4414-856A-4BC93DCF2067", "denominatorUuid": "E05BAE38-1702-461A-8FF8-50E41D18483B", "numeratorUuid": "2D4DFEFA-9E20-46FC-BAFB-2685D0DADC70", "denominatorExclusionUuid": "CC153620-82CB-4D5B-9262-9958EC3DBAD2" }, "name": "180Days" } ] }, { "category": "quality", "measureId": "012", "title": "Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation", "description": "Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more visits during the measurement period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS143v14", "eMeasureUuid": "063baed4-604b-4548-ac6f-432a5c4240b7", "nqfEMeasureId": "0086e", "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Academy of Ophthalmology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1420" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "ophthalmology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0143v14" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients who have an optic nerve head evaluation during one or more visits during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "1E1D1DFF-5C13-468A-8249-3E5BC0EC874C", "denominatorUuid": "6DE21B3D-3977-4CC8-BFD3-494931E7EDCB", "numeratorUuid": "968D1438-3837-4F81-B418-FED09C6CFB22", "denominatorExceptionUuid": "D8DE0149-AC18-4101-858C-A9C15914C451" } } ] }, { "category": "quality", "measureId": "019", "title": "Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care", "description": "Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once during the performance period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS142v14", "eMeasureUuid": "1ff2b3d2-6132-4da7-9598-3f071c73789d", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Ophthalmology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1420" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "ophthalmology", "optometry" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0142v14" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients with documentation, at least once within the measurement period, of the findings of the dilated macular or fundus exam via communication to the physician who manages the patient's diabetic care", "eMeasureUuids": { "initialPopulationUuid": "25A23253-E238-4C41-AC70-556A2C25EBAE", "denominatorUuid": "1FDD8A3A-9815-43BB-A69A-6430BD9D5507", "numeratorUuid": "75CBF5D5-DF61-4232-90AA-E935A07E25BE", "denominatorExceptionUuid": "7C701A84-4CE6-4B35-BC7B-A55104C4318D" } } ] }, { "category": "quality", "measureId": "024", "title": "Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older", "description": "Percentage of patients aged 50 years and older treated for a fracture with documentation of communication, between the physician treating the fracture and the physician or other clinician managing the patient’s on-going care, that a fracture occurred and that the patient was or should be considered for osteoporosis treatment or testing. This measure is submitted by the physician who treats the fracture and who therefore is held accountable for the communication.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0058" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "interventionalRadiology", "orthopedicSurgery", "preventiveMedicine", "rheumatology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_024_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_024_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "039", "title": "Screening for Osteoporosis for Women Aged 65-85 Years of Age", "description": "Percentage of women aged 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) test to check for osteoporosis.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0046", "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0053", "M1366" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "endocrinology", "familyMedicine", "geriatrics", "internalMedicine", "obstetricsGynecology", "preventiveMedicine", "rheumatology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_039_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_039_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "047", "title": "Advance Care Plan", "description": "Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0326", "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0054", "G0055", "M0001", "M0002", "M0004", "M0005", "M1421", "M1424", "M1425", "M1503" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "familyMedicine", "gastroenterology", "generalSurgery", "geriatrics", "hospitalists", "internalMedicine", "nephrology", "neurology", "obstetricsGynecology", "oncology", "orthopedicSurgery", "otolaryngology", "physicalMedicine", "preventiveMedicine", "pulmonology", "rheumatology", "skilledNursingFacility", "thoracicSurgery", "urology", "vascularSurgery" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_047_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_047_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "048", "title": "Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older", "description": "Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "geriatrics", "internalMedicine", "obstetricsGynecology", "physicalTherapyOccupationalTherapy", "preventiveMedicine", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_048_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "050", "title": "Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older", "description": "Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1370", "M1423" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "geriatrics", "internalMedicine", "obstetricsGynecology", "physicalTherapyOccupationalTherapy", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_050_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "052", "title": "Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation and Long-Acting Inhaled Bronchodilator Therapy", "description": "Percentage of patients aged 18 years and older with a diagnosis of COPD with a documented FEV1/FVC <70% measured by spirometry, who are symptomatic and were prescribed a long-acting inhaled bronchodilator.", "metricType": "multiPerformanceRate", "overallAlgorithm": "simpleAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0102", "measureType": "process", "isHighPriority": false, "primarySteward": "American Thoracic Society", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1424" ], "submissionMethods": [ "registry" ], "measureSets": [ "pulmonology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_052_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "spirometry", "description": "Percentage of patients aged 18 years and older with a diagnosis of COPD who have a documented airflow obstruction (FEV1/FVC < 70%) as measured by spirometry." }, { "name": "bronchodilator", "description": "Percentage of patients aged 18 years and older with a diagnosis of COPD who have documented airflow obstruction (FEV1/FVC < 70%) and are symptomatic, who were prescribed a long-acting inhaled bronchodilator." } ] }, { "category": "quality", "measureId": "065", "title": "Appropriate Treatment for Upper Respiratory Infection (URI)", "description": "Percentage of episodes for patients 3 months of age and older with a diagnosis of upper respiratory infection (URI) that did not result in an antibiotic order.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS154v14", "eMeasureUuid": "22233707-222d-473d-9acb-8ef6cedd0690", "nqfEMeasureId": null, "nqfId": "0069", "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0057", "M1368" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "emergencyMedicine", "familyMedicine", "infectiousDisease", "pediatrics", "urgentCare" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0154v14", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_065_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "URI episodes without a prescription for antibiotic medication on or three days after the outpatient visit, telephone visit, virtual encounter, or emergency department visit for an upper respiratory infection", "eMeasureUuids": { "initialPopulationUuid": "50D6E6FD-F841-4E7C-9719-CD484A43AC8A", "denominatorUuid": "5DB707B9-4D8B-4CAF-B8AB-4310B02681D0", "numeratorUuid": "824D23C2-A5B6-472D-BF80-C01FDCE067B5", "denominatorExclusionUuid": "932D4556-8347-4562-9B3A-179FD75D7317", "strata": [ "ecc38660-2537-4dbf-9432-cb8d21bed027", "5040441a-d27d-451b-b610-888525d40317", "a65aac60-e26a-4e79-a358-eead473ed112" ] } } ] }, { "category": "quality", "measureId": "066", "title": "Appropriate Testing for Pharyngitis", "description": "The percentage of episodes for patients 3 years and older with a diagnosis of pharyngitis that resulted in an antibiotic order on or within 3 days after the episode date and a group A Streptococcus (Strep) test in the seven-day period from three days prior to the episode date through three days after the episode date.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS146v14", "eMeasureUuid": "f4aaa047-510b-4cf8-8bcd-13e37ffb68a7", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "emergencyMedicine", "familyMedicine", "infectiousDisease", "otolaryngology", "pediatrics", "urgentCare" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0146v14", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_066_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "A group A streptococcus test in the seven-day period from three days prior to the episode date through three days after the episode date", "eMeasureUuids": { "initialPopulationUuid": "C57B1E01-AC23-4464-A182-23A6CC4848B3", "denominatorUuid": "CF89139C-D474-4B2E-82DE-ECEFCA6926AA", "numeratorUuid": "87675FD5-79CD-43A6-861C-864E5A604961", "denominatorExclusionUuid": "C343340E-9E88-46FD-B6E9-B81C3D3B3170", "strata": [ "efd96bf7-6551-4e37-9135-b2e528b283cb", "b47e61fa-0c76-4342-bec5-4d8e4fa284ef", "3b368213-1fcd-4c92-bc54-ae57f0f7ffbb" ] } } ] }, { "category": "quality", "measureId": "102", "title": "Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients", "description": "Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy who did not have a bone scan performed at any time since diagnosis of prostate cancer.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS129v15", "eMeasureUuid": "360c2fd5-5a41-49cc-b83c-78f6225b8145", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0001" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "oncology", "radiationOncology", "urology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0129v15", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_102_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients who did not have a bone scan performed after diagnosis of prostate cancer and before the end of the measurement period", "eMeasureUuids": { "initialPopulationUuid": "BD03BE75-BCC3-40EB-A93B-2085A1F53A7B", "denominatorUuid": "0E621B55-8522-4202-944F-CCB1DD58D373", "numeratorUuid": "FA99F264-3BD5-4B71-BF14-7AE4B2A4967F", "denominatorExceptionUuid": "6CC0BCC3-733E-4A1A-A7A0-9F4D374FBFB4" } } ] }, { "category": "quality", "measureId": "112", "title": "Breast Cancer Screening", "description": "Percentage of women 40 - 74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the measurement period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS125v14", "eMeasureUuid": "dbd9eccd-c3ea-42db-9344-72ad44f84f51", "nqfEMeasureId": null, "nqfId": "2372", "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [ "112SSP" ], "allowedPrograms": [ "appPlus", "M1366" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0125v14", "claims": 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"group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "128", "title": "Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan", "description": "Percentage of patients aged 18 years and older with a BMI documented during the current encounter or within the previous twelve months AND who had a follow-up plan documented if BMI was outside of normal parameters.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS69v14", "eMeasureUuid": "6eabf62a-209b-4969-829e-04c502db761d", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], 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"urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0068v15", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_130_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Eligible clinician attests to documenting, updating, or reviewing the patient's current medications using all immediate resources available on the date of the encounter", "eMeasureUuids": { "initialPopulationUuid": "F63CAC5B-9592-4E1E-82EE-739A66D86CC9", "denominatorUuid": "0B529CD7-00FB-4CAE-8B1F-B31DE4BB7E40", "numeratorUuid": "C2A96F40-F8F6-47B3-AEE5-157F101D3E6E", "denominatorExceptionUuid": "56553A64-494A-472D-905E-78D1CB7A011A" } } ] }, { "category": "quality", "measureId": "134", "title": "Preventive Care and Screening: Screening for Depression and 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"allowedPrograms": [ "mips", "M0001" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "oncology", "radiationOncology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0157v14", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_143_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "registry", "electronicHealthRecord" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Visits for patients with a diagnosis of cancer who are currently receiving chemotherapy - Population 2: Visits for patients with a diagnosis of cancer who are currently receiving radiation therapy For the purposes of this measure, a single performance rate can be calculated as follows: Performance Rate = (Numerator 1 + Numerator 2)/ (Denominator 1 + Denominator 2)", "eMeasureUuids": { "initialPopulationUuid": "F7415275-1792-42E9-B06D-7940E5F07FEC", "denominatorUuid": "B174B06F-70E3-4E8D-B173-F12DC08FAFB4", "numeratorUuid": "9E2746AB-7FFE-47BD-A962-1F458BEBD694" } } ] }, { "category": "quality", "measureId": "144", "title": "Oncology: Medical and Radiation - Plan of Care for Pain", "description": "Percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0383", "measureType": "process", "isHighPriority": true, "primarySteward": "American Society of Clinical Oncology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0001" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology", "radiationOncology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_144_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "145", "title": "Radiology: Exposure Dose Indices Reported for Procedures Using Fluoroscopy", "description": "Final reports for procedures using fluoroscopy that document radiation exposure indices.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American College of Radiology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1498", "M1499" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "diagnosticRadiology", "interventionalRadiology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_145_MedicarePartBclaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_145_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "155", "title": "Falls: Plan of Care", "description": "Percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0101", "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1370", "M1502" ], "submissionMethods": [ "registry" ], "measureSets": [ "audiology", "familyMedicine", "geriatrics", "internalMedicine", "neurology", "orthopedicSurgery", "otolaryngology", "physicalMedicine", "physicalTherapyOccupationalTherapy", "podiatry", "preventiveMedicine", "skilledNursingFacility" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_155_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "164", "title": "Coronary Artery Bypass Graft (CABG): Prolonged Intubation", "description": "Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation > 24 hours.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0129", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Society of Thoracic Surgeons", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1425" ], "submissionMethods": [ "registry" ], "measureSets": [ "thoracicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_164_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "167", "title": "Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure", "description": "Percentage of patients aged 18 years and older undergoing isolated CABG surgery (without pre-existing renal failure) who develop postoperative renal failure or require dialysis.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0114", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Society of Thoracic Surgeons", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1425" ], "submissionMethods": [ "registry" ], "measureSets": [ "thoracicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_167_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "168", "title": "Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration", "description": "Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require a return to the operating room (OR) for mediastinal bleeding with or without tamponade, unplanned coronary artery intervention (native vessel, graft or both), valve dysfunction, aortic reintervention or other cardiac reason during the current hospitalization.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0115", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Society of Thoracic Surgeons", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1425" ], "submissionMethods": [ "registry" ], "measureSets": [ "thoracicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_168_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "176", "title": "Tuberculosis Screening Prior to First Course of Biologic and/or Immune Response Modifier Therapy", "description": "If a patient has been newly prescribed a biologic and/or immune response modifier that includes a warning for potential reactivation of a latent infection, then the medical record should indicate TB testing in the preceding 12-month period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American College of Rheumatology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0053", "M1421" ], "submissionMethods": [ "registry" ], "measureSets": [ "dermatology", "familyMedicine", "infectiousDisease", "internalMedicine", "rheumatology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_176_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "177", "title": "Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity", "description": "Percentage of patients aged 18 years and older with two or more encounters with diagnoses of rheumatoid arthritis (RA) at least 90 days apart who have an assessment of disease activity using an ACR-preferred RA disease activity assessment tool at ≥50% of encounters for RA for each patient during the performance period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2523", "measureType": "process", "isHighPriority": false, "primarySteward": "American College of Rheumatology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0053" ], "submissionMethods": [ "registry" ], "measureSets": [ "rheumatology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_177_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "178", "title": "Rheumatoid Arthritis (RA): Functional Status Assessment", "description": "Percentage of patients aged 18 years and older with two or more encounters with diagnoses of rheumatoid arthritis (RA) at least 90 days apart for whom a functional status assessment was performed at least once during the performance period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American College of Rheumatology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0053" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "rheumatology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_178_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "180", "title": "Rheumatoid Arthritis (RA): Glucocorticoid Management", "description": "Percentage of patients aged 18 years and older with two or more encounters with diagnoses of rheumatoid arthritis (RA) at least 90 days apart who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone > 5 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan during the performance period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American College of Rheumatology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0053" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery", "rheumatology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_180_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "181", "title": "Elder Maltreatment Screen and Follow-Up Plan", "description": "Percentage of patients aged 60 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening tool on the date of encounter AND a documented follow-up plan on the date of the positive screen.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1500" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "audiology", "clinicalSocialWork", "emergencyMedicine", "familyMedicine", "geriatrics", "internalMedicine", "mentalBehavioralHealth", "neurology", "nutritionDietician", "physicalTherapyOccupationalTherapy", "skilledNursingFacility", "speechLanguagePathology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_181_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_181_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "182", "title": "Functional Outcome Assessment", "description": "Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies within two days of the date of the identified deficiencies.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "audiology", "chiropracticMedicine", "familyMedicine", "nephrology", "orthopedicSurgery", "physicalMedicine", "physicalTherapyOccupationalTherapy", "preventiveMedicine", "speechLanguagePathology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_182_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "187", "title": "Stroke and Stroke Rehabilitation: Thrombolytic Therapy", "description": "Percentage of patients aged 18 years and older with a diagnosis of acute 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false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "191", "title": "Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery", "description": "Percentage of cataract surgeries for patients aged 18 years and older with a diagnosis of uncomplicated cataract and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved in the operative eye within 90 days following the cataract surgery.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS133v14", "eMeasureUuid": "822b9782-49e5-4988-b120-ef0f72e0ce0e", "nqfEMeasureId": "0565e", "nqfId": "0565", "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Academy of Ophthalmology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1420" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0133v14", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_191_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Cataract surgeries with best-corrected visual acuity of 20/40 or better (distance or near) achieved in the operative eye within 90 days following cataract surgery", "eMeasureUuids": { "initialPopulationUuid": "5F6ABED5-5EC4-445B-959F-66B336FDD93A", "denominatorUuid": "F6D5DB1C-966D-4177-BBFB-3AA869BFEC04", "numeratorUuid": "B4484856-393C-4A73-9E21-C070941C52DF", "denominatorExclusionUuid": "10B59341-85F0-4CD7-AF12-4DB7E82EAB1C" } } ] }, { "category": "quality", "measureId": "205", "title": "Sexually Transmitted Infection (STI) Testing for People with HIV", "description": "Percentage of patients 13 years of age and older with a diagnosis of HIV who had tests for syphilis, gonorrhea, and chlamydia performed within the performance period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS1188v3", "eMeasureUuid": "d8167543-0d18-4832-b87a-9d5f1c227215", "nqfEMeasureId": "3755e", "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Health Resources and Services Administration", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1368" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "infectiousDisease", "pediatrics" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms1188v3", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_205_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients who were tested for each of the following at least once during the measurement period: chlamydia, gonorrhea, and syphilis", "eMeasureUuids": { "initialPopulationUuid": "E9614413-6EAC-4C48-A69D-A9DC1A228954", "denominatorUuid": "69732BC0-17DD-40BA-995C-689E8FDB7838", "numeratorUuid": "604D6C9E-C89B-4F4A-A3CB-E14B100E02F3" } } ] }, { "category": "quality", "measureId": "217", "title": "Functional Status Change for Patients with Knee Impairments", "description": "A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with knee impairments. The change in FS is assessed using the FOTO Lower Extremity Physical Function (LEPF) PROM. The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient, individual clinician, and clinic levels to assess quality.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "chiropracticMedicine", "orthopedicSurgery", "physicalTherapyOccupationalTherapy" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_217_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "218", "title": "Functional Status Change for Patients with Hip Impairments", "description": "A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with hip impairments. The change in FS is assessed using the FOTO Lower Extremity Physical Function (LEPF) PROM. The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient, individual clinician, and clinic levels to assess quality.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "chiropracticMedicine", "orthopedicSurgery", "physicalTherapyOccupationalTherapy" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_218_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "219", "title": "Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments", "description": "A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with foot, ankle or lower leg impairments. The change in FS is assessed using the FOTO Lower Extremity Physical Function (LEPF) PROM. The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient, individual clinician, and clinic levels to assess quality.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "chiropracticMedicine", "orthopedicSurgery", "physicalTherapyOccupationalTherapy", "podiatry" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_219_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "220", "title": "Functional Status Change for Patients with Low Back Impairments", "description": "A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with low back impairments. The change in FS is assessed using the FOTO Low Back FS PROM. The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient, individual clinician, and clinic levels to assess quality.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "chiropracticMedicine", "orthopedicSurgery", "physicalTherapyOccupationalTherapy" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_220_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "221", "title": "Functional Status Change for Patients with Shoulder Impairments", "description": "A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with shoulder impairments. The change in FS is assessed using the FOTO Shoulder FS PROM. The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient, individual clinician, and clinic levels to assess quality.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "chiropracticMedicine", "orthopedicSurgery", "physicalTherapyOccupationalTherapy" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_221_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "222", "title": "Functional Status Change for Patients with Elbow, Wrist or Hand Impairments", "description": "A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with elbow, wrist, or hand impairments. The change in FS is assessed using the FOTO Elbow/Wrist/Hand FS PROM. The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient, individual clinician, and clinic levels to assess quality.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "chiropracticMedicine", "orthopedicSurgery", "physicalTherapyOccupationalTherapy" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_222_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "226", "title": "Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention", "description": "Percentage of patients aged 12 years and older who were screened for tobacco use one or more times during the measurement period AND who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period if identified as a tobacco user.", "metricType": "multiPerformanceRate", "overallAlgorithm": "split", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS138v14", "eMeasureUuid": "da725994-3464-49e0-8658-f46ba8500b5d", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366", "M1367", "M1420", "M1421", "M1422", "M1424", "M1425", "M1502", "M1503" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "dermatology", "endocrinology", "gastroenterology", "generalSurgery", "geriatrics", "infectiousDisease", "mentalBehavioralHealth", "nephrology", "neurology", "neurosurgical", "nutritionDietician", "oncology", "ophthalmology", "optometry", "orthopedicSurgery", "otolaryngology", "pediatrics", "physicalMedicine", "physicalTherapyOccupationalTherapy", "plasticSurgery", "podiatry", "pulmonology", "radiationOncology", "rheumatology", "speechLanguagePathology", "thoracicSurgery", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0138v14", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_226_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_226_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Percentage of patients aged 12 years and older who were screened for tobacco use one or more times within the measurement period", "eMeasureUuids": { "initialPopulationUuid": "AB01AB8C-5200-4C98-94B1-785687A9469F", "denominatorUuid": "C13FB76B-61C6-422F-92ED-71D8FFE685FC", "numeratorUuid": "E3DA4ECF-8EE9-4578-B3EB-D269973F8EFB", "denominatorExclusionUuid": "D80F9855-5B82-4EAB-97E7-48F7E5E24510" }, "name": "reporting" }, { "description": "Percentage of patients aged 12 years and older who were identified as a tobacco user during the measurement period who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period", "eMeasureUuids": { "initialPopulationUuid": "C508583F-77CE-4004-AC69-13A84B2641D3", "denominatorUuid": "5D9336BB-1759-4FB0-ACAD-C944F28ACD10", "numeratorUuid": "21D4794A-1450-4C3D-89AE-A4791DF8FA2A", "denominatorExclusionUuid": "D323558D-2C59-476C-A6B9-32E5BCF5D2E8" }, "name": "performance" }, { "description": "Percentage of patients aged 12 years and older who were screened for tobacco use one or more times within the measurement period AND who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period if identified as a tobacco user", "eMeasureUuids": { 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true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [ "236SSP" ], "allowedPrograms": [ "mips", "app1", "appPlus", "G0054", "M0002", "M0005" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [ "cardiology", "endocrinology", "familyMedicine", "internalMedicine", "obstetricsGynecology", "pulmonology", "rheumatology", "vascularSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0165v14", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_236_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_236_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients whose most recent blood pressure is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "A35D89C5-C903-4D4C-BDBC-EA70D1254BEF", "denominatorUuid": "FECE5EB1-842C-42B6-B2BC-7035C79222E4", "numeratorUuid": "73661F57-1A94-4982-8136-EDCE51A9AEA8", "denominatorExclusionUuid": "8D42520C-8C19-47AF-B3E7-A66EAECA0DBD" } } ] }, { "category": "quality", "measureId": "236SSP", "title": "Controlling High Blood Pressure", "description": "Percentage of patients 18-85 years of age who had a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period, and whose most recent blood pressure was adequately controlled (<140/90mmHg) during the measurement period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [ "236" ], "allowedPrograms": [ "appPlus" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "endocrinology", "familyMedicine", "internalMedicine", "obstetricsGynecology", "pulmonology", "rheumatology", "vascularSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_236SSP_MedicareCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "238", "title": "Use of High-Risk Medications in Older Adults", "description": "Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class.", "metricType": "multiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS156v14", "eMeasureUuid": "24a5b98e-0bba-44fb-86ff-fcb3f45c0fc4", "nqfEMeasureId": null, "nqfId": "0022", "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0055", "M0004", "M1421" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "familyMedicine", "geriatrics", "internalMedicine", "oncology", "ophthalmology", "optometry", "otolaryngology", "pulmonology", "rheumatology", "skilledNursingFacility", "urology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0156v14", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_238_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class.", "eMeasureUuids": { "initialPopulationUuid": "F8EF7E4A-80B9-4A74-8461-498D79DA5442", "denominatorUuid": "D1555193-7364-45F6-94A6-F1DC2E78C197", "numeratorUuid": "466F79E9-53CB-427E-AB56-2ACFA1969921", "denominatorExclusionUuid": "A8A6B357-128E-4A03-B7E7-D1BFAB85700B" }, "name": "overall" }, { "description": "Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class, except for appropriate diagnoses.", "eMeasureUuids": { "initialPopulationUuid": "C3552CAC-11F6-4E4E-89D9-F3999A3B9A3B", "denominatorUuid": "FA269FE8-A1D6-4FC0-9CD2-1AA5E1641CB5", "numeratorUuid": "3751D444-5C47-4D54-BEFE-40BAD4E0EB3F", "denominatorExclusionUuid": "FB873FB8-D7A3-4A72-874F-56852D6312E5" }, "name": "appropriateDiagnosis" }, { "description": "Total rate (the sum of the two numerators divided by the denominator, deduplicating for patients in both numerators).", "eMeasureUuids": { "initialPopulationUuid": "CEDAD393-CD57-48F9-979A-C33B9875254C", "denominatorUuid": "A30044E2-4C59-4E0B-A5FD-7553FFA7E851", "numeratorUuid": "14000C16-CD29-44E8-BE5C-D94DED574293", "denominatorExclusionUuid": "154B3202-22A5-4515-B86F-2C7EBB5342DF" }, "name": "totalRate" } ] }, { "category": "quality", "measureId": "239", "title": "Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents", "description": "Percentage of patients 3-17 years of age who had an outpatient visit with a primary care physician (PCP) or obstetrician/gynecologist (OB/GYN) and who had evidence of the following during the measurement period.\n\n - Percentage of patients with height, weight, and body mass index (BMI) percentile documentation\n - Percentage of patients with counseling for nutrition\n - Percentage of patients with counseling for physical activity", "metricType": "multiPerformanceRate", "overallAlgorithm": "simpleAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS155v14", "eMeasureUuid": "6292ec31-c4ae-4327-aa9e-1642bd8f31a7", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "nutritionDietician", "pediatrics" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0155v14" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Percentage of patients with height, weight, and body mass index (BMI) percentile documentation ", "eMeasureUuids": { "initialPopulationUuid": "E5101676-A633-4A07-BBD3-10EA995CC8C4", "denominatorUuid": "DA528032-CE05-4DA3-9DBB-95E0541336A0", "numeratorUuid": "84F42E8A-2547-4019-82FA-757BAED7E44D", "denominatorExclusionUuid": "7D74CEF9-F64D-4E9D-AB7B-27D82769F5B0", "strata": [ "3816ADA1-1322-44F1-B51F-56D6B0EAE697", "C8DDE7EE-387F-4D37-A421-E5EA96A5FDE1" ] }, "name": "percentiles" }, { "description": "Percentage of patients with counseling for nutrition ", "eMeasureUuids": { "initialPopulationUuid": "D839E368-D010-448D-9978-67B90E5884A2", "denominatorUuid": "98C0D643-22F0-4711-8C83-49A304CD5A33", "numeratorUuid": "925AC5D2-BC98-4B64-BC8D-1584E091E047", "denominatorExclusionUuid": "AEE993E6-DAF2-41AD-88CD-82C379686716", "strata": [ "EDF53EA7-004F-4E52-8934-76BA727BB48D", "B8A8B540-E1DE-4CC6-BB12-DD615A26AF0B" ] }, "name": "nutrition" }, { "description": "Percentage of patients with counseling for physical activity", "eMeasureUuids": { "initialPopulationUuid": "66E4AC14-3CD7-415C-9743-3242866D2DAB", "denominatorUuid": "9B7E86ED-146E-4C79-AEDE-8B6C6BE57DC7", "numeratorUuid": "2CFDE036-06CE-41B4-92A3-EE3B467883AD", "denominatorExclusionUuid": "E35E98C5-0770-49BB-807D-58C851D3A6F6", "strata": [ "A35008B6-4328-4E0E-838D-C5C1BBF5ECF7", "957A6BCF-B1AF-4C03-A763-DD0335696C49" ] }, "name": "physicalActivity" } ] }, { "category": "quality", "measureId": "240", "title": "Childhood Immunization Status", "description": "Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three or four H influenza type B (HiB); three hepatitis B (HepB); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (HepA); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS117v14", "eMeasureUuid": "65c8fea2-95e8-434e-8fd0-9450717430d9", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1368" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "infectiousDisease", "pediatrics" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0117v14" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "DTaP Children with any of the following on or before the child’s second birthday meet criteria: - At least four DTaP vaccinations, with different dates of service. Do not count a vaccination administered prior to 42 days after birth. - Anaphylaxis due to the diphtheria, tetanus or pertussis vaccine. - Encephalitis due to the diphtheria, tetanus or pertussis vaccine. IPV Children with either of the following on or before the child’s second birthday meet criteria: - At least three IPV vaccinations, with different dates of service. Do not count a vaccination administered prior to 42 days after birth. - Anaphylaxis due to the IPV vaccine. MMR Children with any of the following meet criteria: - At least one MMR vaccination on or between the child’s first and second birthdays. - Anaphylaxis due to the MMR vaccine on or before the child’s second birthday. - All of the following anytime on or before the child’s second birthday (on the same or different date of service): - History of measles. - History of mumps. - History of rubella. HiB Children with either of the following meet criteria on or before the child’s second birthday: - At least three HiB vaccinations, with different dates of service. Do not count a vaccination administered prior to 42 days after birth. - Anaphylaxis due to the HiB vaccine. HepB Children with any of the following on or before the child’s second birthday meet criteria: - At least three hepatitis B vaccinations, with different dates of service. - One of the three vaccinations can be a newborn hepatitis B vaccination during the eight-day period that begins on the date of birth and ends seven days after the date of birth. For example, if the member’s date of birth is December 1, the newborn hepatitis B vaccination must be on or between December 1 and December 8. - Anaphylaxis due to the hepatitis B vaccine. - History of hepatitis B illness. VZV Children with any of the following meet criteria: - At least one VZV vaccination, with a date of service on or between the child’s first and second birthdays. - Anaphylaxis due to the VZV vaccine on or before the child’s second birthday. - History of varicella zoster (e.g., chicken pox) illness on or before the child’s second birthday. PCV Children with either of the following on or before the child’s second birthday meet criteria: - At least four pneumococcal conjugate vaccinations, with different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth. - Anaphylaxis due to the pneumococcal vaccine. HepA Children with any of the following meet criteria: - At least one hepatitis A vaccination, with a date of service on or between the child’s first and second birthdays. - Anaphylaxis due to the hepatitis A vaccine on or before the child’s second birthday. - History of hepatitis A illness on or before the child’s second birthday. RV Children with any of the following meet criteria: - At least two doses of the two-dose rotavirus vaccine on different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth. - At least three doses of the three-dose rotavirus vaccine on different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth. - At least one dose of the two-dose rotavirus vaccine and at least two doses of the three-dose rotavirus vaccine, all on different dates of service, on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth. - Anaphylaxis due to the rotavirus vaccine on or before the child’s second birthday. Flu Children with either of the following on or before their second birthday meet criteria: - At least two influenza vaccinations, with different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 6 months (180 days) after birth. - One of the two vaccinations can be a Live Attenuated Influenza Vaccine (LAIV) vaccination administered on the child’s second birthday. Do not count a LAIV vaccination administered before the child’s second birthday. - Anaphylaxis due to the influenza vaccine.", "eMeasureUuids": { "initialPopulationUuid": "09CA0EF6-9AE4-4636-A2BF-CAC945A03AF5", "denominatorUuid": "4B91AD4E-0169-4694-843C-89035AF1F85C", "numeratorUuid": "667F8CB8-6C2B-403B-9C04-DF21FB800310", "denominatorExclusionUuid": "A37C5F96-E949-4191-806E-2808BBD2F2BA" } } ] }, { "category": "quality", "measureId": "243", "title": "Cardiac Rehabilitation Patient Referral from an Outpatient Setting", "description": "Percentage of patients evaluated in an outpatient setting who within the previous 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the 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"individual" ] }, { "category": "quality", "measureId": "249", "title": "Barrett's Esophagus", "description": "Percentage of esophageal biopsy reports that document the presence of Barrett's mucosa that also include a statement about dysplasia.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "College of American Pathologists", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1501" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "pathology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_249_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_249_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "claims", "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "250", "title": "Radical Prostatectomy Pathology Reporting", "description": "Percentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin status.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "College of American Pathologists", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1501" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "oncology", "pathology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_250_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_250_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "claims", "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "259", "title": "Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #2)", "description": "Percent of patients undergoing endovascular repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) that do not experience a major complication (discharged to home no later than post-operative day #2).", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Society for Vascular Surgery", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1503" ], "submissionMethods": [ "registry" ], "measureSets": [ "vascularSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_259_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "261", "title": "Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness", "description": "Percentage of patients aged birth and older referred to a physician (preferably a physician specially trained in disorders of the ear) for an otologic evaluation subsequent to an audiologic evaluation after presenting with acute or chronic dizziness.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Audiology Quality Consortium", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "audiology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_261_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_261_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "268", "title": "Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy", "description": "Percentage of all patients of childbearing potential (12 years and older) diagnosed with epilepsy who were counseled at least once a year about how epilepsy and its treatment may affect contraception and pregnancy.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Academy of Neurology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0004" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_268_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "275", "title": "Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy", "description": "Percentage of patients with a diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status assessed and results interpreted prior to initiating anti-TNF (tumor necrosis factor) therapy.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Gastroenterological Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1422" ], "submissionMethods": [ "registry" ], "measureSets": [ "gastroenterology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_275_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "277", "title": "Sleep Apnea: Severity Assessment at Initial Diagnosis", "description": "Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI), a respiratory disturbance index (RDI), or a respiratory event index (REI) documented or measured within 2 months after initial evaluation for suspected obstructive sleep apnea.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Academy of Sleep Medicine", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1367", "M1424" ], "submissionMethods": [ "registry" ], "measureSets": [ "internalMedicine", "neurology", "otolaryngology", "pulmonology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_277_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "279", "title": "Sleep Apnea: Assessment of Adherence to Obstructive Sleep Apnea (OSA) Therapy.", "description": "Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea (OSA) that were prescribed an evidence-based therapy that had documentation that adherence to therapy was assessed at least annually through an objective informatics system or through self-reporting (if objective reporting is not available)", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Academy of Sleep Medicine", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1424" ], "submissionMethods": [ "registry" ], "measureSets": [ "internalMedicine", "neurology", "otolaryngology", "pulmonology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_279_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "281", "title": "Dementia: Cognitive Assessment", "description": "Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within the 12 months preceding a dementia encounter during the measurement period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS149v14", "eMeasureUuid": "b8288310-3006-4c9e-a545-b7aa1a3c3eb5", "nqfEMeasureId": "2872e", "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Academy of Neurology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0004" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "clinicalSocialWork", "geriatrics", "mentalBehavioralHealth", "neurology", "physicalTherapyOccupationalTherapy" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0149v14" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients for whom an assessment of cognition is performed and the results reviewed at least once within the 12 months preceding a dementia encounter during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "9DEED3EA-9939-4772-9F89-9DC1EE3D2B5F", "denominatorUuid": "D998D635-C003-4EE3-857D-B6061DD4C61C", "numeratorUuid": "036F56EA-99A9-4205-8563-D266D328AD2D", "denominatorExceptionUuid": "CECF1BF8-0831-400A-9266-4540BFED53EF" } } ] }, { "category": "quality", "measureId": "282", "title": "Dementia: Functional Status Assessment", "description": "Percentage of patients with dementia for whom an assessment of functional status was performed at least once in the last 12 months.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Academy of Neurology/American Psychiatric Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0004", "M1500" ], "submissionMethods": [ "registry" ], "measureSets": 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"firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Neurology/American Psychiatric Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0004", "M1500" ], "submissionMethods": [ "registry" ], "measureSets": [ "clinicalSocialWork", "geriatrics", "mentalBehavioralHealth", "neurology", "physicalTherapyOccupationalTherapy", "speechLanguagePathology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_286_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "288", "title": "Dementia: Education and Support of Caregivers for Patients with Dementia", "description": "Percentage of patients with dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND were referred to additional resources for support in the last 12 months.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Neurology/American Psychiatric Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0004", "M1500" ], "submissionMethods": [ "registry" ], "measureSets": [ "clinicalSocialWork", "geriatrics", "mentalBehavioralHealth", "neurology", "nutritionDietician", "physicalTherapyOccupationalTherapy", "speechLanguagePathology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_288_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "291", "title": "Assessment of Cognitive Impairment or Dysfunction for Patients with Parkinson's Disease", "description": "Percentage of all patients with a diagnosis of Parkinson's Disease [PD] who were assessed for cognitive impairment or dysfunction once during the measurement period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Academy of Neurology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0004" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurology", "physicalTherapyOccupationalTherapy", "speechLanguagePathology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_291_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "293", "title": "Rehabilitative Therapy Referral for Patients with Parkinson's Disease", "description": "Percentage of all patients with a diagnosis of Parkinson's Disease who were referred to physical, occupational, speech, or recreational therapy once during the measurement period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Neurology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0004" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_293_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "303", "title": "Cataracts: Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery", "description": "Percentage of patients aged 18 years and older who had cataract surgery and had improvement in visual function achieved within 90 days following the cataract surgery, based on completing a pre-operative and post-operative visual function survey.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "American Academy of Ophthalmology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1420" ], "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_303_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "304", "title": "Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery", "description": "Percentage of patients aged 18 years and older who had cataract surgery and were satisfied with their care within 90 days following the cataract surgery, based on completion of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientEngagementExperience", "isHighPriority": true, "primarySteward": "American Academy of Ophthalmology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1420" ], "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_304_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "305", "title": "Initiation and Engagement of Substance Use Disorder Treatment", "description": "Percentage of patients 13 years of age and older with a new substance use disorder (SUD) episode who received the following (Two rates are reported):\r\na. Percentage of patients who initiated treatment, including either an intervention or medication for the treatment of SUD, within 14 days of the new SUD episode. \r\nb. Percentage of patients who engaged in ongoing treatment, including two additional interventions or medication treatment events for SUD, or one long-acting medication event for the treatment of SUD, within 34 days of the initiation.", "metricType": "multiPerformanceRate", "overallAlgorithm": "simpleAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS137v14", "eMeasureUuid": "61d66457-70b7-4162-8ad0-07148f505a5e", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0005", "M1369" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "clinicalSocialWork", "familyMedicine", "internalMedicine", "mentalBehavioralHealth", "pediatrics" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0137v14" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Percentage of patients who initiated treatment, including either an intervention or medication for the treatment of SUD, within 14 days of the new SUD episode.", "eMeasureUuids": { "initialPopulationUuid": "5546F555-1CBE-4E4E-9FC2-7B8329885844", "denominatorUuid": "1090455E-3666-48A9-B6E1-D426F2305B16", "numeratorUuid": "2F6B7018-D8D5-4805-939D-36718237E09F", "denominatorExclusionUuid": "745EF584-6DC8-4E52-BBD3-0FFD9F9488EC", "strata": [ "B2AE3A04-D7F8-463F-A42C-944B9B487B89", "CAE8F49C-FD7B-4BB5-AAEA-D4388AD86153", "A51DA177-B279-4D54-8267-BCFA529DB924" ] }, "name": "14Days" }, { "description": "Percentage of patients who engaged in ongoing treatment, including two additional interventions or medication treatment events for SUD, or one long-acting medication event for the treatment of SUD, within 34 days of the initiation.", "eMeasureUuids": { "initialPopulationUuid": "101EC2CD-4B29-4B76-9A7C-C4E3C6635977", "denominatorUuid": "B85099F9-F649-47B0-97F3-35CB77B559B4", "numeratorUuid": "A5C6CEA6-D567-4990-9E3C-9091D1689A86", "denominatorExclusionUuid": "93736F21-3C4A-4CAE-9B02-EA9452681AE7", "strata": [ "DAE550C2-BED7-42FB-991C-0EAB5F100576", "DEBA0FD9-0EC4-4D64-A9B1-F9D94548400D", "5B711256-F594-4B26-9587-D75325EDCC22" ] }, "name": "34Days" } ] }, { "category": "quality", "measureId": "309", "title": "Cervical Cancer Screening", "description": "Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria:* Women age 21-64 who had cervical cytology performed within the last 3 years* Women age 30-64 who had cervical human papillomavirus (HPV) testing performed within the last 5 years", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS124v14", "eMeasureUuid": "e3e538bf-197a-4b4e-89c7-cc40c550a45f", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "familyMedicine", "internalMedicine", "obstetricsGynecology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0124v14" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Women with one or more screenings for cervical cancer. Appropriate screenings are defined by any one of the following criteria: - Cervical cytology performed during the measurement period or the two years prior to the measurement period for women 24-64 years of age by the end of the measurement period. - Cervical human papillomavirus (HPV) testing performed during the measurement period or the four years prior to the measurement period for women who are 30 years or older at the time of the test.", "eMeasureUuids": { "initialPopulationUuid": "E85A469F-8A90-43B2-8E94-C2AF73A6FA5D", "denominatorUuid": "3B6E90F0-0361-451E-B472-971601A70D4A", "numeratorUuid": "6A236D90-E202-42EE-8AA6-0743B659F06A", "denominatorExclusionUuid": "C9602136-DBDF-43FD-975E-D7153704C947" } } ] }, { "category": "quality", "measureId": "310", "title": "Chlamydia Screening in Women", "description": "Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS153v14", "eMeasureUuid": "59738aab-1f1a-4097-82c1-cd7bf3714afa", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366", "M1368" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "obstetricsGynecology", "pediatrics" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0153v14" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Women with at least one chlamydia test during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "938888B6-FF4F-4431-A464-52E770E6D9ED", "denominatorUuid": "7B198078-DCA5-4E4D-A9DE-5C37D68EABF5", "numeratorUuid": "088B388C-E545-4450-A24F-0A027A58E952", "denominatorExclusionUuid": "0D49F098-5B25-4D08-BA45-8360F3641559", "strata": [ "f71d06b9-1df1-404e-a65f-dfd3227548d8", "a6120934-b093-4c8a-b358-3428bd846fd2" ] } } ] }, { "category": "quality", "measureId": "317", "title": "Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented", "description": "Percentage of patient visits for patients aged 18 years and older seen during the measurement period who were screened for high blood pressure AND a recommended follow-up plan is documented, as indicated, if blood pressure is elevated or hypertensive.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS22v14", "eMeasureUuid": "d237ec57-5948-481a-998c-00acf9ba3fce", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1502" ], "submissionMethods": [ "claims", "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "audiology", "cardiology", "dermatology", "emergencyMedicine", "gastroenterology", "generalSurgery", "mentalBehavioralHealth", "nephrology", "neurology", "oncology", "orthopedicSurgery", "otolaryngology", "physicalMedicine", "physicalTherapyOccupationalTherapy", "plasticSurgery", "podiatry", "rheumatology", "skilledNursingFacility", "urgentCare", "urology", "vascularSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0022v14", "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_317_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_317_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patient visits where patients were screened for high blood pressure AND have a recommended follow-up plan documented, as indicated, if the blood pressure is elevated or hypertensive", "eMeasureUuids": { "initialPopulationUuid": "87F6429F-3797-476F-B687-77CD39427752", "denominatorUuid": "6D261A32-07A6-4C55-A749-02DFC583279E", "numeratorUuid": "1E7D8735-2DE2-45EC-9B7E-F32D049238FA", "denominatorExceptionUuid": "8D49EFFA-E657-44A2-8C6F-7AA726D8CDE2", "denominatorExclusionUuid": "03B6691C-3D31-454C-838D-0EB94DC615F8" } } ] }, { "category": "quality", "measureId": "318", "title": "Falls: Screening for Future Fall Risk", "description": "Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS139v14", "eMeasureUuid": "5cd5918e-b31d-4ecb-af3e-24923d0d594e", "nqfEMeasureId": null, "nqfId": "0101", "measureType": "process", "isHighPriority": true, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1423" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "audiology", "familyMedicine", "geriatrics", "internalMedicine", "nephrology", "orthopedicSurgery", "otolaryngology", "physicalTherapyOccupationalTherapy", "podiatry" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0139v14" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients who were screened for future fall risk at least once within the measurement period", "eMeasureUuids": { "initialPopulationUuid": "2EFD85A8-0F6A-4C9D-B500-B13559B6E000", "denominatorUuid": "45522BD1-875C-4C6D-BC3E-8CE25CA84D36", "numeratorUuid": "AF945143-9A66-47D6-819A-7C8463EF7E30", "denominatorExclusionUuid": "B58EC200-EE42-4105-A721-EDAFBFC7311C" } } ] }, { "category": "quality", "measureId": "320", "title": "Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients", "description": "Percentage of patients aged 45 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of 10 years for repeat colonoscopy documented in their colonoscopy report.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0658", "measureType": "process", "isHighPriority": true, "primarySteward": "American Gastroenterological Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1422" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "gastroenterology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_320_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_320_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "claims" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "321", "title": "CAHPS for MIPs Clinician/Group Survey", "description": "The Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Clinician/Group Survey is comprised of 10 Summary Survey Measures (SSMs) and measures patient experience of care within a group practice. The CBE endorsement status and endorsement id (if applicable) for each SSM utilized in this measure are as follows: \n• Getting Timely Care, Appointments, and Information; (Not endorsed by CBE)\n• How well Providers Communicate; (Not endorsed by CBE)\n• Patient’s Rating of Provider; (CBE endorsed # 0005)\n• Access to Specialists; (Not endorsed by CBE)\n• Health Promotion and Education; (Not endorsed by CBE)\n• Shared Decision-Making; (Not endorsed by CBE) \n• Health Status and Functional Status; (Not endorsed by CBE)\n• Courteous and Helpful Office Staff; (CBE endorsed # 0005)\n• Care Coordination; (Not endorsed by CBE)\n• Stewardship of Patient Resources. (Not endorsed by CBE)", "metricType": "cahps", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0005", "measureType": "patientEngagementExperience", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0057", "M0001", "M0005", "M1423", "M1503" ], "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "familyMedicine", "internalMedicine", "oncology", "urology" ], "measureSpecification": {}, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup" ] }, { "category": "quality", "measureId": "326", "title": "Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy", "description": "Percentage of patients aged 18 years and older with atrial fibrillation (AF) or atrial flutter who were prescribed an FDA-approved oral anticoagulant drug for the prevention of thromboembolism during the measurement period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Heart Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0054", "G0055" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "skilledNursingFacility" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_326_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "331", "title": "Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)", "description": "Percentage of patients, aged 18 years and older, with a diagnosis of acute viral sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery Foundation", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0057", "M1367" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "emergencyMedicine", "familyMedicine", "internalMedicine", "otolaryngology", "urgentCare" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_331_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "332", "title": "Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)", "description": "Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosis.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery Foundation", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1367" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "emergencyMedicine", "familyMedicine", "internalMedicine", "otolaryngology", "urgentCare" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_332_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "335", "title": "Maternity Care: Elective Delivery (Without Medical Indication) at < 39 Weeks (Overuse)", "description": "Percentage of patients, regardless of age, who gave birth during a 12-month period, delivered a live singleton at < 39 weeks of gestation, and had elective deliveries (without medical indication) by cesarean birth or induction of labor.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366" ], "submissionMethods": [ "registry" ], "measureSets": [ "certifiedNurseMidwife", "obstetricsGynecology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_335_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "336", "title": "Maternity Care: Postpartum Follow-up and Care Coordination", "description": "Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for postpartum care before or at 12 weeks of giving birth and received the following at a postpartum visit: breastfeeding evaluation and education, postpartum depression screening, intimate partner violence screening, postpartum glucose screening for gestational diabetes patients, family and contraceptive planning counseling, tobacco use screening and cessation education, healthy lifestyle behavioral advice, and an immunization review and update.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366" ], "submissionMethods": [ "registry" ], "measureSets": [ "certifiedNurseMidwife", "obstetricsGynecology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_336_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "338", "title": "HIV Viral Suppression", "description": "Percentage of patients, regardless of age, diagnosed with HIV prior to or during the first 90 days of the performance period, with an eligible encounter in the first 240 days of the performance period, whose last HIV viral load test result was less than 200 copies/mL during the performance period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS314v3", "eMeasureUuid": "8ea82ad9-51bf-494c-ad91-2b14e8717bc7", "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Health Resources and Services Administration", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1368" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "familyMedicine", "infectiousDisease", "internalMedicine" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0314v3", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_338_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients with a last HIV viral load test result of less than 200 copies/mL during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "3528D887-61BE-4C3C-B7D9-5F47174AEBFF", "denominatorUuid": "D8FB20C1-A50F-4028-AC7F-4DADFE67C998", "numeratorUuid": "6AEBD0C9-6E38-4353-A6BB-DB44FBC6DC87" } } ] }, { "category": "quality", "measureId": "340", "title": "HIV Annual Retention in Care", "description": "Percentage of patients, regardless of age, with a diagnosis of Human Immunodeficiency Virus (HIV) before or during the first 240 days of the performance period who had at least two eligible encounters or at least one eligible encounter and one HIV viral load test that were at least 90 days apart within the performance period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS1157v2", "eMeasureUuid": "6685abfc-63d7-4bcf-a293-ecbfa2c8edf1", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Health Resources and Services Administration", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1368" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "infectiousDisease" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms1157v2", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_340_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Number of patients who had at least one eligible encounter and one HIV viral load test at least 90 days apart during the measurement period, or who had at least two eligible encounters at least 90 days apart during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "CC41EFF0-6053-49C9-8E9F-1536548B147B", "denominatorUuid": "2F0FF94A-A7A7-4DE9-9776-C55A939B6DDF", "numeratorUuid": "13D2124C-C80D-4B32-A76A-8E5BD50DD974" } } ] }, { "category": "quality", "measureId": "344", "title": "Rate of Carotid Endarterectomy (CEA) or Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)", "description": "Percent of asymptomatic patients undergoing Carotid Endarterectomy (CEA) or Carotid Artery Stenting (CAS) without major complication who are discharged to home no later than post-operative day #2.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Society for Vascular Surgery", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0054", "M1503" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "neurosurgical", "vascularSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_344_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "350", "title": "Total Knee or Hip Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy", "description": "Percentage of patients regardless of age undergoing a total knee or total hip replacement with documented shared decision- making with discussion of conservative (non-surgical) therapy (e.g., non-steroidal anti-inflammatory drug (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Association of Hip and Knee Surgeons", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0058" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_350_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "351", "title": "Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation", "description": "Percentage of patients regardless of age undergoing a total knee or total hip replacement who are evaluated for the presence or absence of venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure (e.g., History of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), Myocardial Infarction (MI), Arrhythmia and Stroke).", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Association of Hip and Knee Surgeons", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0058" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_351_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "354", "title": "Anastomotic Leak Intervention", "description": "Percentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American College of Surgeons", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1425" ], "submissionMethods": [ "registry" ], "measureSets": [ "generalSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_354_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "355", "title": "Unplanned Reoperation within the 30-Day Postoperative Period", "description": "Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30-day postoperative period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American College of Surgeons", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1367", "M1425", "M1503" ], "submissionMethods": [ "registry" ], "measureSets": [ "generalSurgery", "interventionalRadiology", "otolaryngology", "plasticSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_355_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "356", "title": "Unplanned Hospital Readmission within 30 Days of Principal Procedure", "description": "Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American College of Surgeons", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1503" ], "submissionMethods": [ "registry" ], "measureSets": [ "generalSurgery", "interventionalRadiology", "plasticSurgery", "thoracicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_356_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "357", "title": "Surgical Site Infection (SSI)", "description": "Percentage of patients aged 18 years and older who had a surgical site infection (SSI).", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American College of Surgeons", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1367", "M1425", "M1503" ], "submissionMethods": [ "registry" ], "measureSets": [ "generalSurgery", "interventionalRadiology", "otolaryngology", "plasticSurgery", "vascularSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_357_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "358", "title": "Patient-Centered Surgical Risk Assessment and Communication", "description": "Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American College of Surgeons", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1423", "M1425", "M1502", "M1503" ], "submissionMethods": [ "registry" ], "measureSets": [ "generalSurgery", "interventionalRadiology", "orthopedicSurgery", "otolaryngology", "plasticSurgery", "podiatry", "thoracicSurgery", "urology", "vascularSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_358_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "360", "title": "Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies", "description": "Percentage of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion or infarct avid imaging) reports for all patients, regardless of age, that document a count of known previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion or infarct avid imaging) studies that the patient has received in the 12-month period prior to the current study.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American College of Radiology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1498" ], "submissionMethods": [ "registry" ], "measureSets": [ "diagnosticRadiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_360_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "364", "title": "Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines", "description": "Percentage of final reports for CT imaging studies with a finding of an incidental pulmonary nodule for patients aged 35 years and older that contain an impression or conclusion that includes a recommended interval and modality for follow-up (e.g., type of imaging or biopsy) or for no follow-up, and source of recommendations (e.g., guidelines such as Fleischner Society, American Lung Association, American College of Chest Physicians).", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American College of Radiology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1498" ], "submissionMethods": [ "registry" ], "measureSets": [ "diagnosticRadiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_364_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "366", "title": "Follow-Up Care for Children Prescribed ADHD Medication", "description": "Percentage of children 6-12 years of age and newly prescribed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported. \na) Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase.\nb) Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.", "metricType": "multiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS136v15", "eMeasureUuid": "511a583c-a282-448d-9415-2a4c6ee166b6", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1369" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "mentalBehavioralHealth", "pediatrics" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0136v15" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase.", "eMeasureUuids": { "initialPopulationUuid": "B88DD062-C0C1-46D4-A739-C607A37BB261", "denominatorUuid": "0EBDF7B3-3C2A-4221-8FC6-5CC442975352", "numeratorUuid": "8AC76953-1D7C-4729-8F96-3AFC552A99EB", "denominatorExclusionUuid": "02DD44D5-0DB1-4DC2-81CF-B2A71663280E" }, "name": "30Days" }, { "description": "Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.", "eMeasureUuids": { "initialPopulationUuid": "B36D1E39-517E-48A2-866F-F4A1C7D12726", "denominatorUuid": "6DC20C09-1A43-4632-8CEB-A3A5FA191E64", "numeratorUuid": "53EB472F-C673-4572-99FF-21AE87C9169B", "denominatorExclusionUuid": "E90337E4-28CC-49DE-9FC6-1139B386F21A" }, "name": "overall" } ] }, { "category": "quality", "measureId": "370", "title": "Depression Remission at Twelve Months", "description": "The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event date.", "metricType": "multiPerformanceRate", "overallAlgorithm": "weightedAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS159v14", "eMeasureUuid": "f76d9f75-58fc-42f4-b97a-2491339dd571", "nqfEMeasureId": "0710e", "nqfId": "0710", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Minnesota Community Measurement", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1369" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "clinicalSocialWork", "familyMedicine", "geriatrics", "internalMedicine", "mentalBehavioralHealth", "pediatrics" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0159v14", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_370_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Percentage of adolescent patients (aged 12-17 years) with a diagnosis of major depression or dysthymia and an initial PHQ-9 or PHQ-9M score greater than nine during the index event who reached remission at twelve months as demonstrated by a twelve month (+/-60 days) PHQ-9 or PHQ-9M score of less than 5", "eMeasureUuids": { "initialPopulationUuid": "B74991E6-6F3A-4A01-A60A-6FEEFC966414", "denominatorUuid": "55D888FB-ADA0-4D51-858F-4E942F0F670E", "numeratorUuid": "BF66AA4C-0510-43F8-BF08-A95A71A1E50E", "denominatorExclusionUuid": "21908786-DDBF-4121-A704-D2E237A676BB", "strata": [ "C4A59042-1634-4A8B-812F-BE0A4450D0D2", "A3418DB5-F6AE-47A4-9F77-EA8B7EA583C9" ] }, "name": "adolescents" }, { "name": "adults", "description": "Percentage of adult patients (aged 18 years or older) with a diagnosis of major depression or dysthymia and an initial PHQ-9 or PHQ-9M score greater than nine during the index event who reached remission at twelve months as demonstrated by a twelve month (+/-60 days) PHQ-9 or PHQ-9M score of less than 5" } ] }, { "category": "quality", "measureId": "374", "title": "Closing the Referral Loop: Receipt of Specialist Report", "description": "Percentage of patients with referrals, regardless of age, for which the referring clinician receives a report from the clinician to whom the patient was referred.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS50v14", "eMeasureUuid": "2af15f05-07a9-4f5c-9a40-11ea768adcda", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1420", "M1422", "M1499", "M1502", "M1503" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "dermatology", "endocrinology", "familyMedicine", "gastroenterology", "generalSurgery", "internalMedicine", "interventionalRadiology", "neurology", "obstetricsGynecology", "oncology", "ophthalmology", "optometry", "orthopedicSurgery", "otolaryngology", "physicalMedicine", "preventiveMedicine", "pulmonology", "rheumatology", "thoracicSurgery", "urology", "vascularSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0050v14", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_374_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Number of patients with a referral on or before October 31, for which the referring clinician received a report from the first clinician to whom the patient was referred", "eMeasureUuids": { "initialPopulationUuid": "D36BF246-D75C-41C1-B4F6-FA174EC27C0D", "denominatorUuid": "894E9268-7EE5-4E26-BF65-4256C215414D", "numeratorUuid": "B5A8F06A-68CE-428F-8FBA-FCCEE730ED0C" } } ] }, { "category": "quality", "measureId": "376", "title": "Functional Status Assessment for Total Hip Replacement", "description": "Percentage of patients 19 years of age and older who received an elective primary total hip arthroplasty (THA) and completed a functional status assessment within 90 days prior to the surgery and in the 300 – 425 days after the surgery.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS56v14", "eMeasureUuid": "9cf0729d-8107-4695-9b3a-e58d332647c0", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0058" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0056v14" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients with patient-reported functional status assessment results (i.e., Veterans RAND 12-item health survey [VR-12], Patient-Reported Outcomes Measurement Information System [PROMIS]-10-Global Health, Hip Disability and Osteoarthritis Outcome Score [HOOS], HOOS Jr.) in the 90 days prior to or on the day of the primary THA procedure, and in the 300 - 425 days after the THA procedure", "eMeasureUuids": { "initialPopulationUuid": "181C14DB-225A-4C87-8D98-517D263B40BB", "denominatorUuid": "DCF64C7D-CF13-4450-830A-6734D90B17FF", "numeratorUuid": "061C67F7-3CE9-4703-A3DB-BC9D3596FB05", "denominatorExclusionUuid": "BF3BAA2C-9FC1-488C-8FBA-FB61D401B534" } } ] }, { "category": "quality", "measureId": "377", "title": "Functional Status Assessments for Heart Failure", "description": "Percentage of patients 18 years of age and older with heart failure who completed initial and follow-up patient-reported functional status assessments.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS90v15", "eMeasureUuid": "fb7a03c0-e898-40a5-8132-f692ce583c54", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0055" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "familyMedicine", "internalMedicine" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0090v15" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients with patient-reported functional status assessment results (i.e., Veterans RAND 12-item health survey [VR-12]; VR-36; Kansas City Cardiomyopathy Questionnaire [KCCQ]; KCCQ-12; Minnesota Living with Heart Failure Questionnaire [MLHFQ]; Patient-Reported Outcomes Measurement Information System [PROMIS]-10 Global Health; PROMIS-29) present in the EHR within two weeks before or during the initial FSA encounter and results for the follow-up FSA at least 30 days but no more than 180 days after the initial FSA", "eMeasureUuids": { "initialPopulationUuid": "B3F0E1F2-9645-402E-8A3E-414E9773BC85", "denominatorUuid": "80370B8C-F59E-4548-B7FA-65BC1B3B83DA", "numeratorUuid": "EDC19F9D-D470-477C-AC64-6ED092F4EBE2", "denominatorExclusionUuid": "C19395B9-D760-45FD-A850-539F0BE7F6D7" } } ] }, { "category": "quality", "measureId": "378", "title": "Children Who Have Dental Decay or Cavities", "description": "Percentage of children, 1 - 20 years of age at the start of the measurement period, who have had tooth decay or cavities during the measurement period as determined by a dentist.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS75v14", "eMeasureUuid": "152d3ffa-49d8-4947-9514-55d3311b5c13", "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "dentistry" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0075v14" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Children who had a diagnosis of cavities or decayed teeth in any part of the measurement period", "eMeasureUuids": { "initialPopulationUuid": "DBD0EEC9-8373-48E8-BCDA-579441BD5004", "denominatorUuid": "8D71CDFB-3183-45E1-B884-5E6A430C2171", "numeratorUuid": "C0E870C1-BA44-40D3-9ADD-C2D04503A404", "denominatorExclusionUuid": "2C15DE33-98F6-48B6-A301-36666E235F2E" } } ] }, { "category": "quality", "measureId": "379", "title": "Primary Caries Prevention Intervention as Offered by Dentists", "description": "Percentage of children, 1 – 20 years of age, who received two fluoride varnish applications during the measurement period as determined by a dentist.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS74v15", "eMeasureUuid": "a4f7c903-dfea-4548-9991-1939695437ec", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "dentistry" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0074v15" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Children who receive two fluoride varnish applications on different days during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "4A7CD43D-16CD-4CF6-9AE4-41DFDAE5AA15", "denominatorUuid": "F2F65A2B-93E7-43A0-B43D-4A4AAD833387", "numeratorUuid": "08A02549-B703-48B3-9548-DACBA6E63ABD", "denominatorExclusionUuid": "C680F977-E081-4CCF-95EA-E47A06E4006C", "strata": [ "02B0863D-66C9-4021-9B6D-FF10C556B9E3", "C752E176-569A-4D6E-9F28-1E86B6E21B23", "A21F8CB1-0BA7-4133-9B43-FDA458BF7DC3" ] } } ] }, { "category": "quality", "measureId": "382", "title": "Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment", "description": "Percentage of patient visits for those patients aged 6 through 16 years at the start of the measurement period with a diagnosis of major depressive disorder (MDD) with an assessment for suicide risk.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS177v14", "eMeasureUuid": "59498f05-2fed-4cb3-b12c-aa70a0955d91", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Mathematica", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1369" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "clinicalSocialWork", "mentalBehavioralHealth", "pediatrics" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0177v14" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patient visits with an assessment for suicide risk", "eMeasureUuids": { "initialPopulationUuid": "7C14B90C-F2F0-48E1-BBCF-00A448D7E473", "denominatorUuid": "970D4B91-57A3-4B37-AB74-5F4A82B5D359", "numeratorUuid": "9FD89923-0BA7-45E2-BC9A-A23AD05BB625" } } ] }, { "category": "quality", "measureId": "383", "title": "Adherence to Antipsychotic Medications For Individuals with Schizophrenia", "description": "Percentage of individuals at least 18 years of age as of the beginning of the performance period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the performance period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1879", "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1369" ], "submissionMethods": [ "registry" ], "measureSets": [ "clinicalSocialWork", "familyMedicine", "internalMedicine", "mentalBehavioralHealth" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_383_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "384", "title": "Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery", "description": "Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment who did not require a return to the operating room within 90 days of surgery.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Academy of Ophthalmology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1420" ], "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_384_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "385", "title": "Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery", "description": "Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment and achieved an improvement in their visual acuity, from their preoperative level, within 90 days of surgery in the operative eye.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Academy of Ophthalmology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1420" ], "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_385_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "386", "title": "Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences", "description": "Percentage of patients diagnosed with Amyotrophic Lateral Sclerosis (ALS) who were offered assistance in planning for end of life issues (e.g., advance directives, invasive ventilation, lawful physician-hastened death, or hospice) or whose existing end of life plan was reviewed or updated at least once annually or more frequently as clinically indicated (i.e., rapid progression).", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Neurology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0004" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurology", "speechLanguagePathology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_386_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "387", "title": "Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users", "description": "Percentage of patients, regardless of age, who are active injection drug users who received screening for HCV infection within the 12-month reporting period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Gastroenterological Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1368" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "infectiousDisease", "internalMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_387_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "389", "title": "Cataract Surgery: Difference Between Planned and Final Refraction", "description": "Percentage of patients aged 18 years and older who had cataract surgery performed and who achieved a final refraction within +/- 1.0 diopters of their planned (target) refraction.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Academy of Ophthalmology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1420" ], "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_389_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "392", "title": "Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation", "description": "Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation. This measure is submitted as four rates stratified by age and gender: Submission Age Criteria 1: Females 18-64 years of age Submission Age Criteria 2: Males 18-64 years of age Submission Age Criteria 3: Females 65 years of age and older Submission Age Criteria 4: Males 65 years of age and older", "metricType": "multiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2474", "measureType": "outcome", "isHighPriority": true, "primarySteward": "American College of Cardiology Foundation", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0055" ], "submissionMethods": [ "registry" ], "measureSets": [ "electrophysiologyCardiacSpecialist" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_392_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "female18-64", "description": "Females 18-64 years of age" }, { "name": "male18-64", "description": "Males 18-64 years of age" }, { "name": "female65+", "description": "Females 65 years of age and older" }, { "name": "male65+", "description": "Males 65 years of age and older" }, { "name": "overall", "description": "Overall percentage of patients with cardiac tamponade and/or pericardiocentesis occurring within 30 days" } ] }, { "category": "quality", "measureId": "393", "title": "Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision", "description": "Infection rate following CIED device implantation, replacement, or revision.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American College of Cardiology Foundation", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0055" ], "submissionMethods": [ "registry" ], "measureSets": [ "electrophysiologyCardiacSpecialist" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_393_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "394", "title": "Immunizations for Adolescents", "description": "The percentage of adolescents 13 years of age who had one dose of meningococcal vaccine (serogroups A, C, W, Y or A, C, W, Y, B), one tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine, and have completed the Human Papillomavirus (HPV) vaccine series by their 13th birthday.", "metricType": "multiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "infectiousDisease", "pediatrics" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_394_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "meningococcal", "description": "Patients who had one dose of meningococcal vaccine (serogroups A, C, W, Y or A, C, W, Y, B), on or between the patient’s 10th and 13th birthdays." }, { "name": "Tdap", "description": "Patients who had one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) on or between the patient’s 10th and 13th birthdays." }, { "name": "HPV", "description": "Patients who have completed the HPV vaccine series with different dates of service on or between the patient’s 9th and 13th birthdays." }, { "name": "overall", "description": "All patients who are compliant for Meningococcal (serogroups A, C, W, Y), Tdap and HPV during the specified timeframes." } ] }, { "category": "quality", "measureId": "395", "title": "Lung Cancer Reporting (Biopsy/Cytology Specimens)", "description": "Pathology reports based on lung biopsy and/or cytology specimens with a diagnosis of primary non-small cell lung cancer classified into specific histologic type following the International Association for the Study of Lung Cancer (IASLC) guidance or classified as non-small cell lung cancer not otherwise specified (NSCLC-NOS) with an explanation included in the pathology report.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "College of American Pathologists", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1501" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "pathology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_395_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_395_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "claims", "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "396", "title": "Lung Cancer Reporting (Resection Specimens)", "description": "Pathology reports based on lung resection specimens with a diagnosis of primary lung carcinoma that include the pT category, pN category and for non-small cell lung cancer (NSCLC), histologic type.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "College of American Pathologists", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1501" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "pathology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_396_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_396_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "397", "title": "Melanoma Reporting", "description": "Pathology reports for primary malignant cutaneous melanoma that include the pT category, thickness, ulceration and mitotic rate, peripheral and deep margin status and presence or absence of microsatellitosis for invasive tumors.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "College of American Pathologists", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1421", "M1501" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "pathology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_397_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_397_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "claims", "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "398", "title": "Optimal Asthma Control", "description": "Composite measure of the percentage of pediatric and adult patients whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools and not at risk for exacerbation.", "metricType": "multiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Minnesota Community Measurement", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1424" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "familyMedicine", "internalMedicine", "otolaryngology", "pediatrics", "pulmonology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_398_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "overall", "description": "Overall Percentage for patients (aged 5-50 years) with well-controlled asthma, without elevated risk of exacerbation" }, { "name": "pedCtrlNoExactRisk", "description": "Percentage of pediatric patients (aged 5-17 years) with well-controlled asthma, without elevated risk of exacerbation" }, { "name": "adultCtrlNoExactRisk", "description": "Percentage of adult patients (aged 18-50 years) with well-controlled asthma, without elevated risk of exacerbation" }, { "name": "pedsWellCtrl", "description": "Asthma well-controlled (submit the most recent specified asthma control tool result) for patients 5 to 17 with Asthma" }, { "name": "adultsWellCtrl", "description": "Asthma well-controlled (submit the most recent specified asthma control tool result) for patients 18 to 50 with Asthma" }, { "name": "pedsNoRiskExact", "description": "Patient not at elevated risk of exacerbation for patients 5 to 17 with Asthma" }, { "name": "adultsNoRiskExact", "description": "Patient not at elevated risk of exacerbation for patients 18 to 50 with Asthma" } ] }, { "category": "quality", "measureId": "400", "title": "One-Time Screening for Hepatitis C Virus (HCV) and Treatment Initiation", "description": "Percentage of patients age ≥ 18 years who have never been tested for Hepatitis C Virus (HCV) infection who receive an HCV infection test AND who have treatment initiated within three months or who are referred to a clinician who treats HCV infection within one month if tested positive for HCV.", "metricType": "multiPerformanceRate", "overallAlgorithm": "simpleAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Gastroenterological Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366", "M1368", "M1422" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "nephrology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_400_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "screening", "description": "Percentage of patients aged ≥ 18 years who have never been tested for HCV antibodies and who receive an HCV antibody test." }, { "name": "follow-up/trtmt", "description": "Percentage of patients aged ≥ 18 years who have a reactive HCV antibody test, who have a follow up HCV viral test, and if HCV viremia is detected, have treatment initiated within three months or are referred to a clinician who treats HCV infection within one month of the reactive HCV antibody test." } ] }, { "category": "quality", "measureId": "401", "title": "Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis", "description": "Percentage of patients aged 18 years and older with a diagnosis of chronic Hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12-month submission period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Gastroenterological Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1368", "M1422" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "gastroenterology", "internalMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_401_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "404", "title": "Anesthesiology Smoking Abstinence", "description": "The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "American Society of Anesthesiologists", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0059" ], "submissionMethods": [ "registry" ], "measureSets": [ "anesthesiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_404_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "405", "title": "Appropriate Follow-up Imaging for Incidental Abdominal Lesions", "description": "Percentage of final reports for imaging studies for patients aged 18 years and older with one or more of the following noted incidentally with a specific recommendation for no follow‐up imaging recommended based on radiological findings:\n• Cystic renal lesion that is simple appearing* (Bosniak I or II)\n• Adrenal lesion less than or equal to 1.0 cm\n• 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", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American College of Radiology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1498" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "diagnosticRadiology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_405_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_405_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "406", "title": "Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients", "description": "Percentage of final reports for computed tomography (CT), CT angiography (CTA) or magnetic resonance imaging (MRI) or magnetic resonance angiogram (MRA) studies of the chest or neck for patients aged 18 years and older with no known thyroid disease with a thyroid nodule < 1.0 cm noted incidentally with follow-up imaging recommended.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American College of Radiology", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1498" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "diagnosticRadiology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_406_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_406_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "claims", "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "410", "title": "Psoriasis: Clinical Response to Systemic Medications", "description": "Percentage of psoriasis vulgaris patients receiving systemic medication who meet minimal physician-or patient- reported disease activity levels. It is implied that establishment and maintenance of an established minimum level of disease control as measured by physician-and/or patient-reported outcomes will increase patient satisfaction with and adherence to treatment.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "American Academy of Dermatology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1421" ], "submissionMethods": [ "registry" ], "measureSets": [ "dermatology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_410_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "413", "title": "Door to Puncture Time for Endovascular Stroke Treatment", "description": "Percentage of patients undergoing endovascular stroke treatment who have a door to puncture time of 90 minutes or less.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "Society of Interventional Radiology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0054", "M1499" ], "submissionMethods": [ "registry" ], "measureSets": [ "interventionalRadiology", "neurosurgical" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_413_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "415", "title": "Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older", "description": "Percentage of emergency department visits for patients aged 18 years and older who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "efficiency", "isHighPriority": true, "primarySteward": "American College of Emergency Physicians", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0057" ], "submissionMethods": [ "registry" ], "measureSets": [ "emergencyMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_415_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "416", "title": "Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years", "description": "Percentage of emergency department visits for patients aged 2 through 17 years who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the Pediatric Emergency Care Applied Research Network (PECARN) prediction rules for traumatic brain injury.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "efficiency", "isHighPriority": true, "primarySteward": "American College of Emergency Physicians", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0057" ], "submissionMethods": [ "registry" ], "measureSets": [ "emergencyMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_416_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "418", "title": "Osteoporosis Management in Women Who Had a Fracture", "description": "The percentage of women 50-85 years of age who suffered a fracture and who had either a bone mineral density (BMD) test or prescription for a drug to treat osteoporosis in the 180 days after the fracture.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0053", "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "endocrinology", "familyMedicine", "internalMedicine", "interventionalRadiology", "obstetricsGynecology", "orthopedicSurgery" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_418_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_418_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "420", "title": "Varicose Vein Treatment with Saphenous Ablation: Outcome Survey", "description": "Percentage of patients treated for varicose veins (CEAP C2-S) who are treated with saphenous ablation (with or without adjunctive tributary treatment) that report an improvement on a disease specific patient reported outcome survey instrument after treatment.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Society of Interventional Radiology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1499" ], "submissionMethods": [ "registry" ], "measureSets": [ "interventionalRadiology", "vascularSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_420_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "421", "title": "Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal", "description": "Percentage of patients in whom a retrievable IVC filter is placed who, within 3 months post-placement, have a documented assessment for the appropriateness of continued filtration, device removal or the inability to contact the patient with at least two attempts.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Society of Interventional Radiology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1499" ], "submissionMethods": [ "registry" ], "measureSets": [ "interventionalRadiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_421_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "422", "title": "Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury", "description": "Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2063", "measureType": "process", "isHighPriority": true, "primarySteward": "American Urogynecologic Society", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366" ], "submissionMethods": [ "claims", "registry" ], "measureSets": [ "obstetricsGynecology" ], "measureSpecification": { "claims": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/2026_Measure_422_MedicarePartBClaims.pdf", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_422_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "430", "title": "Prevention of Post-Operative Nausea and Vomiting (PONV) - Combination Therapy", "description": "Percentage of patients, aged 18 years and older, who undergo a procedure under an inhalational general anesthetic, AND who have three or more risk factors for post-operative nausea and vomiting (PONV), who receive combination therapy consisting of at least two prophylactic pharmacologic antiemetic agents of different classes preoperatively and/or intraoperatively.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Society of Anesthesiologists", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0059" ], "submissionMethods": [ "registry" ], "measureSets": [ "anesthesiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_430_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "431", "title": "Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling", "description": "Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 12 months AND who received brief counseling if identified as an unhealthy alcohol user.", "metricType": "multiPerformanceRate", "overallAlgorithm": "split", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2152", "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366" ], "submissionMethods": [ "registry" ], "measureSets": [ "audiology", "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "familyMedicine", "gastroenterology", "internalMedicine", "mentalBehavioralHealth", "neurology", "nutritionDietician", "obstetricsGynecology", "oncology", "otolaryngology", "physicalMedicine", "preventiveMedicine", "pulmonology", "urgentCare", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_431_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "reporting", "description": "Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 12 months." }, { "name": "performance", "description": "Percentage of patients aged 18 years and older who were identified as unhealthy alcohol users who received brief counseling." }, { "name": "combinedPopulations", "description": "Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 12 months AND who received brief counseling if identified as unhealthy alcohol users." } ] }, { "category": "quality", "measureId": "432", "title": "Proportion of Patients Sustaining a Bladder or Bowel Injury at the time of any Pelvic Organ Prolapse Repair", "description": "Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by a bladder or bowel injury at the time of index surgery that is recognized intraoperatively or within 30 days after surgery.", "metricType": "multiPerformanceRate", "overallAlgorithm": "simpleAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Urogynecologic Society", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366" ], "submissionMethods": [ "registry" ], "measureSets": [ "obstetricsGynecology", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_432_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "bladderInjury", "description": "Percentage of patients undergoing prolapse repair who sustain a bladder injury that necessitates repair either intraoperatively or within 30 days after surgery ." }, { "name": "bowelInjury", "description": "Percentage of patients undergoing prolapse repair who sustain a bowel injury that necessitates repair either intraoperatively or within 30 days after surgery." } ] }, { "category": "quality", "measureId": "438", "title": "Statin Therapy for the Prevention and Treatment of Cardiovascular Disease", "description": "Percentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the performance period:\r\n•\tAll patients who were previously diagnosed with or currently have a diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD), including an ASCVD procedure; OR\r\n•\tPatients aged 20 to 75 years 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\r\n•\tPatients aged 40 to 75 years with a diagnosis of diabetes; OR\r\n•\tPatients aged 40 to 75 with a 10-year ASCVD risk score of ≥ 20 percent.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": "CMS347v9", "eMeasureUuid": "22ea0c5f-5a85-422b-8089-91c24c31bcbb", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0054", "M0005", "M1503" ], "submissionMethods": [ "electronicHealthRecord", "registry" ], "measureSets": [ "cardiology", "endocrinology", "familyMedicine", "internalMedicine", "preventiveMedicine" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0347v9", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_438_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Percentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the measurement period: - All patients who were previously diagnosed with or currently have a diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD), including an ASCVD procedure; OR - Patients aged 20 to 75 years 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; OR - Patients aged 40 to 75 with a 10-year ASCVD risk score of >= 20 percent.", "eMeasureUuids": { "initialPopulationUuid": "DC7EE1FA-285A-447A-AB71-621A180BECBB", "denominatorUuid": "F5A7F615-7471-4549-88FD-C8B447C9685F", "numeratorUuid": "E87BD132-0762-43F1-B61F-427E13BBE7FD", "denominatorExceptionUuid": "5F2E3CBA-C623-492F-8590-A298A5A5240D", "denominatorExclusionUuid": "589CFFC5-DA6E-4A83-822F-97A5025D400B" } } ] }, { "category": "quality", "measureId": "440", "title": "Skin Cancer: Biopsy Reporting Time - Pathologist to Clinician", "description": "Percentage of biopsies with a diagnosis of cutaneous basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), or melanoma (including in situ disease) in which the pathologist communicates results to the clinician within 7 days from the time when the tissue specimen was received by the pathologist.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Dermatology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1421", "M1501" ], "submissionMethods": [ "registry" ], "measureSets": [ "dermatology", "pathology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_440_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "441", "title": "Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)", "description": "The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization's total IVD denominator. All-or-None Outcome Measure (Optimal Control) - Using the IVD denominator optimal results include:\n• Most recent blood pressure (BP) measurement is less than or equal to 130/80 mm Hg -- AND\n• Most recent tobacco status is Tobacco Free -- AND\n• Daily Aspirin or Other Antiplatelet Unless Contraindicated – AND\n• High Intensity Statin Use Unless Contraindicated", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "Wisconsin Collaborative for Healthcare Quality", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0054", "G0055" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "familyMedicine", "internalMedicine", "vascularSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_441_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "445", "title": "Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)", "description": "Percent of patients aged 18 years and older undergoing isolated CABG who die, including both all deaths occurring during the hospitalization in which the CABG was performed, even if after 30 days, and those deaths occurring after discharge from the hospital, but within 30 days of the procedure.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0119", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Society of Thoracic Surgeons", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1425" ], "submissionMethods": [ "registry" ], "measureSets": [ "thoracicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_445_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "448", "title": "Appropriate Workup Prior to Endometrial Ablation", "description": "Percentage of patients, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy and results are documented before undergoing an endometrial ablation.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366" ], "submissionMethods": [ "registry" ], "measureSets": [ "obstetricsGynecology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_448_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "450", "title": "Appropriate Treatment for Patients with Stage I (T1c) - III HER2 Positive Breast Cancer", "description": "Percentage of patients aged 18 to 70 with stage I (T1c) – III HER2 positive breast cancer for whom appropriate treatment is initiated.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1858", "measureType": "process", "isHighPriority": true, "primarySteward": "American Society of Clinical Oncology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0001" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_450_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "451", "title": "RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who Receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy", "description": "Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor (EGFR) monoclonal antibody (MoAb) therapy for whom RAS (KRAS and NRAS) gene mutation testing was performed before initiation of anti-EGFR MoAb.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1859", "measureType": "process", "isHighPriority": false, "primarySteward": "American Society of Clinical Oncology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0001" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_451_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "453", "title": "Percentage of Patients Who Died from Cancer Receiving Systemic Cancer-Directed Therapy in the Last 14 Days of Life (lower score – better)", "description": "Percentage of patients who died from cancer receiving systemic cancer-directed therapy in the last 14 days of life.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0210", "measureType": "process", "isHighPriority": true, "primarySteward": "American Society of Clinical Oncology", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0001" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_453_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "457", "title": "Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score - better)", "description": "Percentage of patients who died from cancer, and admitted to hospice and spent less than 3 days there.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0216", "measureType": "process", "isHighPriority": true, "primarySteward": "American Society of Clinical Oncology", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0001" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_457_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "459", "title": "Back Pain After Lumbar Surgery", "description": "For patients 18 years of age or older who had a lumbar discectomy/laminectomy or fusion procedure, back pain is rated by the patients as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain scale or a numeric pain scale at three months (6 to 20 weeks) postoperatively for discectomy/laminectomy or at one year (9 to 15 months) postoperatively for lumbar fusion patients. Rates are stratified by procedure type; lumbar discectomy/laminectomy or fusion procedure.", "metricType": "multiPerformanceRate", "overallAlgorithm": "weightedAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2018, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Minnesota Community Measurement", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1425" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurosurgical", "orthopedicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_459_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "lumbarDiscectomy", "description": "Percentage of lumbar discectomy/laminectomy procedures for which the patient reports back pain less than or equal to 3.0 OR an improvement of 5.0 points or greater on the VAS or Numeric Pain scale at three months (6 to 20 weeks) postoperatively" }, { "name": "lumbarFusion", "description": "Percentage of lumbar fusion procedures for which the patient reports back pain less than or equal to 3.0 OR an improvement of 5.0 points or greater on the VAS or Numeric pain scale at one year (9 to 15 months) postoperatively" } ] }, { "category": "quality", "measureId": "461", "title": "Leg Pain After Lumbar Surgery", "description": "For patients 18 years of age or older who had a lumbar discectomy/laminectomy or fusion procedure, leg pain is rated by the patient as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain scale or a numeric pain scale at three months (6 to 20 weeks) for discectomy/laminectomy or at one year (9 to 15 months) postoperatively for lumbar fusion patients. Rates are stratified by procedure type; lumbar discectomy/laminectomy or fusion procedure.", "metricType": "multiPerformanceRate", "overallAlgorithm": "weightedAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2018, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Minnesota Community Measurement", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1425" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurosurgical", "orthopedicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_461_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "lumbarDiscectomy", "description": "Percentage of lumbar discectomy/laminectomy procedures for which the patient reports leg pain less than or equal to 3.0 OR an improvement of 5.0 points or greater on the VAS or Numeric Pain scale at three months (6 to 20 weeks) postoperatively" }, { "name": "lumbarFusion", "description": "Percentage of lumbar fusion procedures for which the patient reports leg pain less than or equal to 3.0 OR an improvement of 5.0 points or greater on the VAS or Numeric Pain scale at one year (9 to 15 months) postoperatively after lumbar fusion." } ] }, { "category": "quality", "measureId": "462", "title": "Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy", "description": "Patients determined as having prostate cancer who are currently starting or undergoing androgen deprivation therapy (ADT), for an anticipated period of 12 months or greater and who receive an initial bone density evaluation. The bone density evaluation must be prior to the start of ADT or within 3 months of the start of ADT.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2018, "lastPerformanceYear": null, "eMeasureId": "CMS645v9", "eMeasureUuid": "4536b54a-8ef4-418a-8944-d1426c6a58de", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Oregon Urology Institute", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0001", "M1423" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "endocrinology", "oncology", "urology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0645v9" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients with a bone density evaluation within the two years prior to the start of or less than three months after the start of ADT treatment", "eMeasureUuids": { "initialPopulationUuid": "786E05E4-F16E-492D-BAD4-2555F1CA3F40", "denominatorUuid": "B876332D-519E-444E-839F-7FA9C919F1A6", "numeratorUuid": "474E39BC-B7EA-4BBA-A7ED-62D50806F61D", "denominatorExceptionUuid": "34047550-15EF-4204-9A8F-A0285CFE8F4F" } } ] }, { "category": "quality", "measureId": "463", "title": "Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics)", "description": "Percentage of patients aged 3 through 17 years, who undergo a procedure under general anesthesia in which an inhalational anesthetic is used for maintenance AND who have two or more risk factors for post-operative vomiting (POV), who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively and/or intraoperatively.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2018, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Society of Anesthesiologists", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0059" ], "submissionMethods": [ "registry" ], "measureSets": [ "anesthesiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_463_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "464", "title": "Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use", "description": "Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2018, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0657", "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery Foundation", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "otolaryngology", "pediatrics", "urgentCare" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_464_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "465", "title": "Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian Arteries", "description": "The percentage of patients with documentation of angiographic endpoints of embolization AND the documentation of embolization strategies in the presence of unilateral or bilateral absent uterine arteries.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2018, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Society of Interventional Radiology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1499" ], "submissionMethods": [ "registry" ], "measureSets": [ "interventionalRadiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_465_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "468", "title": "Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)", "description": "Percentage of adults aged 18 years and older with pharmacotherapy for opioid use disorder (OUD) who have at least 180 days of continuous treatment.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2019, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "University of Southern California", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1369" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "mentalBehavioralHealth", "physicalMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_468_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "470", "title": "Functional Status After Primary Total Knee Replacement", "description": "For patients age 18 and older who had a primary total knee replacement procedure, functional status is rated by the patient as greater than or equal to 37 on the Oxford Knee Score (OKS) or a 71 or greater on the KOOS, JR tool at one year (9 to 15 months) postoperatively.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2019, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Minnesota Community Measurement", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0058" ], "submissionMethods": [ "registry" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_470_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "471", "title": "Functional Status After Lumbar Surgery", "description": "For patients age 18 and older who had lumbar discectomy/laminectomy or fusion procedure, functional status is rated by the patient as less than or equal to 22 OR an improvement of 30 points or greater on the Oswestry Disability Index (ODI version 2.1a) * at three months (6 to 20 weeks) postoperatively for discectomy/laminectomy or at one year (9 to 15 months) postoperatively for lumbar fusion patients. Rates are stratified by procedure type; lumbar discectomy/laminectomy or fusion procedure. * hereafter referred to as ODI", "metricType": "multiPerformanceRate", "overallAlgorithm": "weightedAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2019, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Minnesota Community Measurement", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1425" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurosurgical", "orthopedicSurgery" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_471_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "lumbarDiscectomy", "description": "Percentage of lumbar discectomy/laminectomy procedures for which the patient reports functional status is less than or equal to 22 OR an improvement of 30 points or greater on the Oswestry Disability Index (ODI version 2.1a) at three months (6 to 20 weeks) postoperatively" }, { "name": "lumbarFusion", "description": "Percentage of lumbar fusion procedures for which the patient reports functional status is less than or equal to 22 OR an improvement of 30 points or greater on the Oswestry Disability Index (ODI Version 2.1a) patient reported outcome tool at one year (9 to 15 months) postoperatively" } ] }, { "category": "quality", "measureId": "475", "title": "HIV Screening", "description": "Percentage of patients aged 15-65 at the start of the measurement period who were between 15-65 years old when tested for Human immunodeficiency virus (HIV).", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2019, "lastPerformanceYear": null, "eMeasureId": "CMS349v8", "eMeasureUuid": "afc7962b-4e03-4844-9971-ede97d8b6383", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Disease Control and Prevention", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0005", "M1366", "M1368" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "certifiedNurseMidwife", "familyMedicine", "infectiousDisease", "internalMedicine", "obstetricsGynecology", "preventiveMedicine" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0349v8" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients with documentation of an HIV test performed on or after their 15th birthday and before their 66th birthday", "eMeasureUuids": { "initialPopulationUuid": "D9B32E8C-4DAE-4FE1-A876-068600695912", "denominatorUuid": "5A9314BA-D97B-465B-8B85-A45FD3F9ABE2", "numeratorUuid": "F5430ED0-63AB-4E8B-AD99-3DE79F592129", "denominatorExceptionUuid": "2841A0A9-75E9-4F09-884A-47173061F2C2", "denominatorExclusionUuid": "5A6EBD39-0BA6-4AC4-87AB-94A0132AF7BC" } } ] }, { "category": "quality", "measureId": "476", "title": "Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia", "description": "Percentage of patients with an office visit within the measurement period and with a new diagnosis of clinically significant Benign Prostatic Hyperplasia who have International Prostate Symptoms Score (IPSS) or American Urological Association (AUA) Symptom Index (SI) documented at time of diagnosis and again 6-12 months later with an improvement of 3 points.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": "CMS771v7", "eMeasureUuid": "7e9ed220-274d-4f27-8ff0-6fd0cb482cf6", "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Large Urology Group Practice Association and Oregon Urology Institute", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1423" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "familyMedicine", "geriatrics", "internalMedicine", "urology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0771v7" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients with a documented improvement of at least 3 points in their urinary symptom score during the measurement period", "eMeasureUuids": { "initialPopulationUuid": "F5F30C86-7504-463A-822F-2A7773AD62E8", "denominatorUuid": "73DF06D9-B793-4CBC-85D5-AE7D396F23BD", "numeratorUuid": "A064DE1F-FC50-4199-AFC4-816074DA3E1F", "denominatorExclusionUuid": "4D96A847-9BCC-478A-A6E0-D01638CF5F00" } } ] }, { "category": "quality", "measureId": "477", "title": "Multimodal Pain Management", "description": "Percentage of patients, aged 18 years and older, undergoing selected surgical procedures that were managed with multimodal pain management.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Society of Anesthesiologists", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0059" ], "submissionMethods": [ "registry" ], "measureSets": [ "anesthesiology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_477_MIPSCQM.pdf" }, "isSevenPointCapRemoved": true, "sevenPointCapRemoved": [ "registry" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "478", "title": "Functional Status Change for Patients with Neck Impairments", "description": "A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with neck impairments. The change in FS is assessed using the FOTO Neck FS PROM. The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk-adjusted) and used as a performance measure at the patient, individual clinician, and clinic levels to assess quality.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3461", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Focus on Therapeutic Outcomes, Inc.", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [ "chiropracticMedicine", "orthopedicSurgery", "physicalTherapyOccupationalTherapy" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_478_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "479", "title": "Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups", "description": "This measure is a re-specified version of the measure, “Risk-adjusted readmission rate (RARR) of unplanned readmission within 30 days of hospital discharge for any condition” (NQF 1789), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to MIPS participating clinician groups and assesses each group’s readmission rate. The measure comprises a single summary score, derived from the results of five models, one for each of the following specialty cohorts (groups of discharge condition categories or procedure categories): medicine, surgery/gynecology, cardio-respiratory, cardiovascular, and neurology.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "decimal", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/479_MIPS_Hospital-Wide-Readmission_2026_MIF_508.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "480", "title": "Risk-standardized complication rate (RSCR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) for Merit-based Incentive Payment System (MIPS)", "description": "This measure is a re-specified version of the measure, “Hospital-level Risk-standardized Complication rate (RSCR) following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA)” (National Quality Forum 1550), which was developed for patients 65 years and older using Medicare claims. This re-specified measure attributes outcomes to Merit-based Incentive Payment System participating clinicians and/or clinician groups (“provider”) and assesses each provider’s complication rate, defined as any one of the specified complications occurring from the date of index admission to up to 90 days post date of the index procedure.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3493", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "decimal", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0058" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [ "orthopedicSurgery" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/480_MIPS_THA_TKA_2026_MIF_508.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "481", "title": "Intravesical Bacillus-Calmette-Guerin for Non-Muscle Invasive Bladder Cancer", "description": "Percentage of patients initially diagnosed with non-muscle invasive bladder cancer and who received intravesical Bacillus-Calmette-Guerin (BCG) within 6 months of bladder cancer staging.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": "CMS646v6", "eMeasureUuid": "a08c5ba7-6c2a-465b-8415-92861ee15fa4", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Oregon Urology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1423" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "urology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0646v6" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Intravesical Bacillus-Calmette Guerin (BCG) instillation for initial dose or series: BCG is initiated within 6 months of the bladder cancer staging", "eMeasureUuids": { "initialPopulationUuid": "AA2E8D12-F5D5-49A4-B15A-5C16B5F18667", "denominatorUuid": "C3968A41-F665-4131-9EF4-E850845E2D1F", "numeratorUuid": "EAD93629-C7CB-4682-B599-EE13B03FEF38", "denominatorExceptionUuid": "D629A3FE-F02D-40A7-ACE3-99A465A9BE83", "denominatorExclusionUuid": "E1CA1D66-73AB-4CA4-997F-0CBACD08C4B4" } } ] }, { "category": "quality", "measureId": "482", "title": "Hemodialysis Vascular Access: Practitioner Level Long-term Catheter Rate", "description": "Percentage of adult hemodialysis (HD) patient-months using a catheter continuously for three months or longer for vascular access attributable to an individual practitioner or group practice.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0002" ], "submissionMethods": [ "registry" ], "measureSets": [ "nephrology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_482_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "483", "title": "Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM)", "description": "The Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM) uses the PCPCM Patient Reported Outcome Measure (PROM) a comprehensive and parsimonious set of 11 patient-reported items - to assess the broad scope of primary care. Unlike other primary care measures, the PCPCM PRO-PM measures the high value aspects of primary care based on a patient’s relationship with the clinician or practice.", "metricType": "nonProportion", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3568", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "The American Board of Family Medicine", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0005" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_483_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "484", "title": "Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (MCC)", "description": "The measure is a risk-standardized rate of acute, unplanned hospital admissions for the Merit-based Incentive Payment System (MIPS) among Medicare Fee-for-Service (FFS) patients aged 65 years and older with multiple chronic conditions (MCCs); i.e., two or more of nine qualifying chronic conditions. The measure is adjusted for age, chronic condition categories, and other clinical and frailty risk factors present at the start of the 12-month measurement period as well as social risk factors. The measure attributes admissions to MIPS participating clinicians and/or clinician groups, as identified by their National Provider Identifiers (NPIs) and/or Taxpayer Identification Number (TIN) and assesses each clinician’s or clinician group’s admission rate.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3597", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus", "G0053", "G0054", "G0055", "G0057", "G0058", "G0059", "M0001", "M0002", "M0004", "M0005", "M1366", "M1367", "M1368", "M1369", "M1370", "M1420", "M1421", "M1422", "M1423", "M1424", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/484_PY2026-MIPS-Admin-Claims-MCC-MIF.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "485", "title": "Psoriasis - Improvement in Patient-Reported Itch Severity", "description": "The percentage of patients, aged 8 years and older, with a diagnosis of psoriasis where at an initial (index) visit have a patient reported itch severity assessment performed, score greater than or equal to 4, and who achieve a score reduction of 3 or more points at a follow up visit.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "American Academy of Dermatology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1421" ], "submissionMethods": [ "registry" ], "measureSets": [ "dermatology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_485_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "486", "title": "Dermatitis – Improvement in Patient-Reported Itch Severity", "description": "The percentage of patients, aged 8 years and older, with a diagnosis of dermatitis where at an initial (index) visit have a patient reported itch severity assessment performed, score greater than or equal to 4, and who achieve a score reduction of 3 or more points at a follow up visit.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "American Academy of Dermatology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1421" ], "submissionMethods": [ "registry" ], "measureSets": [ "dermatology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_486_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "488", "title": "Kidney Health Evaluation", "description": "Percentage of patients aged 18--85 years with a diagnosis of diabetes who received a kidney health evaluation defined by an Estimated Glomerular Filtration Rate (eGFR) AND Urine Albumin-Creatinine Ratio (uACR) within the performance period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": "CMS951v4", "eMeasureUuid": "79d13667-8fea-4cf6-bf7b-98966acb0eb5", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "National Kidney Foundation", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0002" ], "submissionMethods": [ "registry", "electronicHealthRecord" ], "measureSets": [ "endocrinology", "familyMedicine", "geriatrics", "internalMedicine", "nephrology", "preventiveMedicine", "urgentCare", "urology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms0951v4", "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_488_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients who received a kidney health evaluation during the measurement period. Kidney health evaluation is defined by an eGFR AND uACR within the measurement period OR an eGFR and a Urine Albumin and Urine Creatine result documented less than or equal to four days apart", "eMeasureUuids": { "initialPopulationUuid": "38EEC8FC-7350-4F83-B58E-79DC9515423D", "denominatorUuid": "611F9C98-6875-40C3-BC40-D6BDA58640E6", "numeratorUuid": "9CCB6F0C-DA06-40C0-AB1A-D38DD8EF34C9", "denominatorExclusionUuid": "D07D6FCB-7FC7-4226-B930-913E559D33AD" } } ] }, { "category": "quality", "measureId": "489", "title": "Adult Kidney Disease: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy", "description": "Percentage of patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (Stages 1-5, not receiving Renal Replacement Therapy (RRT)) and proteinuria who were prescribed ACE inhibitor or ARB therapy within the 12-month measurement period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "1662", "measureType": "process", "isHighPriority": false, "primarySteward": "Renal Physicians Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0002" ], "submissionMethods": [ "registry" ], "measureSets": [ "geriatrics", "nephrology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_489_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "490", "title": "Appropriate Intervention of Immune-related Diarrhea and/or Colitis in Patients Treated with Immune Checkpoint Inhibitors", "description": "Percentage of patients, aged 18 years and older, with a diagnosis of cancer, on immune checkpoint inhibitor therapy, and grade 2 or above diarrhea and/or grade 2 or above colitis, who have immune checkpoint inhibitor therapy held and corticosteroids or immunosuppressants prescribed or administered.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Society for Immunotherapy of Cancer (SITC)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0001" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_490_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "491", "title": "Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status", "description": "Percentage of surgical pathology reports for primary colorectal, endometrial, gastroesophageal or small bowel carcinoma, biopsy or resection, that contain impression or conclusion of or recommendation for testing of mismatch repair (MMR) by immunohistochemistry (biomarkers MLH1, MSH2, MSH6, and PMS2), or microsatellite instability (MSI) by DNA-based testing status, or both.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3661", "measureType": "process", "isHighPriority": true, "primarySteward": "College of American Pathologists", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1501" ], "submissionMethods": [ "registry" ], "measureSets": [ "pathology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_491_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "492", "title": "Risk-Standardized Acute Cardiovascular-Related Hospital Admission Rates for Patients with Heart Failure under the Merit-based Incentive Payment System", "description": "Annual risk-standardized rate of acute, unplanned cardiovascular-related admissions among Medicare Fee-for-Service (FFS) patients aged 65 years and older with heart failure (HF) or cardiomyopathy.", "metricType": "costScore", "isRegistryMeasure": false, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "N/A", "measureType": "outcome", "isHighPriority": true, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0055" ], "submissionMethods": [ "administrativeClaims" ], "measureSets": [], "measureSpecification": { "default": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/Claims-Registry-Measures/492_PY2026-MIPS-Admin-Claims-HF-MIF.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup" ] }, { "category": "quality", "measureId": "493", "title": "Adult Immunization Status", "description": "Percentage of patients 19 years of age and older who are up-to-date on recommended routine vaccines for influenza; tetanus and diphtheria (Td) or tetanus, diphtheria and acellular pertussis (Tdap); zoster; pneumococcal; and hepatitis B.", "metricType": "multiPerformanceRate", "overallAlgorithm": "weightedAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3620", "measureType": "process", "isHighPriority": false, "primarySteward": "National Committee for Quality Assurance", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0053", "M0002", "M0005", "M1366", "M1368" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "endocrinology", "familyMedicine", "geriatrics", "infectiousDisease", "internalMedicine", "nephrology", "obstetricsGynecology", "oncology", "otolaryngology", "preventiveMedicine", "pulmonology", "rheumatology", "skilledNursingFacility" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_493_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "historic_benchmarks": { "registry": "removed" }, "strata": [ { "name": "influenza", "description": "Percentage of patients (19 years of age and older on the date of the encounter) who received an influenza vaccine on or between July 1 of the year prior to the measurement period and June 30 of the measurement period." }, { "name": "Tdap", "description": "Percentage of patients (19 years of age and older on the date of the encounter) who received at least 1 tetanus and diphtheria (Td) vaccine or 1 tetanus, diphtheria, and pertussis (Tdap) vaccine between 9 years prior to the encounter and the end of the measurement period." }, { "name": "herpesZoster", "description": "Percentage of patients (50 years of age and older on the date of the encounter) who received 2 doses of the herpes zoster recombinant vaccine anytime on October 20, 2017, through the end of the measurement period." }, { "name": "pneumococcal", "description": "Percentage of patients (66 years of age or older on the date of the encounter) who were administered any pneumococcal conjugate vaccine or polysaccharide vaccine, on or after their 19th birthday and before the end of the measurement period." }, { "name": "hepB", "description": "Percentage of patients (19 years of age and older on the date of the encounter) who were administered a hepatitis B vaccine series." } ] }, { "category": "quality", "measureId": "494", "title": "Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Clinician Level)", "description": "This measure provides a standardized method for monitoring the performance of diagnostic CT to discourage unnecessarily high radiation doses, a risk factor for cancer, while preserving image quality. It is expressed as a percentage of patients with CT exams that are out-of-range based on having either excessive radiation dose or inadequate image quality relative to evidence-based thresholds based on the clinical indication for the exam. All diagnostic CT exams of specified anatomic sites performed in inpatient, outpatient and ambulatory care settings are eligible. This measure is not telehealth eligible. This eCQM requires the use of additional software to access primary data elements stored within radiology electronic health records and translate them into data elements that can be ingested by this eCQM. Additional details are included in the Guidance field.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": "CMS1056v3", "eMeasureUuid": "1463d715-c1d7-49de-8473-348ce1fc81ca", "nqfEMeasureId": "3633e", "nqfId": "3633e\n3662e", "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "Alara Imaging, Inc. in collaboration with the University of California, San Francisco (UCSF)", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1498" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "diagnosticRadiology" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms1056v3" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients with one or more eligible CT scans with calculated CT Size-Adjusted Dose greater than or equal to a threshold specific to the CT Dose and Image Quality Category, or Calculated CT Global Noise value greater than or equal to a threshold specific to the CT Dose and Image Quality Category", "eMeasureUuids": { "initialPopulationUuid": "1FFCCC84-6F19-4B0A-9DF0-6B851CE34C24", "denominatorUuid": "B6F347A2-7768-4D3F-96E5-5DECFCDA059F", "numeratorUuid": "BA85E0B1-3886-4000-B694-8D0E158731C5", "denominatorExclusionUuid": "2E1C63E1-5790-4E94-9081-ACA574B3DB47" } } ] }, { "category": "quality", "measureId": "495", "title": "Ambulatory Palliative Care Patients’ Experience of Feeling Heard and Understood", "description": "The percentage of top-box responses among patients aged 18 years and older who had an ambulatory palliative care visit and report feeling heard and understood by their palliative care clinician and team within 2 months (60 days) of the ambulatory palliative care visit.", "metricType": "multiPerformanceRate", "overallAlgorithm": "weightedAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3665", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "American Academy of Hospice and Palliative Medicine (AAHPM)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0054", "G0055", "M0001", "M0002", "M0004" ], "submissionMethods": [ "registry" ], "measureSets": [ "cardiology", "clinicalSocialWork", "familyMedicine", "geriatrics", "internalMedicine", "nephrology", "neurology", "oncology", "pulmonology", "skilledNursingFacility" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_495_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "heard", "description": "Patient felt heard and understood by this provider and team" }, { "name": "bestInterest", "description": "Patient felt this provider and team put my best interests first when making recommendations about my care" }, { "name": "seen", "description": "Patient felt this provider and team saw me as a person, not just someone with a medical problem" }, { "name": "understood", "description": "Patient felt this provider and team understood what is important to me in my life" } ] }, { "category": "quality", "measureId": "496", "title": "Cardiovascular Disease (CVD) Risk Assessment Measure - Proportion of Pregnant/Postpartum Patients that Receive CVD Risk Assessment with a Standardized Instrument", "description": "Percentage of pregnant or postpartum patients who received a cardiovascular disease (CVD) risk assessment with a standardized instrument.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "University of California, Irvine", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1366" ], "submissionMethods": [ "registry" ], "measureSets": [ "certifiedNurseMidwife", "obstetricsGynecology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_496_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "497", "title": "Preventive Care and Wellness (composite)", "description": "Percentage of patients who received age- and sex-appropriate preventive screenings and wellness services. This measure is a composite of seven component measures that are based on recommendations for preventive care by the U.S. Preventive Services Task Force (USPSTF), Advisory Committee on Immunization Practices (ACIP), American Association of Clinical Endocrinology (AACE), and American College of Endocrinology (ACE).", "metricType": "multiPerformanceRate", "overallAlgorithm": "weightedAverage", "isRegistryMeasure": false, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0005" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "internalMedicine", "obstetricsGynecology", "preventiveMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_497_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "influenza", "description": "Percentage of patients who received an influenza immunization or who reported previous receipt of an influenza immunization" }, { "name": "pneumococcal", "description": "Percentage of patients 65 years of age or older who received a pneumococcal vaccination on or after their 19th birthday" }, { "name": "mammogram", "description": "Percentage of patients with a mammogram during the 27 months prior to the end of the measurement period" }, { "name": "colorectal", "description": "Percentage of patients with one or more appropriate colorectal cancer screenings" }, { "name": "BMI", "description": "Percentage of patients with a documented Body Mass Index (BMI), with follow-up plan if applicable, during the encounter or during the previous 12 months" }, { "name": "tobacco", "description": "Percentage of patients screened for tobacco use and, if identified as a tobacco user, received cessation intervention during the encounter or within the previous six months" }, { "name": "HBP", "description": "Percentage of visits where patients were screened for high blood pressure with a documented follow-up plan, as indicated" } ] }, { "category": "quality", "measureId": "499", "title": "Appropriate Screening and Plan of Care for Elevated Intraocular Pressure Following Intravitreal or Periocular Steroid Therapy", "description": "Percentage of patients who had an intravitreal or periocular corticosteroid injection (e.g., triamcinolone, preservative-free triamcinolone, dexamethasone, dexamethasone intravitreal implant, or fluocinolone intravitreal implant) who, within seven (7) weeks following the date of injection, are screened for elevated intraocular pressure (IOP) with tonometry with documented IOP =<25 mm Hg for injected eye OR if the IOP was >25 mm Hg, a plan of care was documented.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Society of Retina Specialists", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1420" ], "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_499_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "500", "title": "Acute Posterior Vitreous Detachment Appropriate Examination and Follow-up", "description": "Percentage of patients with a diagnosis of acute posterior vitreous detachment (PVD) in either eye who were appropriately evaluated during the initial exam and were re-evaluated no later than 8 weeks.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Society of Retina Specialists", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1420" ], "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_500_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "historic_benchmarks": { "registry": "removed" } }, { "category": "quality", "measureId": "501", "title": "Acute Posterior Vitreous Detachment and Acute Vitreous Hemorrhage Appropriate Examination and Follow-up", "description": "Percentage of patients with a diagnosis of acute posterior vitreous detachment (PVD) and acute vitreous hemorrhage in either eye who were appropriately evaluated during the initial exam and were re-evaluated no later than 2 weeks.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Society of Retina Specialists", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1420" ], "submissionMethods": [ "registry" ], "measureSets": [ "ophthalmology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_501_MIPSCQM .pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "historic_benchmarks": { "registry": "removed" } }, { "category": "quality", "measureId": "502", "title": "Improvement or Maintenance of Functioning for Individuals with a Mental and/or Substance Use Disorder", "description": "The percentage of patients aged 18 and older with a mental and/or substance use disorder who demonstrated improvement or maintenance of functioning based on results from the 12-item World Health Organization Disability Assessment Schedule (WHODAS 2.0) or Sheehan Disability Scale (SDS) 30 to 180 days after an index assessment.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "American Psychiatric Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1369" ], "submissionMethods": [ "registry" ], "measureSets": [ "clinicalSocialWork", "familyMedicine", "internalMedicine", "mentalBehavioralHealth", "physicalTherapyOccupationalTherapy" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_502_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "503", "title": "Gains in Patient Activation Measure (PAM®) Scores at 12 Months", "description": "The Patient Activation Measure® (PAM®) is a 10- or 13- item questionnaire that assesses an individual's knowledge, skills and confidence for managing their health and health care. The measure assesses individuals on a 0-100 scale that converts to one of four levels of activation, from low (1) to high (4). The PAM® performance measure (PAM®-PM) is the change in score on the PAM® from baseline to follow-up measurement.", "metricType": "multiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": false, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "2483", "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Insignia Health, LLC, a wholly owned subsidiary of Phreesia", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "G0053", "G0055", "M0001", "M0002", "M0004", "M1420", "M1421", "M1422", "M1423", "M1424" ], "submissionMethods": [ "registry" ], "measureSets": [ "allergyImmunology", "cardiology", "certifiedNurseMidwife", "clinicalSocialWork", "dermatology", "endocrinology", "familyMedicine", "gastroenterology", "geriatrics", "infectiousDisease", "internalMedicine", "nephrology", "neurology", "obstetricsGynecology", "oncology", "physicalTherapyOccupationalTherapy", "podiatry", "preventiveMedicine", "pulmonology", "rheumatology", "urology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_503_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "overall", "description": "Percentage of patients aged 14 years and older who achieved a net increase in PAM® score of at least 3 points in a 4 to 12 month period" }, { "name": "6points", "description": "Percentage of patients aged 14 years and older who achieved a net increase in PAM® score of at least 6 points in a 4 to 12 month period" } ] }, { "category": "quality", "measureId": "504", "title": "Initiation, Review, And/Or Update To Suicide Safety Plan For Individuals With Suicidal Thoughts, Behavior, Or Suicide Risk", "description": "Percentage of patients aged 12 years and older with suicidal ideation or behavior symptoms (based on results of a standardized assessment tool or screening tool) or increased suicide risk (based on the clinician's evaluation or clinician-rating tool) for whom a suicide safety plan is initiated, reviewed, and/or updated in collaboration between the patient and their clinician.", "metricType": "multiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": false, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Psychiatric Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0005", "M1369" ], "submissionMethods": [ "registry" ], "measureSets": [ "certifiedNurseMidwife", "clinicalSocialWork", "familyMedicine", "internalMedicine", "mentalBehavioralHealth", "obstetricsGynecology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_504_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "24hour", "description": "Percentage of patients for whom a suicide safety plan is initiated, reviewed, or updated in collaboration between the patient and their clinician (concurrent or within 24 hours of clinical encounter)" }, { "name": "overall", "description": "Percentage of patients for whom a suicide safety plan is initiated, reviewed, or updated in collaboration between the individual and their clinician at the time the suicidal ideation, behavior or risk is identified (concurrent or within 24 hours of clinical encounter) AND reviewed and updated within 120 days after initiation." } ] }, { "category": "quality", "measureId": "505", "title": "Reduction in Suicidal Ideation or Behavior Symptoms", "description": "The percentage of patients aged 18 and older with a mental and/or substance use disorder AND suicidal thoughts, behaviors or risk symptoms who demonstrated a reduction in suicidal ideation and/or behavior symptoms based on results from the Columbia-Suicide Severity Rating Scale (C-SSRS) 'Screen Version' or 'Since Last Visit' within 120 days after an index assessment.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "American Psychiatric Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1369" ], "submissionMethods": [ "registry" ], "measureSets": [ "certifiedNurseMidwife", "clinicalSocialWork", "familyMedicine", "mentalBehavioralHealth", "obstetricsGynecology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_505_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "506", "title": "Positive PD-L1 Biomarker Expression Test Result Prior to First-Line Immune Checkpoint Inhibitor Therapy", "description": "Percentage of patients, aged 18 years and older, with a diagnosis of metastatic non-small cell lung cancer (NSCLC) or squamous cell carcinoma of head and neck (HNSCC) on first-line immune checkpoint inhibitor (ICI) therapy, who had a positive PD-L1 biomarker expression test result prior to giving ICI therapy.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Society for Immunotherapy of Cancer (SITC)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0001" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_506_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "507", "title": "Appropriate Germline Testing for Ovarian Cancer Patients", "description": "Percentage of patients, aged 18 and older, diagnosed with epithelial ovarian, fallopian tube, or primary peritoneal cancer who undergo germline testing within 6 months of diagnosis.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Society of Clinical Oncology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0001" ], "submissionMethods": [ "registry" ], "measureSets": [ "oncology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_507_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "509", "title": "Melanoma: Tracking and Evaluation of Recurrence", "description": "Percentage of patients who had an excisional surgery for melanoma or melanoma in situ with initial American Joint Committee on Cancer (AJCC) staging of 0, I, or II, in the past 5 years in which the operating provider examines and/or diagnoses the patient for recurrence of melanoma.", "metricType": "multiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": false, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Dermatology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1421" ], "submissionMethods": [ "registry" ], "measureSets": [ "dermatology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_509_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "overall", "description": "Documentation by the clinician who performed the surgery that an exam for recurrence of melanoma was performed on the patient within the performance period" }, { "name": "incidence", "description": "All patients that were diagnosed with a recurrent melanoma in the current performance period" } ] }, { "category": "quality", "measureId": "510", "title": "First Year Standardized Kidney Transplant Waitlist Ratio (FYSWR)", "description": "The number of newly initiated patients on dialysis in a practitioner group who are under the age of 75 and were either listed on the kidney or kidney-pancreas transplant waitlist or received a living donor transplant within the first year of initiating dialysis. The practitioner group is inclusive of physicians and advanced practice providers. The measure is the ratio-observed number of waitlist events in a practitioner group to its expected number of waitlist events. The measure uses the expected waitlist events calculated from a Cox model, which is adjusted for age, patient comorbidities, and other risk factors at the time of dialysis.", "metricType": "nonProportion", "isRegistryMeasure": false, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0002" ], "submissionMethods": [ "registry" ], "measureSets": [ "nephrology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_510_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "511", "title": "Percentage of Prevalent Patients Waitlisted for Kidney Transplant (PPPW) and Percentage of Prevalent Patients Waitlisted for Kidney Transplant in Active Status (aPPPW)", "description": "The measure tracks dialysis patients who are under the age of 75 in a practitioner group and on the kidney or kidney-pancreas transplant waitlist (all patients or patients in active status). This measure is a risk-adjusted percentage of waitlist events among dialysis patients.", "metricType": "multiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": false, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0002" ], "submissionMethods": [ "registry" ], "measureSets": [ "nephrology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_511_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "waitlisted", "description": "Percentage of Prevalent Patients Waitlisted (PPPW)." }, { "name": "overall", "description": "Percentage of Prevalent Patients Waitlisted in Active Status (aPPPW)." } ] }, { "category": "quality", "measureId": "512", "title": "Prevalent Standardized Kidney Transplant Waitlist Ratio (PSWR)", "description": "The number of prevalent dialysis patients in a practitioner group who are under the age of 75 and were listed on the kidney or kidney-pancreas transplant waitlist or received a living donor transplant. The practitioner group is inclusive of physicians and advanced practice providers. The measure is the ratio-observed number of waitlist events in a practitioner group to its expected number of waitlist events. The measure uses the expected waitlist events calculated from a Cox model, which is adjusted for age, patient comorbidities, and other risk factors at the time of dialysis.", "metricType": "nonProportion", "isRegistryMeasure": false, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Centers for Medicare & Medicaid Services", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0002" ], "submissionMethods": [ "registry" ], "measureSets": [ "nephrology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_512_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "513", "title": "Patient Reported Falls and Plan of Care", "description": "Percentage of patients (or caregivers as appropriate) with an active diagnosis of a movement disorder, multiple sclerosis, a neuromuscular disorder, dementia, or stroke who reported a fall occurred and those that fell had a plan of care for falls documented at every visit.", "metricType": "multiPerformanceRate", "overallAlgorithm": "split", "isRegistryMeasure": false, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Neurology", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M0004" ], "submissionMethods": [ "registry" ], "measureSets": [ "neurology" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_513_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "name": "reporting", "description": "Patients with a diagnosis of a movement disorder, multiple sclerosis, a neuromuscular disorder, dementia, or stroke who were assessed for at each visit during the performance period" }, { "name": "performance", "description": "Patients with a diagnosis of a movement disorder, multiple sclerosis, a neuromuscular disorder, dementia, or stroke who report a fall occurred since the last visit AND who have a plan of care for falls" } ] }, { "category": "quality", "measureId": "514", "title": "Diagnostic Delay of Venous Thromboembolism in Primary Care", "description": "Percentage of episodes for patients 18 years of age and older with documented Venous Thromboembolism (VTE) symptoms in the primary care setting and who had a diagnosis of VTE that occurs > 24 hours and within 30 days following the index primary care visit where symptoms for the VTE were first present.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": "CMS1173v1", "eMeasureUuid": "70d4b6a1-005c-4d11-834a-e68fb823264e", "nqfEMeasureId": "3749e", "nqfId": null, "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "Brigham and Women's Hospital", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "familyMedicine" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms1173v1" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "All qualified VTE encounters in which the VTE diagnosis occurs greater than 24 hours and within 30 days following the index PCP visit.", "eMeasureUuids": { "initialPopulationUuid": "F4EDC6E6-F7CF-4357-B7DF-43CCC90A59D0", "denominatorUuid": "98168B78-61BD-4A76-AFDC-970EA9346D55", "numeratorUuid": "CDB0E40C-83D8-4501-A29A-F5733B1026F3", "denominatorExclusionUuid": "113FFDC6-0639-4A98-AF90-5BE356266257" } } ] }, { "category": "quality", "measureId": "515", "title": "Screening for Abnormal Glucose Metabolism in Patients at Risk of Developing Diabetes", "description": "Percentage of adult patients with risk factors for type 2 diabetes who are due for glycemic screening for whom the screening process was completed during the measurement period.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": "CMS1154v1", "eMeasureUuid": "570f2da4-29d5-4b36-98fd-f843e7165cb8", "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Medical Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "electronicHealthRecord" ], "measureSets": [ "familyMedicine", "internalMedicine" ], "measureSpecification": { "electronicHealthRecord": "https://ecqi.healthit.gov/ecqm/ec/2026/cms1154v1" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "strata": [ { "description": "Patients who had a glycemic screening test performed during the measurement period.", "eMeasureUuids": { "initialPopulationUuid": "0AC4A085-8D50-415B-A439-3BB6A0797B03", "denominatorUuid": "52872F27-C32B-4296-91AB-ADF9B44B44F3", "numeratorUuid": "2BACF9F5-EE61-4E40-9621-92F9ACC49E5D", "denominatorExclusionUuid": "44F3408C-28CD-49B4-BABF-468588E3C134" } } ] }, { "category": "quality", "measureId": "516", "title": "Hepatitis C Virus (HCV): Sustained Virological Response (SVR)", "description": "Percentage of patients aged greater than or equal to 18 years with active hepatitis C (HCV) with negative/undetectable HCV ribonucleic acid (RNA) at least 20 weeks to 12 months after positive/detectable HCV RNA test result.", "metricType": "singlePerformanceRate", "isRegistryMeasure": false, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Gastroenterological Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "companionMeasureId": [], "allowedPrograms": [ "mips", "M1368", "M1422" ], "submissionMethods": [ "registry" ], "measureSets": [ "familyMedicine", "gastroenterology", "infectiousDisease", "internalMedicine" ], "measureSpecification": { "registry": "https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2026_Measure_516_MIPSCQM.pdf" }, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "quality", "measureId": "AAD6", "title": "Skin Cancer: Biopsy Reporting Time - Clinician to Patient", "description": "Percentage of patients with skin biopsy specimens with a diagnosis of cutaneous basal or squamous cell carcinoma or melanoma (including in situ disease) or primary cutaneous malignancies who are notified of their final biopsy pathology findings within less than or equal to 8 days from the time the biopsy was performed.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "AAD’s DataDerm™", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1421" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4649789" ] }, { "category": "quality", "measureId": "AAD8", "title": "Chronic Skin Conditions: Patient Reported Quality-of-Life", "description": "The percentage of patients aged 18 years and older with a chronic skin condition whose self-assessed quality-of-life was recorded at least once in the medical record within the measurement period.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "AAD’s DataDerm™", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1421" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4649789" ] }, { "category": "quality", "measureId": "AAD12", "title": "Melanoma: – Appropriate Surgical Margins", "description": "Percentage of primary excisional surgeries for melanoma or melanoma in situ with Breslow depth and appropriate surgical margins per the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology- Melanoma (NCCN Guideline).", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "AAD’s DataDerm™", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1421" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4649789" ] }, { "category": "quality", "measureId": "AAD15", "title": "Psoriasis – Appropriate Assessment & Treatment of Severe Psoriasis", "description": "Percentage of patients with a diagnosis of psoriasis with a documented Body Surface Area (BSA) greater than 10% for whom phototherapy or an oral systemic or biologic medication was prescribed.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "AAD’s DataDerm™", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4649789" ] }, { "category": "quality", "measureId": "AAD16", "title": "Avoidance of Post-operative Systemic Antibiotics for Office-based Closures and Reconstruction After Skin Cancer Procedures", "description": "Percentage of procedures in patients aged 18 and older with a diagnosis of skin cancer who underwent intermediate layer or complex linear closure or reconstruction after skin cancer resection in the office-based* setting who were prescribed post-operative systemic antibiotics to be taken immediately following reconstruction surgery (inverse measure).\n\nThis measure is stratified by intermediate layer or complex linear closure or reconstructive procedures.", "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": true, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "AAD’s DataDerm™", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M1421" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4649789" ], "strata": [ { "name": "resection", "description": "Strata 1: Intermediate layer or complex linear closures after skin cancer resection" }, { "name": "reconstruction", "description": "Strata 2: Reconstruction after skin cancer resection " }, { "name": "overall", "description": "Strata 3: FOR REPORTING\r\nStrata 1 + Strata 2; Calculate as (numerator 1 + numerator 2 )/(denominator 1 + denominator 2), not the average of the performance rates" } ] }, { "category": "quality", "measureId": "AAD20", "title": "Actinic Keratosis: Patient-Reported Treatment Effectiveness and Care Satisfaction", "description": "Percentage of adult patients (greater than or equal to 18 years old) who self-report favorable outcomes resulting from a recommended treatment or management approach for Actinic Keratosis (AK) and who self-report satisfaction with the treatment or management of AK. Patients provide a global assessment of the perceived effectiveness of the AK treatment or management plan, followed by their satisfaction and future treatment preference. Evaluating both treatment effectiveness and patient satisfaction supports patient-provider communication and promotes patient-centered approaches to AK care.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "AAD’s DataDerm™", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4649789" ] }, { "category": "quality", "measureId": "AAD21", "title": "Actinic Keratosis: Appropriate Documentation and Shared Decision Making of AK", "description": "Percentage of adult patients (>18 years old) diagnosed with Actinic Keratosis (AK) whose healthcare provider has recorded the following information in the patient’s medical record 1) documentation of the number or range of AKs, 2) location(s) of AK, 3) documentation of prior squamous cell carcinoma, or prior keratinocyte carcinomas and types if known, 4) age, 5) gender, and 6) immunosuppression and have engaged in bi-directional communication with the patient regarding the risk of malignant transformation and a discussion of at least two options for managing AK.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "AAD’s DataDerm™", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4649789" ] }, { "category": "quality", "measureId": "AAO12", "title": "Tympanostomy Tubes: Topical Ear Drop Monotherapy for Acute Otorrhea", "description": "Percentage of patients aged 6 months to 12 years of age at the time of the visit with a current diagnosis of an uncomplicated acute tympanostomy tube otorrhea (TTO) who were prescribed or recommended to use topical antibiotic eardrops and NOT prescribed systemic (IV or PO) antibiotics for acute TTO", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2018, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8365868" ] }, { "category": "quality", "measureId": "AAO13", "title": "Bell's Palsy: Inappropriate Use of Magnetic Resonance Imaging or Computed Tomography Scan", "description": "Percentage of patients aged 16 years and older with a new onset diagnosis of Bell’s palsy who had a magnetic resonance imaging (MRI) or a computed tomography (CT) scan of the internal auditory canal, head, neck, or brain ordered within 3 months after diagnosis", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2018, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8365868" ] }, { "category": "quality", "measureId": "AAO16", "title": "Age-Related Hearing Loss: Comprehensive Audiometric Evaluation", "description": "Percentage of patients aged 50 years and older who failed a hearing screening and/or who report suspected hearing loss who received, were ordered, or were referred for comprehensive audiometric evaluation within 4 weeks of the office visit", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2018, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1367" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8365868" ] }, { "category": "quality", "measureId": "AAO20", "title": "Tympanostomy Tubes: Comprehensive Audiometric Evaluation", "description": "Percentage of patients aged 6 months through 12 years with a diagnosis of otitis media with effusion (OME) who received tympanostomy tube insertion and received a comprehensive audiometric evaluation within 6 months prior to tympanostomy tube insertion", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2018, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1367" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8365868" ] }, { "category": "quality", "measureId": "AAO21", "title": "Otitis Media with Effusion (OME): Comprehensive Audiometric Evaluation for Chronic OME > or = 3 months", "description": "Percentage of patients aged 6 months to 12 years of age with a diagnosis of otitis media with effusion (OME) including chronic serous, mucoid, or nonsuppurative OME of > or = 3 months duration who had or received an order or referral for comprehensive audiometric evaluation", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2018, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1367" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8365868" ] }, { "category": "quality", "measureId": "AAO32", "title": "Standard Benign Positional Paroxysmal Vertigo (BPPV) Management", "description": "Percentage of patients diagnosed with Benign Positional Paroxysmal Vertigo (BPPV) who received vestibular testing, imaging, and antihistamine, benzodiazepine, or vestibular suppressant medications.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2019, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8365868" ] }, { "category": "quality", "measureId": "AAO36", "title": "Tympanostomy Tubes: Resolution of Otitis Media with Effusion (OME) in Adults and Children", "description": "Percentage of patients aged 6 months and older with a diagnosis of otitis media with effusion (OME) who are seen 2 to 8 weeks after tympanostomy tube surgery and OME is resolved", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8365868" ] }, { "category": "quality", "measureId": "AAO37", "title": "Dysphonia: Laryngeal Examination", "description": "Percentage of patients who were diagnosed with dysphonia that failed to resolve within 4 weeks and received a laryngoscopy", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8365868" ] }, { "category": "quality", "measureId": "AAO39", "title": "Neck Mass Evaluation", "description": "Percentage of patients aged 18 years and older diagnosed with a neck mass and suspected/increased risk of malignancy who had a fine needle aspiration (FNA), or refer the patient to someone who can perform FNA and receive a neck computed tomography (or magnetic resonance imaging) with contrast.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8365868" ] }, { "category": "quality", "measureId": "AAO40", "title": "Tonsillectomy: Post-Tonsillectomy Pain Management in Pediatric Patients", "description": "Percentage of patients aged 12 years and younger who underwent a tonsillectomy and were given opioids within the 5-day postoperative period.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8365868" ] }, { "category": "quality", "measureId": "AAO41", "title": "Tonsillectomy: Post-Tonsillectomy Hemorrhage", "description": "Percentage of patients aged 1 year and older who underwent a tonsillectomy and had a post-tonsillectomy hemorrhage requiring reevaluation or surgical intervention within the 21-day postoperative period.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8365868" ] }, { "category": "quality", "measureId": "AAO42", "title": "Obstructive Sleep Apnea: Improvement of Obstructive Sleep Apnea after a Corrective Surgical Procedure", "description": "Percentage of patients aged 18 years and older who have a diagnosis of obstructive sleep apnea and received a corrective procedure for the obstructive sleep apnea and had an improvement in their post-operative sleep study results (i.e., Apnea-Hypopnea Index [AHI], Respiratory Disturbance Index [RDI]) compared to their pre-operative results.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8365868" ] }, { "category": "quality", "measureId": "AAO43", "title": "Otolaryngologic Surgical Procedures: Avoidance of Unnecessary Antibiotic Use", "description": "Percentage of patients aged 1 year and older who underwent an otolaryngologic surgical procedure and did not receive perioperative or postoperative antibiotics when there were no clinical indications, based on evidence-based guidelines.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) Reg-entSM Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8365868" ] }, { "category": "quality", "measureId": "ABFM13", "title": "Measuring the Value-Functions of Primary Care: Comprehensiveness of Care", "description": "This measure evaluates the extent primary care physicians (PCPs) perform care-based and procedural-based services core to primary care (licensure ensures competence of these services). For each PCP, the resulting value reflects an average of the weighted proportion of services within each category performed during the measurement period. \r\n\r\nScores are based on weighted averages of 19 care-based and 20 procedural-based core primary care services resulting in scores between 0 and 100. \r\n\r\nInclusion criteria: Primary care physicians who have provided care to 30 or more patients regardless of age within the measurement period (the performance year and the 12 months prior to the performance year).See Figure 1: Physician and Care Site Identifier in the Measure Specification Figures and Tables document under the Additional Supporting Documentation section for the variables used to determine if physicians meet the inclusion criteria (Step 1 and 2 of the Measure Calculation Algorithm (also found in the Measure Specification Figures and Tables document). \r\n\r\nThroughout this application, since the fields do not accept scientific formulas, tables or figures, we have attached those items in the Additional Supporting Documentation section.", "metricType": "nonProportion", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "ABFM PRIME", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4849508" ] }, { "category": "quality", "measureId": "ABFM14", "title": "Measuring the Value-Functions of Primary Care: Physician Level Continuity of Care Measure", "description": "The measure calculates the percentage of a physician’s patients who have a continuity index of at least 0.7 (excluding patients with < 2 primary care visits during the measurement period). This is a physician-level measure for use in evaluating physician behavior; it leverages a previously validated continuity index that quantifies the extent to which patients experience continuity of provider in their primary care visits.\r\n\r\nThis measure evaluates the extent to which primary care physicians (PCPs) are supporting the continuity of care of their patients. High care continuity is shown to improve patient outcomes and physician well-being, is associated with decreased health care costs (total, ED, inpatient, primary care, and costs for specific conditions or treatments) and health care utilization (ED visits and hospitalizations). As a byproduct of building a trusting relationship over time, issues of equity and social risk can be addressed. Physicians who perform better are likely to have specific structures and processes in place that are conducive to allowing patients to achieve higher care continuity. \r\n\r\nCompared to lower scores (e.g., 0.6 or lower), continuity index scores of 0.7 or higher have been associated with significantly lower Medicare expenditures and significantly lower odds of hospitalization.1 \r\n\r\nReferences: \r\n1. Higher Primary Care Physician Continuity is Associated with Lower Costs and Hospitalizations. Bazemore et al. Annals of Family Medicine. 2018. 16, 492-497.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3617", "measureType": "efficiency", "isHighPriority": true, "primarySteward": "ABFM PRIME", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4849508" ] }, { "category": "quality", "measureId": "ABG44", "title": "Low Flow Inhalational General Anesthesia", "description": "Percentage of patients aged 18 years or older, who undergo an elective procedure lasting 30 minutes or longer requiring inhalational general anesthesia who during the maintenance phase of the anesthetic have a total fresh gas flow less than or equal to 1 L/min (less than or equal to 2 L/min for Sevoflurane).", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "efficiency", "isHighPriority": true, "primarySteward": "ABG QCDR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "G0059" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5551268", "6169123", "6775913", "9181695", "7418330" ] }, { "category": "quality", "measureId": "ABG45", "title": "Aspiration prevention in patients with gastric distension", "description": "Percentage of patients 18 years and older with a current diagnosis of gastrointestinal obstruction, ileus, incarcerated hernia, or patients taking GLP-1 receptor agonists, or patients with gastroparesis, who undergo a surgical procedure under anesthesia and are treated preoperatively with a mitigation strategy that reduces the risk of aspiration during the surgical procedure. \r\n\r\nInstructions \r\nThis measure is to be reported each time an adult patient with one or more of the following conditions undergoes a surgical procedure under anesthesia:\r\n\r\na)\thas gastrointestinal obstruction, ileus, or an incarcerated hernia \r\nb)\tis taking a GLP-1 receptor agonists \r\nc)\thas gastroparesis", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "ABG QCDR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5551268", "6169123", "6775913", "9181695" ] }, { "category": "quality", "measureId": "ACEP22", "title": "Appropriate Emergency Department Utilization of CT for Pulmonary Embolism", "description": "Percentage of emergency department visits during which patients aged 18 years and older had a CT pulmonary angiogram (CTPA) ordered by an emergency care provider, regardless of discharge disposition, with either moderate or high pre-test clinical probability for pulmonary embolism or elevated D-dimer level", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2016, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5133825" ] }, { "category": "quality", "measureId": "ACEP25", "title": "Tobacco Use: Screening and Cessation Intervention for Patients with Asthma and COPD", "description": "Percentage of patients aged 18 years and older with a diagnosis of asthma or COPD seen in the ED and discharged who were screened for tobacco use during any ED encounter AND who received tobacco cessation intervention if identified as a tobacco user", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2016, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1424" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5133825" ] }, { "category": "quality", "measureId": "ACEP31", "title": "Foley Catheter: Appropriate Foley catheter use in the emergency department", "description": "Percentage of emergency department visits for admitted patients aged 18 years and older where an indwelling Foley catheter is ordered and the patient had at least one indication for an indwelling Foley catheter", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2016, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5133825" ] }, { "category": "quality", "measureId": "ACEP50", "title": "ED Median Time from ED arrival to ED departure for all Adult Patients", "description": "Time (in minutes) from ED arrival to ED departure for all Adult Patients", "metricType": "nonProportion", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": true, "isIcdImpacted": false, "allowedPrograms": [ "mips", "G0057" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5133825" ] }, { "category": "quality", "measureId": "ACEP51", "title": "ED Median Time from ED arrival to ED departure for all Pediatric ED Patients", "description": "Time (in minutes) from ED arrival to ED departure for all Pediatric Patients", "metricType": "nonProportion", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": true, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5133825" ] }, { "category": "quality", "measureId": "ACEP52", "title": "Appropriate Emergency Department Utilization of Lumbar Spine Imaging for Acute Atraumatic Low Back Pain", "description": "Percentage of emergency department visits during which patients aged 18 years and older had a CT or MRI of the Lumbar Spine ordered by an emergency care provider, regardless of discharge disposition, presenting with acute, atraumatic low back pain.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "G0057" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5133825", "1718371" ] }, { "category": "quality", "measureId": "ACEP53", "title": "Appropriate Use of Imaging for Recurrent Renal Colic", "description": "Percentage of emergency department visits for patients aged 18-50 years presenting with flank pain with a history of kidney stones during which no imaging is ordered, OR appropriate imaging (plain film radiography or ultrasound) is ordered.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5133825" ] }, { "category": "quality", "measureId": "ACEP59", "title": "Chest Pain – Avoidance of admission for adult patients with low-risk chest pain.", "description": "Percentage of adult patients who came to the Emergency Department with low-risk chest pain and were discharged.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5133825", "1718371", "1725296" ] }, { "category": "quality", "measureId": "ACEP60", "title": "Syncope – Avoidance of admission for adult patients with low-risk syncope", "description": "Percentage of emergency department (ED) visits for patients aged 18-50 years with a diagnosis of low-risk syncope who were discharged", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5133825", "1718371" ] }, { "category": "quality", "measureId": "ACEP61", "title": "Avoidance of Chest X-ray in pediatric patients with Asthma, Bronchiolitis or Croup", "description": "Percentage of ED visits for pediatric patients with Asthma, Bronchiolitis or Croup for whom a Chest X-ray was ordered/performed.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5133825", "1725296" ] }, { "category": "quality", "measureId": "ACEP62", "title": "Avoidance of Opioid therapy for dental pain.", "description": "All acute encounters for patients aged 18 years and older with, diagnosis of dental pain, who were not prescribed Opioids or Opiates", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5133825" ] }, { "category": "quality", "measureId": "ACEP63", "title": "Avoidance of Acute High-Risk Prescriptions in geriatric patients at discharge", "description": "The percentage of adults 65 years of age and older who were prescribed an Acute High-Risk Medication at discharge", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5133825", "1725296" ] }, { "category": "quality", "measureId": "ACEP64", "title": "Avoidance of admission for adult patients in Emergency Department with low-risk Deep Vein Thrombosis (DVT).", "description": "Percentage of patients 18 years and older who present to the Emergency Department with low-risk Deep Vein Thrombosis (DVT) and are discharged home", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5133825", "1718371", "1725296" ] }, { "category": "quality", "measureId": "ACEP65", "title": "Appropriate Utilization of Imaging in rAAA (ruptured Abdominal Aortic Aneurysm) patients in Emergency Department", "description": "Percentage of adult patients aged 55 years and older presenting to the Emergency Department with abdominal pain or back pain and hypotension for whom a POC Ultrasound or CT scan was performed.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5133825" ] }, { "category": "quality", "measureId": "ACEP67", "title": "Avoidance of Admission for Atrial Fibrillation", "description": "Percentage of adult patients aged 18 years and older presenting to the Emergency Department with atrial fibrillation who were discharged to home", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5133825", "1718371", "1725296" ] }, { "category": "quality", "measureId": "ACEP68", "title": "Point-of-care ultrasound (POCUS) in Cardiac Arrest", "description": "Percentage of patients ages 18 and older presenting to the Emergency Department with cardiac arrest who received point-of care ultrasound", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5133825", "1718371", "1725296" ] }, { "category": "quality", "measureId": "ACEP69", "title": "Blood Pressure Control Among Adult ED Patients with Nontraumatic Intracranial Hemorrhage", "description": "Percentage of patients with an ED diagnosis of Intracerebral Hemorrhage for whom the last two recorded systolic blood pressure (SBP) readings were >= 90mm of Hg and <150mm of Hg.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5133825" ] }, { "category": "quality", "measureId": "ACEP70", "title": "Syphilis testing among ED patients with a positive pregnancy test", "description": "Percentage of patients with a positive pregnancy identification in an ED for whom a Syphilis test was ordered.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5133825" ] }, { "category": "quality", "measureId": "ACEP71", "title": "Emergency Medicine: Coagulation Studies in Patients Presenting to the Emergency Department with No Coagulopathy or Bleeding", "description": "Percentage of emergency department visits for patients aged 18 years and older during which coagulation studies were ordered by an emergency care provider.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5133825" ] }, { "category": "quality", "measureId": "ACEP72", "title": "Sepsis diagnosis and management: Lactate Level Measurement, Antibiotics Ordered, and Fluid \r\nSeptic shock outcomes: Lactate clearance rate of greater than equal to 10%", "description": "This measure will be calculated with 2 performance rates:\r\n1.\tPercentage of patients aged ≥ 18 years visiting the emergency department with sepsis or septic shock resulting in hospital admission or transfers and who had an order for all the following: a serum lactate level, antibiotics, and >= 1 L of crystalloids.\r\n2.\tPercentage of patients aged ≥ 18 years visiting the emergency department with septic shock resulting in hospital admission or transfers who had an initial and repeat lactate performed, where the first serum lactate result (>2mmol/L) is elevated and a lactate clearance rate of >= 10% achieved during the emergency department visit.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "ACEP's Clinical Emergency Data Registry (CEDR)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5133825" ] }, { "category": "quality", "measureId": "ACR10", "title": "Hepatitis B Safety Screening", "description": "If a patient is newly initiating biologic OR new synthetic DMARD therapy (e.g. methotrexate, leflunomide, etc.), then the medical record should indicate appropriate screening for hepatitis B in the preceding 12 month period.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "RISE (Rheumatology Informatics System for Effectiveness)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "G0053" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5598408" ] }, { "category": "quality", "measureId": "ACR12", "title": "Disease Activity Measurement for Patients with PsA", "description": "If a patient has psoriatic arthritis, then disease activity using a standardized measurement tool should be assessed at >=50% of encounters for PsA.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "RISE (Rheumatology Informatics System for Effectiveness)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "G0053" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5598408" ] }, { "category": "quality", "measureId": "ACR14", "title": "Gout: Serum Urate Target", "description": "The percentage of patients aged 18 and older with at least one clinician encounter (including telehealth) during the measurement period and an active diagnosis of gout treated with urate-lowering therapy (ULT) for at least 12 months, whose most recent serum urate result is less than 6.0 mg/dL.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "RISE (Rheumatology Informatics System for Effectiveness)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "G0053" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5598408" ] }, { "category": "quality", "measureId": "ACR15", "title": "Safe Hydroxychloroquine Dosing", "description": "If a patient is using hydroxychloroquine, then the average daily dose should be less than or equal to 5 mg/kg.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "RISE (Rheumatology Informatics System for Effectiveness)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "G0053" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5598408" ] }, { "category": "quality", "measureId": "ACR17", "title": "Methotrexate to Biologic Adherence to Treatment Pathway for Patients with Rheumatoid Arthritis", "description": "Percentage of patients aged 18 years or older with a diagnosis of RA AND receiving a first course therapy using a biologic disease-modifying antirheumatic drug (DMARD) who had a prescription for a conventional synthetic (cs) DMARD at least 10 weeks prior to newly initiated biologic therapy during the measurement year.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "RISE (Rheumatology Informatics System for Effectiveness)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5598408" ] }, { "category": "quality", "measureId": "ACR18", "title": "Patient Reported Outcome Physical Function Survey for Patients with Rheumatology Conditions", "description": "Percentage of patients aged 18 years and older with 2 or more rheumatology encounters with a documented diagnosis of rheumatoid arthritis (RA), psoriatic arthritis (PsA), or systemic lupus erythematosus (SLE) who have an assessment for physical function using ACR-preferred assessment tools or other tools deemed acceptable by the ACR at least once during the measurement year.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "RISE (Rheumatology Informatics System for Effectiveness)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5598408" ] }, { "category": "quality", "measureId": "ACR19", "title": "Avoiding the Prolonged Use of Moderate/High Dose Glucocorticoids for Patients with Systemic Lupus Erythematosus", "description": "Percentage of patients aged 18 years or older with a diagnosis of systemic lupus erythematosus (SLE), who are not prescribed an oral a glucocorticoid at a dose exceeding 5 mg per day prednisone equivalent for greater than 6 months.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "RISE (Rheumatology Informatics System for Effectiveness)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5598408" ] }, { "category": "quality", "measureId": "ACR20", "title": "Hydroxychloroquine Use in Patients with Systemic Lupus Erythematosus", "description": "Percentage of patients aged 18 years or older with a diagnosis of systemic lupus erythematosus (SLE), who have an active prescription for hydroxychloroquine during the measurement year.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "RISE (Rheumatology Informatics System for Effectiveness)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5598408" ] }, { "category": "quality", "measureId": "ACRAD34", "title": "Multi-strata weighted average for 3 CT Exam Types: Overall Percent of CT exams for which Dose Length Product is at or below the size-specific diagnostic reference level (for CT Abdomen-pelvis with contrast/single phase scan, CT Chest without contrast/single phase scan and CT Head/Brain without contrast/single phase scan)", "description": "Weighted average of 3 former QCDR measures, ACRad 31, ACRad 32, ACRad 33.", "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "weightedAverage", "isRegistryMeasure": true, "firstPerformanceYear": 2019, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "3621", "measureType": "outcome", "isHighPriority": true, "primarySteward": "American College of Radiology National Radiology Data Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5303416" ], "strata": [ { "name": "abdomen", "description": "Percent of CT Abdomen-pelvis exams with contrast (single phase scan) for which Dose Length Product is at or below the size-specific diagnostic reference level" }, { "name": "chest", "description": "Percent of CT Chest exams without contrast (single phase scan) for which Dose Length Product is at or below the size-specific diagnostic reference level" }, { "name": "head", "description": "Percent of CT Head/brain exams without contrast (single phase scan) for which Dose Length Product is at or below the size-specific diagnostic reference level" } ] }, { "category": "quality", "measureId": "ACRAD44", "title": "Comprehensive Reporting of Coronary Artery Calcification (CAC) on Chest CT", "description": "Percentage of final reports for any chest CT examinations (non-cardiac, with or without contrast) performed on patients, aged 18 and older, that:\r\n1. Document the presence or absence of coronary artery calcification (CAC),\r\n2. If CAC is present, include documentation of a qualitative visual assessment of CAC and a recommendation that the patient consult with their primary care clinician for a comprehensive cardiovascular risk assessment, or a quantitative ordinal assessment of CAC for each of the four main coronary arteries. Recommendations for cardiovascular risk assessment should accompany any non-zero score.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American College of Radiology National Radiology Data Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5303416", "6394618", "6704504", "7037323" ] }, { "category": "quality", "measureId": "ACRAD45", "title": "Interpretation of CT Pulmonary Angiography (CTPA) for Pulmonary Embolism", "description": "Percentage of final reports for patients aged 18 years and older undergoing CT pulmonary angiography (CTPA) with a finding of PE that specify the branching order level of the most proximal level of embolus (i.e. main, lobar, interlobar, segmental, subsegmental); AND right ventricle to left ventricle (RV/LV) ratio, when assessable. If the RV/LV ratio is ?1.0, report the specific ratio value, as this may be associated with increased risk for adverse outcomes, and if the RV/LV ratio is <1.0, report that the ratio is within normal limits, optionally including a range (e.g., 0.7-0.9) to support clinical context.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American College of Radiology National Radiology Data Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5303416", "6394618", "7037323" ] }, { "category": "quality", "measureId": "ACRAD46", "title": "Standardized Spine Fracture Classification Using Validated Systems", "description": "Percentage of final reports for patients with acute spinal fractures undergoing initial CT of the spine that include descriptive imaging findings.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American College of Radiology National Radiology Data Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5303416" ] }, { "category": "quality", "measureId": "AJRR7", "title": "Postoperative Ambulation", "description": "Percentage of patients ages 18 years and older, undergoing elective total hip and knee arthroplasty, who ambulated postoperatively on the day of surgery.", "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "simpleAverage", "isRegistryMeasure": true, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "AAOS Orthopaedic Quality Resource Center", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5224253", "3967247" ], "strata": [ { "name": "hip", "description": "represents total hip arthroplasty" }, { "name": "knee", "description": "represents total knee arthroplasty." } ] }, { "category": "quality", "measureId": "AJRR9", "title": "Risk-Standardized Routine Discharge Rate Following Elective Primary Hip and Knee Arthroplasty", "description": "Risk-standardized rate for routine discharge for elective primary total hip and knee arthroplasty.", "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "simpleAverage", "isRegistryMeasure": true, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "AAOS Orthopaedic Quality Resource Center", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": true, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5224253", "1157686", "3967247" ], "strata": [ { "name": "hip", "description": "represents total hip arthroplasty" }, { "name": "knee", "description": "represents total knee arthroplasty." } ] }, { "category": "quality", "measureId": "AJRR10", "title": "Cement Use for Displaced Femoral Neck Fracture in Older Adults", "description": "Percentage of patients ages 70 years and older, undergoing hip arthroplasty with a displaced femoral neck fracture, who received a cemented femoral stem", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "AAOS Orthopaedic Quality Resource Center", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5224253", "3967247" ] }, { "category": "quality", "measureId": "AJRR15", "title": "90-Day Composite Complication Rate for Degenerative Spine Procedures", "description": "Percentage of patients ages 18 years and older, undergoing a lumbar or cervical procedure, who had a post-operative complication.", "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "simpleAverage", "isRegistryMeasure": true, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "AAOS Orthopaedic Quality Resource Center", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5224253", "1157686" ], "strata": [ { "name": "cervicalspine", "description": "All patients experiencing at least one complication within 90 days postoperative cervical spine surgery. " }, { "name": "lumbarspine", "description": "All patients experiencing at least one complication within 90 days postoperative lumbar spine surgery." } ] }, { "category": "quality", "measureId": "AJRR16", "title": "Physical Health Outcomes in Total Hip and Knee Arthroplasty", "description": "Percentage of patients with patient-reported meaningful improvement in anatomic specific HOOS/KOOS JR after elective total hip and knee arthroplasty.", "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "simpleAverage", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "AAOS Orthopaedic Quality Resource Center", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5224253", "1157686", "3967247", "6394618" ], "strata": [ { "name": "hip", "description": "represents total hip arthroplasty" }, { "name": "knee", "description": "represents total knee arthroplasty." } ] }, { "category": "quality", "measureId": "AJRR17", "title": "Improvement in Pain Assessment Following Spine Fusion Procedures", "description": "Percentage of patients with patient-reported meaningful improvement in pain following lumbar or cervical spine procedures", "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "simpleAverage", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "AAOS Orthopaedic Quality Resource Center", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5224253", "1157686", "3967247" ], "strata": [ { "name": "neckpain", "description": "Percentage of denominator patients who showed a statistically significant improvement in comparison to initial assessment, measured by minimum clinically important difference (MCID), in neck pain." }, { "name": "backpain", "description": "Percentage of denominator patients who showed a statistically significant improvement in comparison to initial assessment, measured by minimum clinically important difference (MCID), in back pain." }, { "name": "legpain", "description": "Percentage of denominator patients who showed a statistically significant improvement in comparison to initial assessment, measured by minimum clinically important difference (MCID) in leg pain." } ] }, { "category": "quality", "measureId": "AQI18", "title": "Coronary Artery Bypass Graft (CABG): Prolonged Intubation – Inverse Measure", "description": "Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation greater than 24 hours", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2016, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) in Collaboration with American Society of Anesthesiologists (ASA)", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5551268", "6169123", "6775913", "7418330", "9181695" ] }, { "category": "quality", "measureId": "AQI48", "title": "Patient-Reported Experience with Anesthesia", "description": "Percentage of patients, aged 18 and older, who were surveyed on their patient experience and satisfaction with anesthesia care and who reported a positive experience. \n\nThis measure will consist of two performance rates:\n\nAQI48a: Percentage of patients, aged 18 and older, who were surveyed on their patient experience and satisfaction with anesthesia care \n\nAQI48b: Percentage of patients, aged 18 and older, who completed a survey on their patient experience and satisfaction with anesthesia care who report a positive experience with anesthesia care within 60 days of receipt of the survey.\n\nNOTE: The measure requires that a valid survey, as defined in the numerator of AQI48a, be sent to patients between discharge from the facility and within 30 days of facility discharge. To report AQI48b, a minimum number of 20 surveys with the mandatory question completed must be reported. ** In order to be scored on this measure, clinicians must report BOTH AQI48a AND AQI48b.", "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": true, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) in Collaboration with American Society of Anesthesiologists (ASA)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "G0059" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5551268", "6169123", "6775913", "9181695", "7418330" ], "strata": [ { "name": "surveyed", "description": "AQI48a, percentage of surgical patients who receive a survey of their experience with anesthesia care." }, { "name": "overall", "description": "AQI48b, percentage of surgical patients who report a positive experience with anesthesia care." } ] }, { "category": "quality", "measureId": "AQI65", "title": "Avoidance of Cerebral Hyperthermia for Procedures Involving Cardiopulmonary Bypass", "description": "Percentage of patients, aged 18 years and older, undergoing a procedure using cardiopulmonary bypass who did not have a documented intraoperative pulmonary artery, oropharyngeal, or nasopharyngeal temperature greater than or equal to 37.0 degrees Celsius during the period of cardiopulmonary bypass", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2019, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) in Collaboration with American Society of Anesthesiologists (ASA)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6169123", "5551268", "6775913", "9181695", "7418330" ] }, { "category": "quality", "measureId": "AQI71", "title": "Ambulatory Glucose Management", "description": "Percentage of diabetic patients, aged 18 years and older, who receive an office-based or ambulatory surgery whose blood glucose level is appropriately managed throughout the perioperative period.\n\nThe measure consists of four performance rates:\n\na.\tPercentage of patients, aged 18 years and older, with a current diagnosis of diabetes mellitus receiving anesthesia services for office-based or ambulatory surgery whose blood glucose level is tested prior to the start of anesthesia\n\nb.\tPercentage of patients, aged 18 years and older, with a current diagnosis of diabetes mellitus receiving anesthesia services for office-based or ambulatory surgery who experienced a blood glucose level greater than or equal to 180 mg/dL (10.0 mmol/L) who received insulin prior to anesthesia end time\n\nc.\tPercentage of patients, aged 18 years and older, with a current diagnosis of diabetes mellitus receiving anesthesia services for office-based or ambulatory surgery who received insulin perioperatively and who received a follow-up blood glucose level check following the administration of insulin and prior to discharge\n\nd.\tPercentage of patients, aged 18 years and older, with a current diagnosis of diabetes mellitus receiving anesthesia services for office-based or ambulatory surgery who experienced a blood glucose level greater than or equal to 180 mg/dL (10.0 mmol/L) who received education on managing their glucose in the postoperative period prior to discharge", "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": true, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) in Collaboration with American Society of Anesthesiologists (ASA)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5551268", "6169123", "6775913", "9181695", "7418330" ], "strata": [ { "name": "overall", "description": "The overall measure score will be calculated as an average of the performance rates of parts A, B, C and D. (Rates 2, 3, 4 & 5) " }, { "name": "testedPrior", "description": " Percentage of patients, aged 18 years and older, with a current diagnosis of diabetes mellitus receiving anesthesia services for office-based or ambulatory surgery whose blood glucose level is tested prior to the start of anesthesia" }, { "name": "insulinPerioperative", "description": " Percentage of patients, aged 18 years and older, with a current diagnosis of diabetes mellitus receiving anesthesia services for office-based or ambulatory surgery who experienced a blood glucose level greater than 180 mg/dL (10.0 mmol/L) who received insulin prior to anesthesia end time" }, { "name": "followupTest", "description": " Percentage of patients, aged 18 years and older, with a current diagnosis of diabetes mellitus receiving anesthesia services for office-based or ambulatory surgery who received insulin perioperatively and who received a follow-up blood glucose level check following the administration of insulin and prior to discharge" }, { "name": "glucoseEducation", "description": " Percentage of patients, aged 18 years and older, with a current diagnosis of diabetes mellitus receiving anesthesia services for office-based or ambulatory surgery who experienced a blood glucose level greater than 180 mg/dL (10.0 mmol/L) who received education on managing their glucose in the postoperative period prior to discharge" } ] }, { "category": "quality", "measureId": "AQI79", "title": "Neuromuscular Blockade and Quantitative Train-of-Four", "description": "The percentage of patients, aged 1 and above, who undergo a surgical, therapeutic, or diagnostic procedure that involves using a non-depolarizing neuromuscular blockade medication who have a documented quantitative train-of-four ratio of greater than or equal to 0.9 before tracheal extubation in the operating room, post-anesthesia care unit, non-operating room anesthetizing location, or earliest extubation.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) in Collaboration with American Society of Anesthesiologists (ASA)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6169123", "6775913", "9181695" ] }, { "category": "quality", "measureId": "AQI80", "title": "Continuation of Buprenorphine for Inpatient Surgical Patients or Methadone Therapy during the Perioperative Period for Inpatient and Ambulatory Surgical Patients", "description": "Percentage of patients, age 13 and older, undergoing an inpatient surgical procedure who have an outpatient prescription for buprenorphine/naloxone or suboxone in their admissions documentation, who are continued on buprenorphine for the duration of their inpatient stay or undergoing an inpatient or ambulatory surgical procedure who are taking methadone as outpatients or who have a prescription for methadone in their admittance documentation, and where methadone is either continued or changed to an equivalent IV dose to maintain the therapeutic level regimen during the perioperative period. For patients receiving care in an ambulatory surgical setting, methadone medication was provided as scheduled before surgery.\r\n\r\nThis measure will consist of two performance rates: \r\nMeasure A: Percentage of patients, age 13 and older, undergoing an inpatient surgical procedure who have an outpatient prescription for buprenorphine/naloxone or suboxone in their admissions documentation are continued on buprenorphine for the duration of their inpatient stay. \r\n\r\nMeasure B: Percentage of patients, 13 years and older, undergoing an inpatient or ambulatory surgical procedure who are taking methadone as outpatients or who have a prescription for methadone in their admittance documentation and where methadone is either continued or changed to an equivalent IV dose to maintain the therapeutic level regimen during the perioperative period. For patients receiving care in an ambulatory surgical setting, methadone medication was provided as scheduled before surgery. \r\n\r\nNOTE: The overall measure score will be calculated as an average of the performance rates of A and B. In order to be scored on this measure, clinicians must have at least one eligible case reported for each sub-metric: Measure A and Measure B.", "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "simpleAverage", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) in Collaboration with American Society of Anesthesiologists (ASA)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6169123", "5551268", "6775913", "9181695" ], "strata": [ { "name": "buprenorphine", "description": "Patients who received a continuation of buprenorphine during their inpatient stay. " }, { "name": "methadone", "description": "Patients whose Methadone therapy is continued or changed to an equivalent IV dose to maintain the therapeutic level regimen during the perioperative period or, if in an ambulatory setting, methadone was provided as scheduled prior to surgery. " } ] }, { "category": "quality", "measureId": "AQI81", "title": "Use of Peripheral Nerve Blocks for Pain Management in Hip Fracture Patients", "description": "All patients, aged 65 and older, who are diagnosed with a hip fracture and receive peripheral nerve blocks for pain management in the emergency room or inpatient setting.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) in Collaboration with American Society of Anesthesiologists (ASA)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6169123", "6775913", "9181695", "7418330" ] }, { "category": "quality", "measureId": "AQI82", "title": "Intraoperative Antibiotic Redosing in Open Cardiac Surgeries", "description": "Percentage of patients who undergo an open cardiac procedure over 240 minutes duration and who receive initial cephalosporin within 60 minutes before surgical incision and receive either a bolus infusion or an intravenous cephalosporin antibiotic re-dose at four-hour intervals.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) in Collaboration with American Society of Anesthesiologists (ASA)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6169123", "6775913", "9181695", "7418330" ] }, { "category": "quality", "measureId": "AQUA8", "title": "Hospital Admissions or Infectious Complications Within 30 days of Prostate Biopsy", "description": "Percentage of patients with urinary retention, infection, inpatient consultation, or hospital admission for infection or sepsis within 30 days of undergoing a prostate biopsy", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Urological Association Quality (AQUA) Registry", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1423" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8758330" ] }, { "category": "quality", "measureId": "AQUA14", "title": "Stones: Repeat Shock Wave Lithotripsy (SWL) Within 6 Months of Initial Treatment", "description": "Percentage of patients who underwent repeat Shock Wave Lithotripsy within 6 months of initial procedure", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Urological Association Quality (AQUA) Registry", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1423" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8758330" ] }, { "category": "quality", "measureId": "AQUA15", "title": "Stones: Urinalysis or Urine Culture Performed Before Surgical Stone Procedures", "description": "Percentage of patients with a documented urinalysis or urine culture within 14 days prior to surgical stone procedures", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Urological Association Quality (AQUA) Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1423" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8758330" ] }, { "category": "quality", "measureId": "AQUA16", "title": "Non-Muscle Invasive Bladder Cancer: Repeat Transurethral Resection of Bladder Tumor (TURBT) for T1 disease", "description": "Percentage of patients with T1 disease who had a second transurethral resection of bladder tumor (TURBT) within 6 weeks of the initial TURBT", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1423" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8758330" ] }, { "category": "quality", "measureId": "AQUA35", "title": "Non-Muscle Invasive Bladder Cancer: Initial Management/Surveillance for Non-Muscle Invasive Bladder Cancer", "description": "Percentage of patients with appropriate initial management/surveillance after initial diagnosis of non-muscle invasive bladder cancer", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8758330" ] }, { "category": "quality", "measureId": "AQUA36", "title": "Prostate Cancer: Confirmation Biopsy in Newly Diagnosed Patients on Active Surveillance", "description": "Percentage of newly diagnosed low risk patients on active surveillance who receive confirmation biopsy within 24 months of diagnosis", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "American Urological Association Quality (AQUA) Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8758330" ] }, { "category": "quality", "measureId": "AVBC2", "title": "Echocardiogram Stewardship in Congestive Heart Failure (CHF): Avoiding Repeat Tests without Clinical Indication", "description": "This measure assesses the appropriate use of echocardiograms in patients with CHF. It evaluates the percentage of patients who receive echocardiograms without a clinical change or cardiac procedure within 24 months of the date of service (DOS), indicating potential overuse of this diagnostic test.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "A Value-Based Care Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6397246" ] }, { "category": "quality", "measureId": "AVBC3", "title": "SGLT2 Inhibitors for Patients with Chronic Kidney Disease (CKD) with or without type 2 diabetes mellitus", "description": "This measure evaluates the percentage of patients aged 18 years and older with chronic kidney disease (CKD) stages 2 and 3 who are prescribed an SGLT2 inhibitor during the measurement period. The goal is to increase the use of SGLT2 inhibitors, which have been shown to slow the progression of CKD and reduce cardiovascular events in this population.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "A Value-Based Care Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6397246" ] }, { "category": "quality", "measureId": "AVBC4", "title": "Noninvasive Ischemic Imaging Stewardship in Chronic Coronary Disease: Avoiding Testing without Clinical Indication", "description": "This measure assesses the appropriate use of noninvasive ischemic imaging in patients with chronic coronary disease in accordance with the 2023 ACC/AHA guidelines on the management of chronic coronary disease. It evaluates the percentage of patients who received imaging without a clinical change or pre-operative indication, signaling potential overuse of cardiac imaging.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "A Value-Based Care Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6397246" ] }, { "category": "quality", "measureId": "CAHPS_1", "title": "CAHPS for MIPS SSM: Getting Timely Care, Appointments, and Information", "description": "", "metricType": "cahps", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0005", "measureType": "patientEngagementExperience", "isHighPriority": true, "primarySteward": "Agency for Healthcare Research & Quality", "isInverse": false, "dataDisplayFormat": "percentage", "isIcdImpacted": false, "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus" ], "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "generalPracticeFamilyMedicine" ], "measureSpecification": null, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup" ], "strata": [] }, { "category": "quality", "measureId": "CAHPS_2", "title": "CAHPS for MIPS SSM: How Well Providers Communicate", "description": "", "metricType": "cahps", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0005", "measureType": "patientEngagementExperience", "isHighPriority": true, "primarySteward": "Agency for Healthcare Research & Quality", "isInverse": false, "dataDisplayFormat": "percentage", "isIcdImpacted": false, "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus" ], "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "generalPracticeFamilyMedicine" ], "measureSpecification": null, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup" ], "strata": [] }, { "category": "quality", "measureId": "CAHPS_3", "title": "CAHPS for MIPS SSM: Patient’s Rating of Provider", "description": "", "metricType": "cahps", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientEngagementExperience", "isHighPriority": true, "primarySteward": "Agency for Healthcare Research & Quality", "isInverse": false, "dataDisplayFormat": "percentage", "isIcdImpacted": false, "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus" ], "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "generalPracticeFamilyMedicine" ], "measureSpecification": null, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup" ], "strata": [] }, { "category": "quality", "measureId": "CAHPS_4", "title": "CAHPS for MIPS SSM: Access to Specialists", "description": "", "metricType": "cahps", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientEngagementExperience", "isHighPriority": true, "primarySteward": "Agency for Healthcare Research & Quality", "isInverse": false, "dataDisplayFormat": "percentage", "isIcdImpacted": false, "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus" ], "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "generalPracticeFamilyMedicine" ], "measureSpecification": null, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup" ], "strata": [] }, { "category": "quality", "measureId": "CAHPS_5", "title": "CAHPS for MIPS SSM: Health Promotion and Education", "description": "", "metricType": "cahps", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientEngagementExperience", "isHighPriority": true, "primarySteward": "Agency for Healthcare Research & Quality", "isInverse": false, "dataDisplayFormat": "percentage", "isIcdImpacted": false, "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus" ], "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "generalPracticeFamilyMedicine" ], "measureSpecification": null, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup" ], "strata": [] }, { "category": "quality", "measureId": "CAHPS_6", "title": "CAHPS for MIPS SSM: Shared Decision Making", "description": "", "metricType": "cahps", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientEngagementExperience", "isHighPriority": true, "primarySteward": "Agency for Healthcare Research & Quality", "isInverse": false, "dataDisplayFormat": "percentage", "isIcdImpacted": false, "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus" ], "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "generalPracticeFamilyMedicine" ], "measureSpecification": null, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup" ], "strata": [] }, { "category": "quality", "measureId": "CAHPS_7", "title": "CAHPS for MIPS SSM: Health Status and Functional Status", "description": "", "metricType": "cahps", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientEngagementExperience", "isHighPriority": true, "primarySteward": "Agency for Healthcare Research & Quality", "isInverse": false, "dataDisplayFormat": "percentage", "isIcdImpacted": false, "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus" ], "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "generalPracticeFamilyMedicine" ], "measureSpecification": null, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup" ], "strata": [] }, { "category": "quality", "measureId": "CAHPS_8", "title": "CAHPS for MIPS SSM: Care Coordination", "description": "", "metricType": "cahps", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientEngagementExperience", "isHighPriority": true, "primarySteward": "Agency for Healthcare Research & Quality", "isInverse": false, "dataDisplayFormat": "percentage", "isIcdImpacted": false, "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus" ], "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "generalPracticeFamilyMedicine" ], "measureSpecification": null, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup" ], "strata": [] }, { "category": "quality", "measureId": "CAHPS_9", "title": "CAHPS for MIPS SSM: Courteous and Helpful Office Staff", "description": "", "metricType": "cahps", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": "0005", "measureType": "patientEngagementExperience", "isHighPriority": true, "primarySteward": "Agency for Healthcare Research & Quality", "isInverse": false, "dataDisplayFormat": "percentage", "isIcdImpacted": false, "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus" ], "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "generalPracticeFamilyMedicine" ], "measureSpecification": null, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup" ], "strata": [] }, { "category": "quality", "measureId": "CAHPS_11", "title": "CAHPS for MIPS SSM: Stewardship of Patient Resources", "description": "", "metricType": "cahps", "isRegistryMeasure": false, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientEngagementExperience", "isHighPriority": true, "primarySteward": "Agency for Healthcare Research & Quality", "isInverse": false, "dataDisplayFormat": "percentage", "isIcdImpacted": false, "companionMeasureId": [], "allowedPrograms": [ "mips", "app1", "appPlus" ], "submissionMethods": [ "certifiedSurveyVendor" ], "measureSets": [ "generalPracticeFamilyMedicine" ], "measureSpecification": null, "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup" ], "strata": [] }, { "category": "quality", "measureId": "CAP30", "title": "Urinary Bladder Cancer: Complete Analysis and Timely Reporting", "description": "Percentage of urinary bladder carcinoma pathology reports that include the procedure, histologic tumor grade, histologic type, presence/absence of muscularis propria, presence/absence of lymphovascular invasion, and tumor extent. \nAND \nmeet the maximum 2 business day turnaround time (TAT) requirement (Report Date – Accession Date is less than or equal to 2 business days). \n\nINSTRUCTIONS: This measure has two performance rates that contribute to the overall performance score:\nStratum 1.\tPercent of cases for which all required data elements of the urinary bladder carcinoma pathology report are included.\nStratum 2.\tPercent of cases that meet the maximum 2 business day turnaround time.\nThe overall performance score submitted is a weighted average of: \n(Performance rate 1 x 70%)+(Performance rate 2 x 30%)", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Pathologists Quality Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1501" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5688621" ] }, { "category": "quality", "measureId": "CAP34", "title": "Molecular Assessment: Biomarkers in Non-Small Cell Lung Cancer", "description": "Percentage of non-small cell lung cancer (NSCLC) pathology reports that include anaplastic lymphoma kinase (ALK), epidermal growth factor receptor (EGFR), AND tyrosine protein kinase ROS1 mutation status.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Pathologists Quality Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1501" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5688621" ] }, { "category": "quality", "measureId": "CAP40", "title": "Squamous Cell Skin Cancer: Complete Reporting", "description": "Percentage of final pathology reports for excisions for squamous cell carcinoma of the skin that include a comment on margin status, degree of differentiation/histologic grade, depth or level of invasion, presence of perineural invasion* and presence of lymphovascular invasion\r\n\r\n*Perineural invasion defined as tumor cells within the nerve sheath of a nerve deep to the dermis or with a caliber of 0.1 mm or higher.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Pathologists Quality Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M1501" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5688621" ] }, { "category": "quality", "measureId": "CAP42", "title": "Barrett’s Esophagus: Complete Analysis with Appropriate Consultation", "description": "Percentage of esophageal biopsy reports with a diagnosis of Barrett's esophagus that include documentation of a consultation* with a second pathologist for confirmation of dysplasia grading.\r\n\r\n*Consultation at the time of diagnosis or addendum to preliminary pathology report", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Pathologists Quality Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5688621" ] }, { "category": "quality", "measureId": "CAP43", "title": "Complete Reporting of Gastrointestinal Metaplasia", "description": "Percentage of pathology reports for gastric specimens with intestinal metaplasia that comment on the presence or absence of H. pylori and of dysplasia. If dysplasia is present, comment on the grade of dysplasia. If dysplasia is not present, comment on completeness of intestinal metaplasia.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Pathologists Quality Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5688621" ] }, { "category": "quality", "measureId": "CAP44", "title": "Molecular Assessment for Endometrial Carcinoma", "description": "Percentage of pathology reports for endometrial carcinoma that comment on POLE and p53 testing status, and status of IHC for PMS2 and MSH6.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Pathologists Quality Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5688621" ] }, { "category": "quality", "measureId": "ECPR46", "title": "Avoidance of Opiates for Low Back Pain or Migraines", "description": "Percentage of Patients with Low Back Pain and/or Migraines Who Were Not Prescribed an Opiate", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2018, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "E-CPR (Emergency - Clinical Performance Registry)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "G0057" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "1718371", "5133825", "4757099" ] }, { "category": "quality", "measureId": "ECPR51", "title": "Discharge Prescription of Naloxone after Opioid Poisoning or Overdose", "description": "Percentage of Opioid Poisoning or Overdose Patients Presenting to An Acute Care Facility Who Were Prescribed Naloxone at Discharge", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2019, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "E-CPR (Emergency - Clinical Performance Registry)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "1718371", "4757099", "8483899" ] }, { "category": "quality", "measureId": "ECPR52", "title": "Appropriate Treatment of Psychosis and Agitation in the Emergency Department", "description": "Percentage of Adult Patients With Psychosis or Agitation Who Were Ordered an Oral Antipsychotic Medication in the Emergency Department", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2019, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "E-CPR (Emergency - Clinical Performance Registry)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "1718371", "4757099" ] }, { "category": "quality", "measureId": "ECPR55", "title": "Avoidance of Long-Acting (LA) or Extended-Release (ER) Opiate Prescriptions and Opiate Prescriptions for Greater Than 3 Days Duration for Acute Pain", "description": "Percentage of Adult Patients Who Were Prescribed an Opiate Who Were Not Prescribed a Long-Acting (LA) or Extended-Release (ER) Formulation and for Whom the Prescription Duration Was Not Greater than 3 days for Acute Pain", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "E-CPR (Emergency - Clinical Performance Registry)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "1718371", "4757099" ] }, { "category": "quality", "measureId": "ECPR56", "title": "Opioid Withdrawal: Initiation of Medication for Opioid Use Disorder (MOUD) and Referral to Outpatient Opioid Treatment", "description": "Percentage of Patients Presenting with Opioid Withdrawal Who Were Given Medication for Opioid Use Disorder (MOUD) and Referred to Outpatient Opioid Treatment", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "E-CPR (Emergency - Clinical Performance Registry)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "1718371", "4757099", "8483899" ] }, { "category": "quality", "measureId": "ECPR58", "title": "Patient-Reported Understanding of Discharge Diagnosis and Plan of Care", "description": "Percentage of Adult Patients Who Completed a Survey Regarding Their Care Visit Who Reported Understanding of Their Discharge Diagnosis and Plan of Care", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "E-CPR (Emergency - Clinical Performance Registry)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "1718371", "4757099", "8483899" ] }, { "category": "quality", "measureId": "ECPR59", "title": "Patient Reported Trust in Provider", "description": "Percentage of Adult Patients Who Completed a Survey Regarding Their Care Visit Who Reported They Would Trust the Doctor/Provider to Care for their Friends/Family", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientEngagementExperience", "isHighPriority": true, "primarySteward": "E-CPR (Emergency - Clinical Performance Registry)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "1718371", "4757099", "8483899" ] }, { "category": "quality", "measureId": "ECPR60", "title": "Avoidance of Advanced Imaging for Pediatric Patients with Unprovoked, Generalized Seizure", "description": "Percentage of patients aged younger than 18 years with diagnosis of seizure that did not have a CT or MRI of the head ordered.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "efficiency", "isHighPriority": true, "primarySteward": "E-CPR (Emergency - Clinical Performance Registry)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "1718371", "3967247", "1725296" ] }, { "category": "quality", "measureId": "ECPR61", "title": "Inhaled Corticosteroid for Patients with Acute Asthma Exacerbation", "description": "Percentage of patients aged 6+ diagnosed with an acute asthma exacerbation and prescribed inhaled corticosteroid", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "E-CPR (Emergency - Clinical Performance Registry)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "1718371", "4757099" ] }, { "category": "quality", "measureId": "EPREOP31", "title": "Intraoperative Hypotension (IOH) among Non-Emergent Noncardiac Surgical Cases", "description": "Percentage of general, neuraxial, or regional anesthesia care cases in which the mean arterial pressure (MAP) fell below 65 mmHg for a cumulative total of 15 minutes or more", "metricType": "nonProportion", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "Anesthesia Quality Registry (AQR QCDR) in Collaboration with Anesthesia Quality Institute (AQI) and American Society of Anesthesiologists (ASA)", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": true, "isIcdImpacted": false, "allowedPrograms": [ "mips", "G0059" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6775913", "5551268", "6169123", "7418330" ] }, { "category": "quality", "measureId": "FOTO4", "title": "Functional Status Change for Patients with Upper or Lower Quadrant Edema", "description": "This is a patient-reported outcome performance measure (PRO-PM) consisting of a patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients aged 14 years and older with lymphedema or other causes of edema. For patients with such conditions affecting the arm, hand, chest, or breast body regions, the change in FS is assessed using the FOTO Upper Quadrant Edema (UQE) FS PROM.1 For patients with such conditions affecting the leg, foot, groin, or lower trunk regions, the change in FS is assessed using the FOTO Lower Quadrant Edema (LQE) FS PROM.2 PROM scores were scaled to the 0-100 metric, with higher scores representing higher perceived functional status. \r\n\r\nTo fairly measure performance between providers, the measure is risk-adjusted to patient characteristics known to be associated with FS outcomes and used as a performance measure at the patient and provider levels to assess quality.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "FOTO QCDR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": true, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8311170" ] }, { "category": "quality", "measureId": "FOTO5", "title": "Functional Status Change in Balance Confidence", "description": "This is a patient-reported outcome performance measure (PRO-PM) consisting of a patient-reported outcome measure (PROM) of risk-adjusted functional status (FS) change in balance confidence for patients aged 14+ with balance impairments. The change in FS is assessed using the FOTO Balance Confidence, an item-response theory-based PROM derived from the 16-items of the Activities-specific Balance Confidence (ABC) Scale©, (1-3) scored using the T-score metric (mean=50, SD=10), with higher scores representing higher balance confidence.(4)\r\n\r\nPatient responses to ABC Scale© items may be used to directly score Balance Confidence PROM, thus allowing clinicians flexibility of choice of PROM used in routine clinical care without adding to patient response burden. In order to fairly measure performance between providers, this quality measure is risk-adjusted to patient characteristics known to be associated with FS outcomes and used as a performance measure the patient and provider levels to assess quality.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "FOTO QCDR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": true, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8311170" ] }, { "category": "quality", "measureId": "FOTO7", "title": "Functional Status Change for Patients Post Stroke", "description": "This is a patient-reported outcome performance measure (PRO-PM) consisting of a patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients aged 14 years and older who have experienced a stroke with sequelae impacting physical functional abilities. For patients with such conditions affecting use of the hand, arm, and upper trunk, the change in FS is assessed using the FOTO Stroke Upper Extremity (SUE) FS PROM.1 For patients with such conditions affecting the foot, leg, and lower trunk, the change in FS is assessed using the FOTO Stroke Lower Extremity (SLE) FS PROM.1 PROM cores were scaled to the 0-100 metric, with higher scores representing higher perceived functional status. In order to fairly measure performance between providers, the measure is risk-adjusted to patient characteristics known to be associated with FS outcomes and used as a performance measure (PM) at the patient and provider levels to assess quality.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "FOTO QCDR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": true, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8311170" ] }, { "category": "quality", "measureId": "FOTO8", "title": "Jaw Functional Status Scale (JFSS) Change", "description": "This is a patient-reported outcome performance measure (PRO-PM) consisting of a patient-reported outcome measure (PROM) of risk-adjusted functional status (FS) change in jaw functional status for patients aged 14+ with impairments related to jaw function. The change in FS is assessed using the FOTO Jaw Functional Status Scale (JFSS), an item-response theory (IRT)-based PROM derived from 13 of the 20 items of the Jaw Functional Limitation Scale (JFLS).1, 2 The JFLS is a condition-specific PROM for functional limitations in the masticatory system.3 The 13-item FOTO JFSS is scored using the T-score metric (mean=50, SD=10), with higher scores representing higher functional status. The JFSS PROM can be administered using either computerized adaptive test (CAT)4 or a 6-item short form. \r\n\r\nIn order to fairly measure performance between providers, this quality measure is risk-adjusted to patient characteristics known to be associated with FS outcomes and used as a performance measure at the patient and provider levels to assess quality.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "FOTO QCDR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": true, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8311170" ] }, { "category": "quality", "measureId": "GIQIC23", "title": "Appropriate follow-up interval based on pathology findings in screening colonoscopy", "description": "Percentage of procedures among average-risk patients aged 45 to 75 years receiving a screening colonoscopy with biopsy or polypectomy and pathology findings who had a follow-up interval consistent with US Multi-Society Task Force (USMSTF) recommendations for repeat colonoscopy documented in their colonoscopy report", "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": true, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "GIQuIC in Collaboration with American College of Gastroenterology, American Society for Gastrointestinal Endoscopy", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1422" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5846856" ], "strata": [ { "name": "overall", "description": "Overall percentage of procedures among average-risk patients aged 45 to 75 years receiving a screening colonoscopy with biopsy or polypectomy and pathology findings who had a follow-up interval consistent with US Multi-Society Task Force (USMSTF) recommendations for repeat colonoscopy documented in their colonoscopy report" }, { "name": "hyperPolyps&FollowUp", "description": "Percentage of complete and adequately prepped screening colonoscopies of average-risk patients aged 45 to 75 years with biopsy or polypectomy and pathology findings of only hyperplastic polyps for which a recommended follow-up interval of 10 years for repeat colonoscopy was given to the patient" }, { "name": "1-2adenoma&FollowUp", "description": "Percentage of complete and adequately prepped screening colonoscopies of average-risk patients aged 45 to 75 years with biopsy or polypectomy and pathology findings of 1-2 tubular adenoma(s) for which a recommended follow-up interval of not less than 7 years and not greater than 10 years was given to the patient" }, { "name": "3-4adenomas&FollowUp", "description": "Percentage of complete and adequately prepped screening colonoscopies of average-risk patients aged 45 to 75 years with biopsy or polypectomy and pathology findings of 3-4 tubular adenomas for which a recommended follow-up interval of not less than 3 years and not greater than 5 years was given to the patient" }, { "name": "5-10adenoma&FollowUp", "description": "Percentage of complete and adequately prepped screening colonoscopies of average-risk patients aged 45 to 75 years with biopsy or polypectomy and pathology findings of 5-10 tubular adenomas for which a recommended follow-up interval of 3 years was given to the patient" }, { "name": "neoplasm&FollowUp", "description": "Percentage of complete and adequately prepped screening colonoscopies of average-risk patients aged 45 to 75 years with biopsy or polypectomy and pathology findings of Advanced Neoplasm (>= 10 mm, high grade dysplasia, villous component) for which a recommended follow-up interval of 3 years for repeat colonoscopy was given to the patient" }, { "name": "serration&FollowUp", "description": "Percentage of complete and adequately prepped screening colonoscopies of average-risk patients aged 45 to 75 years with biopsy or polypectomy and pathology findings of Sessile serrated polyp >= 10 mm OR sessile serrated polyp with dysplasia OR traditional serrated adenoma who had a recommended follow-up interval of 3 years for repeat colonoscopy consistent was given to the patient" } ] }, { "category": "quality", "measureId": "GIQIC26", "title": "Screening Colonoscopy Adenoma Detection Rate", "description": "The percentage of patients aged 45 to 75 years with at least one conventional adenoma or colorectal cancer detected during screening colonoscopy", "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "GIQuIC in Collaboration with American College of Gastroenterology, American Society for Gastrointestinal Endoscopy", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M1422" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5846856" ], "strata": [ { "name": "overall", "description": "Simple average of Rate 2 and Rate 3" }, { "name": "male", "description": "The percentage of male patients aged 45 to 75 years with at least one conventional adenoma or colorectal cancer detected during screening colonoscopy" }, { "name": "female", "description": "The percentage of female patients aged 45 to 75 years with at least one conventional adenoma or colorectal cancer detected during screening colonoscopy" } ] }, { "category": "quality", "measureId": "HCPR24", "title": "Appropriate Utilization of Vancomycin for Cellulitis", "description": "Percentage of Patients with Cellulitis Who Did Not Receive Vancomycin Unless MRSA Infection or Risk for MRSA Infection Was Identified", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "H-CPR (Hospitalist –Clinical Performance Registry)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "G0057" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8483899", "5133825", "1718371" ] }, { "category": "quality", "measureId": "HCPR25", "title": "Physician’s Orders for Life-Sustaining Treatment (POLST) Form", "description": "Percentage of Patients with Advanced Illness with Physician’s Orders for Life-Sustaining Treatment (POLST) Forms Completed.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "H-CPR (Hospitalist –Clinical Performance Registry)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8483899", "1718371" ] }, { "category": "quality", "measureId": "HCPR27", "title": "Point-of-Care Ultrasound: Evaluation for Pneumothorax after Central Venous Catheter (CVC) Placement", "description": "Percentage of Patients Aged 18 years and Older Who Undergo Central Venous Catheter (CVC) Insertion for Whom Point-of-Care Ultrasound Was Performed to Evaluate for Pneumothorax.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "H-CPR (Hospitalist –Clinical Performance Registry)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8483899", "1718371", "4757099" ] }, { "category": "quality", "measureId": "HCPR28", "title": "Heart Failure (HF): SGLT-2 Inhibitor Therapy for Left Ventricular Systolic Dysfunction (LVSD)", "description": "Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) less than or equal to 40% who were prescribed SGLT-2 Inhibitors during their SNF stay or at the time of discharge.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "The PQR; H-CPR (Hospitalist –Clinical Performance Registry)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4757099", "1725296", "8483899", "3967247" ] }, { "category": "quality", "measureId": "HCPR29", "title": "Avoidance of DVT Ultrasound for Patients Diagnosed with Cellulitis", "description": "Percentage of patients aged 18 years and older with diagnosis of lower extremity cellulitis that did not have a DVT ultrasound ordered", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "H-CPR (Hospitalist –Clinical Performance Registry)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8483899", "4757099", "3967247", "1725296" ] }, { "category": "quality", "measureId": "HCPR30", "title": "Avoidance of Sliding-Scale Insulin Monotherapy for Admitted Diabetic Patients", "description": "Percentage of patients aged 18 years and older admitted to the hospital with diagnosis of diabetes mellitus that received order for basal insulin therapy", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "H-CPR (Hospitalist –Clinical Performance Registry)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8483899", "3967247", "1725296" ] }, { "category": "quality", "measureId": "HCPR31", "title": "Point-of-Care Ultrasound for Evaluation and Management of Shock", "description": "Percentage of patients aged 18 years and older with diagnosis of Shock and that had Point-of-Care Ultrasound performed.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "H-CPR (Hospitalist –Clinical Performance Registry)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8483899", "1718371", "3967247" ] }, { "category": "quality", "measureId": "HCPR32", "title": "Medication for Alcohol Use Disorder (MAUD) for Patients with Alcohol Use Disorder", "description": "Percentage of patients diagnosed with Alcohol Use Disorder who were prescribed a Medication for Alcohol Use Disorder (MAUD)", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "H-CPR (Hospitalist -Clinical Performance Registry)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8483899", "1718371", "4757099" ] }, { "category": "quality", "measureId": "HM7", "title": "Functional Status Change for Patients with Vestibular Dysfunction", "description": "Percentage of patients aged 14 years and older diagnosed with vestibular dysfunction who achieve a Minimal Clinically Important Difference (MCID) as measured via the validated Dizziness Handicap Inventory or equivalent instrument to indicate functional, emotional, and physical improvement \n·        Submission Age Criteria 1: Patients aged 14-17 years of age \n·        Submission Age Criteria 2: Patients aged 18-64 years of age\n·        Submission Age Criteria 3: Patients aged 65 years and older\n·        Submission Criteria 4: Overall total rate of patients aged 14 years and older \nThe measure is adjusted to patient characteristics known to be associated with functional status and quality of life outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality.", "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "MIPSPRO ENTERPRISE", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "7037323", "3471690", "3967247" ], "strata": [ { "name": "14to17", "description": "SUBMISSION CRITERIA 1: Patients aged 14-17 years of age on date of encounter" }, { "name": "18to64", "description": "SUBMISSION CRITERIA 2: Patients aged 18-64 years and older on date of encounter" }, { "name": "65over", "description": "SUBMISSION CRITERIA 3: Patients aged 65 years of age and older on date of encounter " }, { "name": "overall", "description": "SUBMISSION CRITERIA 4: Patients aged 14 years of age and older on date of encounter" } ] }, { "category": "quality", "measureId": "IRIS1", "title": "Endothelial Keratoplasty - Post-operative improvement in best corrected visual acuity to 20/40 or better", "description": "Percentage of endothelial keratoplasty patients with a best corrected visual acuity of 20/40 or better within 90 days after surgery", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2015, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "3927141" ] }, { "category": "quality", "measureId": "IRIS2", "title": "Glaucoma – Intraocular Pressure Reduction", "description": "Percentage of glaucoma patient visits where their IOP was below a threshold level based on the severity of their diagnosis.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2015, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1420" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "3927141" ] }, { "category": "quality", "measureId": "IRIS13", "title": "Diabetic Macular Edema - Loss of Visual Acuity", "description": "Percentage of patients with a diagnosis of diabetic macular edema with a loss of less than 3 Snellen lines (which is equivalent to less than 0.3 logMAR) within the past 12 months.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2015, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1420" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "3927141" ] }, { "category": "quality", "measureId": "IRIS17", "title": "Acute Anterior Uveitis: Post-treatment Grade 0 anterior chamber cells", "description": "Percentage of patients with acute anterior uveitis post-treatment with Grade 0 anterior chamber cells", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2015, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "3927141" ] }, { "category": "quality", "measureId": "IRIS23", "title": "Refractive Surgery: Patients with a postoperative uncorrected visual acuity (UCVA) of 20/20 or better within 30 days", "description": "Percentage of patients with an uncorrected visual acuity (UCVA) of 20/20 or better within 30 days", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "3927141" ] }, { "category": "quality", "measureId": "IRIS38", "title": "Endothelial Keratoplasty – Dislocation Requiring Surgical Intervention", "description": "Percentage of endothelial keratoplasty patients with a rebubbling or revision or repair procedure within 90 days after surgery", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2019, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "3927141" ] }, { "category": "quality", "measureId": "IRIS39", "title": "Intraocular Pressure Reduction Following Trabeculectomy or an Aqueous Shunt Procedure", "description": "Percentage of patients who underwent trabeculectomy or aqueous shunt procedure who had IOP reduced by 20% or more from their pretreatment between 3 and 4 months of treatment or a reduction in overall number of glaucoma medications.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2019, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1420" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "3927141" ] }, { "category": "quality", "measureId": "IRIS50", "title": "Amblyopia: Interocular visual acuity", "description": "Percentage of newly diagnosed amblyopic patients with one or more of the following: A. a corrected interocular (or if not reported, the uncorrected) visual acuity difference less than 0.23 logMAR 3-12 months after first diagnosis of amblyopia OR B. an improvement in the corrected visual acuity of the amblyopic eye of 3 or more Snellen lines (> or = 0.30 logMAR) 3-12 months after first diagnosis of amblyopia OR C. a final visual acuity in the amblyopic eye equal to 20/30 or better (less than or equal to 0.18 log Mar) 3-12 months after first diagnosis of amblyopia", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2019, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "3927141" ] }, { "category": "quality", "measureId": "IRIS54", "title": "Complications After Cataract Surgery", "description": "Percentage of eyes of patients aged 18 years and older with a diagnosis of cataract who had cataract surgery and had the following complications with 90 days after cataract surgery: prolonged inflammation, incision complications, iris complications, retinal detachment, cystoid macular edema, corneal complications, or a return to OR.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1420" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "3927141" ] }, { "category": "quality", "measureId": "IRIS58", "title": "Improved Visual Acuity after Vitrectomy for Complications of Diabetic Retinopathy within 120 Days", "description": "Percentage of patients with a 20% or greater improvement in visual acuity within 120 days following vitrectomy for complications of diabetic retinopathy", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1420" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "3927141" ] }, { "category": "quality", "measureId": "IRIS59", "title": "Regaining Vision After Cataract Surgery", "description": "Percentage of eyes of patients aged 18 years and older with a diagnosis of cataract had cataract surgery and had 20/20 best-corrected distance visual acuity or better OR an improvement in best-corrected distance visual acuity achieved within 30 days following the cataract surgery. Weighted average of performance rates reported.", "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "weightedAverage", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "3927141" ], "strata": [ { "name": "nocormorbid20/20", "description": "Eyes of patients with no comorbidities or additional procedures on the same date as the cataract surgery and a 20/20 or better post-operative best corrected distance visual acuity" }, { "name": "comorbid20/200", "description": "Eyes of patients with comorbidities with a pre-operative visual acuity of 20/200 or better and a 2 lines or better improvement in the post-operative best-corrected distance visual acuity from preoperative visual acuity" }, { "name": "comorbid20/400", "description": "Eyes of patients with comorbidities with a pre-operative visual acuity of 20/400 or worse and a 1 line or better improvement in the post-operative best-corrected distance visual acuity from pre-operative visual acuity" } ] }, { "category": "quality", "measureId": "IRIS61", "title": "Visual Acuity Improvement Following Cataract Surgery and Minimally Invasive Glaucoma Surgery", "description": "Percentage of eyes of patients aged 18 years and older with a diagnosis of cataract who had cataract surgery and minimally invasive glaucoma surgery and achieved 20/30 best-corrected distance visual acuity or better within 4 months following the cataract surgery.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M1420" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "3927141" ] }, { "category": "quality", "measureId": "IRIS63", "title": "Exudative Age-Related Macular Degeneration: Gain of Visual Acuity", "description": "Percentage of patients with a diagnosis of exudative age-related macular degeneration, being treated with anti-VEGF agents, with a gain of 1 Snellen line or more (which is equivalent to 0.1 logMAR or more) of visual acuity within the past 12 months compared to pre-treatment. Weighted average of performance rates reported.", "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "weightedAverage", "isRegistryMeasure": true, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "3927141" ], "strata": [ { "name": "5ormoretreatments", "description": "Percentage of patients with a diagnosis of exudative age-related macular degeneration, treated with 5 or more treatments of Anti-VEGF Agents over the reporting year, with a gain of 1 Snellen line or more (which is equivalent to 0.1 logMAR or more) of visual acuity within the past 12 months compared to pre-treatment. " }, { "name": "lessthan5treatments", "description": "Percentage of patients with a diagnosis of exudative age-related macular degeneration, treated with 1 to 4 treatments of Anti-VEGF Agents over the reporting year, with a gain of 1 Snellen line or more (which is equivalent to 0.1 logMAR or more) of visual acuity within the past 12 months compared to pre-treatment." } ] }, { "category": "quality", "measureId": "MBHR1", "title": "Use of Anxiety Severity Measure", "description": "The percentage of adult patients (18 years and older) with an anxiety disorder diagnosis (e.g., generalized anxiety disorder, social anxiety disorder, or panic disorder) who have completed a standardized tool (e.g., GAD-7, BAI) during measurement period", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2018, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "MBHR Mental and Behavioral Health Registry in Collaboration with Healthmonix", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4067715" ] }, { "category": "quality", "measureId": "MBHR2", "title": "Anxiety Response at 6-months", "description": "The percentage of adult patients (18 years of age or older) with an anxiety disorder (e.g., generalized anxiety disorder, social anxiety disorder, or panic disorder) who demonstrated a response to treatment (GAD-7 score at least 25% less than score at index event) at 6-months (+/- 60 days) after an index visit.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2018, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "MBHR Mental and Behavioral Health Registry in Collaboration with Healthmonix", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1369" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4067715" ] }, { "category": "quality", "measureId": "MBHR7", "title": "Posttraumatic Stress Disorder (PTSD) Outcome Assessment for Adults and Children", "description": "The percentage of patients with a history of a traumatic event (i.e., an experience that was unusually or especially frightening, horrible, or traumatic) who report symptoms consistent with PTSD for at least one month following the traumatic event AND with documentation of a standardized symptom monitor (PCL-5 for adults, CATS for child/adolescent) AND demonstrated a response to treatment at six months (+/- 120 days) after the index visit.\n\nThis measure is a multi-strata measure, which addresses symptom monitoring for both child and adult patients being treated for post-traumatic stress symptoms. Assessment instruments monitoring severity of symptoms for PTSD are validated either for adult or child populations. Thus, while the measurement structure will be similar for both populations, the specified instruments for symptom monitoring will be different.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "MBHR Mental and Behavioral Health Registry in Collaboration with Healthmonix", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1369" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4067715" ] }, { "category": "quality", "measureId": "MBHR19", "title": "Trauma Screening and Re-Traumatization Prevention", "description": "Adult patients (18 years of age or older) included in the denominator have been screened for a history of life-time trauma exposure using a systematic screening method during a 12-month measurement period AND if positive (e.g., patient endorses being exposed to trauma) the patient is screened for current symptoms of PTSD.\r\n\r\nInstructions:\r\nThis measure is to be submitted once per performance period for patients seen during the performance period. This measure is intended to reflect systematic screening for a history of trauma. There is no diagnosis associated with this measure. This measure may be submitted by Merit-based Incentive Payment Systems (MIPS) eligible clinicians who perform the quality measure based on the services provided and the measure-specific denominator coding. For the purposes of this measure, the most recent denominator eligible encounter should be used to determine if the numerator action for the submission criteria was performed within the 12-month look back period.\r\n\r\nNote: Patient encounters for this measure conducted via telehealth (e.g., encounters coded with 95 or POS 02) are allowable.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "MBHR Mental and Behavioral Health Registry in Collaboration with Healthmonix", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4067715" ] }, { "category": "quality", "measureId": "MBHR20", "title": "Differential Cognitive Assessment with Safety and Risk Counseling", "description": "Percentage of patients, regardless of age, referred for evaluation due to concerns for cognitive impairment for whom 1) a standardized valid assessment of cognition was performed and 2) results of assessment informed determination of diagnosis or further clarified etiological factors of cognitive impairment or complaints, and 3) reporting of results included counseling on safety and potential risks for patents who displayed cognitive impairment that could negatively impact safety.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "MBHR Mental and Behavioral Health Registry in Collaboration with Healthmonix", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4067715" ] }, { "category": "quality", "measureId": "MEDNAX55", "title": "Use of ASPECTS (Alberta Stroke Program Early CT Score) for non-contrast CT Head performed for suspected acute stroke.", "description": "Percentage non-contrast CT Head performed for suspected acute stroke whose final reports include an ASPECTS value.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2019, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "MSN Healthcare Solutions, LLC", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6394618", "5303416" ] }, { "category": "quality", "measureId": "MEX5", "title": "Hammer Toe Outcome", "description": "Percentage of patients with a who have a lesser toe deformity (hammer and claw toes) causing pain that receive an intervention and have clinically significant reduction in pain as a result of that intervention.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2018, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Registry Clearinghouse in Collaboration with Ohio Foot and Ankle Medical Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1502" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4117893" ] }, { "category": "quality", "measureId": "MSK1", "title": "Patients Suffering From a Neck Injury who Improve Physical Function", "description": "Percentage of patients 18 years or older suffering from a neck injury who achieve the Minimal Clinically Important Difference (MCID) in the NDI or PROMIS Pain Interference, or like mapped measure during the performance year. \n\n\nAdditionally, a risk-adjusted MCID proportional difference determined by calculating the difference between the risk model predicted and observed MCID proportion will be reported for each PT/OT/MSK Provider/Group. The risk adjustment will be calculated using a logistic regression model using: baseline function score, baseline pain score, age, sex, payer, surgical status, and symptom duration (time from surgery or symptom onset to baseline physical therapy visit) as well as instrument tool used. These measures will serve as a PT/OT/MSK Provider performance measure at the eligible PT/OT/MSK Provider or group level.\n\nThis measure will include one rate:\n1) The overall performance rate of non-surgical and surgical patients who achieve the MCID in NDI/PROMIS Pain Interference/or like mapped measure.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Advancing Musculoskeletal (MSK) Care and Rehabilitation QCDR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": true, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "3471690", "7037323", "3967247", "1157686" ] }, { "category": "quality", "measureId": "MSK2", "title": "Patients Suffering From an Upper Extremity Injury who Improve Physical Function", "description": "Percentage of patients 18 years or older suffering from an upper extremity injury who achieve the Minimal Clinically Important Difference (MCID) in the QDASH or PROMIS Upper Extremity, or like mapped measure during the performance year. \n\n\nAdditionally, a risk-adjusted MCID proportional difference determined by calculating the difference between the risk model predicted and observed MCID proportion will be reported for each PT/OT/MSK Provider/Group. The risk adjustment will be calculated using a logistic regression model using: baseline function score, baseline pain score, age, sex, payer, surgical status, and symptom duration (time from surgery or symptom onset to baseline physical therapy visit) as well as instrument tool used. These measures will serve as a PT/OT/MSK Provider performance measure at the eligible PT/OT/MSK Provider or group level.\n\nThis measure will include one rate:\n1) The overall performance rate of non-surgical and surgical patients who achieve the MCID in QDASH/PROMIS Upper Extremity/or like mapped measure.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Advancing Musculoskeletal (MSK) Care and Rehabilitation QCDR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": true, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "3471690", "7037323", "3967247", "1157686" ] }, { "category": "quality", "measureId": "MSK3", "title": "Patients Suffering From a Back Injury who Improve Physical Function", "description": "Percentage of patients 18 years or older suffering from a back injury who achieve the Minimal Clinically Important Difference (MCID) in the MDQ or PROMIS Pain Interference, or like mapped measure during the performance year. \n\n\nAdditionally, a risk-adjusted MCID proportional difference determined by calculating the difference between the risk model predicted and observed MCID proportion will be reported for each PT/OT/MSK Provider/Group. The risk adjustment will be calculated using a logistic regression model using: baseline function score, baseline pain score, age, sex, payer, surgical status, and symptom duration (time from surgery or symptom onset to baseline physical therapy visit) as well as instrument tool used. These measures will serve as a PT/OT/MSK Provider performance measure at the eligible PT/OT/MSK Provider or group level.\n\nThis measure will include one rate:\n1) The overall performance rate of non-surgical and surgical patients who achieve the MCID in MDQ/PROMIS Pain Interference/or like mapped measure.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Advancing Musculoskeletal (MSK) Care and Rehabilitation QCDR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": true, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "3471690", "7037323", "3967247", "1157686" ] }, { "category": "quality", "measureId": "MSK4", "title": "Patients Suffering From a Lower Extremity Injury who Improve Physical Function", "description": "Percentage of patients 18 years or older suffering from a lower extremity injury who achieve the Minimal Clinically Important Difference (MCID) in the LEFS or PROMIS Physical Function, or like mapped measure during the performance year. \n\n\nAdditionally, a risk-adjusted MCID proportional difference determined by calculating the difference between the risk model predicted and observed MCID proportion will be reported for each PT/OT/MSK Provider/Group. The risk adjustment will be calculated using a logistic regression model using: baseline function score, baseline pain score, age, sex, payer, surgical status, and symptom duration (time from surgery or symptom onset to baseline physical therapy visit) as well as instrument tool used. These measures will serve as a PT/OT/MSK Provider performance measure at the eligible PT/OT/MSK Provider or group level.\n\nThis measure will include one rate:\n1) The overall performance rate of non-surgical and surgical patients who achieve the MCID in LEFS/PROMIS Physical Function/or like mapped measure.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Advancing Musculoskeletal (MSK) Care and Rehabilitation QCDR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": true, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "3471690", "7037323", "3967247", "1157686" ] }, { "category": "quality", "measureId": "MSK5", "title": "Patients Suffering From a Knee Injury who Improve Physical Function", "description": "Percentage of patients 18 years or older suffering from a knee injury who achieve the Minimal Clinically Important Difference (MCID) in the KOS or PROMIS Physical Function, or like mapped measure during the performance year. \n\n\nAdditionally, a risk-adjusted MCID proportional difference determined by calculating the difference between the risk model predicted and observed MCID proportion will be reported for each PT/OT/MSK Provider/Group. The risk adjustment will be calculated using a logistic regression model using: baseline function score, baseline pain score, age, sex, payer, surgical status, and symptom duration (time from surgery or symptom onset to baseline physical therapy visit) as well as instrument tool used. These measures will serve as a PT/OT/MSK Provider performance measure at the eligible PT/OT/MSK Provider or group level.\n\nThis measure will include one rate:\n1) The overall performance rate of non-surgical and surgical patients who achieve the MCID in KOS/PROMIS Physical Function/or like mapped measure.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Advancing Musculoskeletal (MSK) Care and Rehabilitation QCDR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": true, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "3471690", "7037323", "3967247", "1157686" ] }, { "category": "quality", "measureId": "MSK6", "title": "Patients Suffering From a Neck Injury who Improve Pain", "description": "Percentage of patients 18 years or older suffering from a neck injury who achieve the Minimal Clinically Important Difference (MCID) in the Numeric Pain Rating Scale, or like mapped measure during the performance year. \n\n\nAdditionally, a risk-adjusted MCID proportional difference determined by calculating the difference between the risk model predicted and observed MCID proportion will be reported for each PT/OT/MSK Provider/Group. The risk adjustment will be calculated using a logistic regression model using: baseline function score, baseline pain score, age, sex, payer, surgical status, and symptom duration (time from surgery or symptom onset to baseline physical therapy visit) as well as instrument tool used. These measures will serve as a PT/OT/MSK Provider performance measure at the eligible PT/OT/MSK Provider or group level.\n\nThis measure will include one rate:\n1) The overall performance rate of non-surgical and surgical patients who achieve the MCID in the Numeric Pain Rating Scale like mapped measure.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Advancing Musculoskeletal (MSK) Care and Rehabilitation QCDR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": true, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "3471690", "7037323", "3967247", "1157686" ] }, { "category": "quality", "measureId": "MSK7", "title": "Patients Suffering From an Upper Extremity Injury who Improve Pain", "description": "Percentage of patients 18 years or older suffering from an upper extremity injury who achieve the Minimal Clinically Important Difference (MCID) in the Numeric Pain Rating Scale, or like mapped measure during the performance year. \n\n\nAdditionally, a risk-adjusted MCID proportional difference determined by calculating the difference between the risk model predicted and observed MCID proportion will be reported for each PT/OT/MSK Provider/Group. The risk adjustment will be calculated using a logistic regression model using: baseline function score, baseline pain score, age, sex, payer, surgical status, and symptom duration (time from surgery or symptom onset to baseline physical therapy visit) as well as instrument tool used. These measures will serve as a PT/OT/MSK Provider performance measure at the eligible PT/OT/MSK Provider or group level.\n\nThis measure will include one rate:\n1) The overall performance rate of non-surgical and surgical patients who achieve the MCID in the Numeric Pain Rating Scale like mapped measure.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Advancing Musculoskeletal (MSK) Care and Rehabilitation QCDR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": true, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "3471690", "7037323", "3967247", "1157686" ] }, { "category": "quality", "measureId": "MSK8", "title": "Patients Suffering From a Back Injury who Improve Pain", "description": "Percentage of patients 18 years or older suffering from a back injury who achieve the Minimal Clinically Important Difference (MCID) in the Numeric Pain Rating Scale, or like mapped measure during the performance year. \n\n\nAdditionally, a risk-adjusted MCID proportional difference determined by calculating the difference between the risk model predicted and observed MCID proportion will be reported for each PT/OT/MSK Provider/Group. The risk adjustment will be calculated using a logistic regression model using: baseline function score, baseline pain score, age, sex, payer, surgical status, and symptom duration (time from surgery or symptom onset to baseline physical therapy visit) as well as instrument tool used. These measures will serve as a PT/OT/MSK Provider performance measure at the eligible PT/OT/MSK Provider or group level.\n\nThis measure will include one rate:\n1) The overall performance rate of non-surgical and surgical patients who achieve the MCID in the Numeric Pain Rating Scale like mapped measure.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Advancing Musculoskeletal (MSK) Care and Rehabilitation QCDR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": true, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "3471690", "7037323", "3967247", "1157686" ] }, { "category": "quality", "measureId": "MSK9", "title": "Patients Suffering From a Lower Extremity Injury who Improve Pain", "description": "Percentage of patients 18 years or older suffering from a lower extremity injury who achieve the Minimal Clinically Important Difference (MCID) in the Numeric Pain Rating Scale, or like mapped measure during the performance year. \n\n\nAdditionally, a risk-adjusted MCID proportional difference determined by calculating the difference between the risk model predicted and observed MCID proportion will be reported for each PT/OT/MSK Provider/Group. The risk adjustment will be calculated using a logistic regression model using: baseline function score, baseline pain score, age, sex, payer, surgical status, and symptom duration (time from surgery or symptom onset to baseline physical therapy visit) as well as instrument tool used. These measures will serve as a PT/OT/MSK Provider performance measure at the eligible PT/OT/MSK Provider or group level.\n\nThis measure will include one rate:\n1) The overall performance rate of non-surgical and surgical patients who achieve the MCID in the Numeric Pain Rating Scale like mapped measure.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Advancing Musculoskeletal (MSK) Care and Rehabilitation QCDR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": true, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M1370" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "3471690", "7037323", "3967247", "1157686" ] }, { "category": "quality", "measureId": "MSK10", "title": "Patients Suffering From a Knee Injury who Improve Pain", "description": "Percentage of patients 18 years or older suffering from a knee injury who achieve the Minimal Clinically Important Difference (MCID) in the Numeric Pain Rating Scale, or like mapped measure during the performance year. \n\n\nAdditionally, a risk-adjusted MCID proportional difference determined by calculating the difference between the risk model predicted and observed MCID proportion will be reported for each PT/OT/MSK Provider/Group. The risk adjustment will be calculated using a logistic regression model using: baseline function score, baseline pain score, age, sex, payer, surgical status, and symptom duration (time from surgery or symptom onset to baseline physical therapy visit) as well as instrument tool used. These measures will serve as a PT/OT/MSK Provider performance measure at the eligible PT/OT/MSK Provider or group level.\n\nThis measure will include one rate:\n1) The overall performance rate of non-surgical and surgical patients who achieve the MCID in the Numeric Pain Rating Scale like mapped measure.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Advancing Musculoskeletal (MSK) Care and Rehabilitation QCDR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": true, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "3471690", "7037323", "3967247", "1157686" ] }, { "category": "quality", "measureId": "MUSIC4", "title": "Prostate Cancer: Active Surveillance/Watchful Waiting for Newly Diagnosed Low Risk Prostate Cancer Patients", "description": "Proportion of patients newly diagnosed with low-risk prostate cancer managed with active surveillance or watchful waiting", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2014, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "American Urological Association Quality (AQUA) Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1423" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8758330" ] }, { "category": "quality", "measureId": "NHCR4", "title": "Repeat screening or surveillance colonoscopy recommended within one year due to inadequate bowel preparation", "description": "Percentage of patients recommended for repeat screening or surveillance colonoscopy or an alternate tier 1 or tier 2 colorectal cancer screening modality within one year or less due to inadequate bowel preparation quality", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2015, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "GIQuIC in Collaboration with American College of Gastroenterology, American Society for Gastrointestinal Endoscopy", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1422" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "5846856" ] }, { "category": "quality", "measureId": "OQH1", "title": "Dihydropyrimidine Dehydrogenase (DPD) Deficiency Testing Prior to Fluoropyrimidine Treatment", "description": "Percentage of patients receiving fluoropyrimidine treatment who were tested for dihydropyrimidine dehydrogenase (DPD) deficiency prior to the initial initiation of treatment", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "The Oncology Quality Hub", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "2755787" ] }, { "category": "quality", "measureId": "PIMSH1", "title": "Oncology: Advance Care Planning in Metastatic Cancer Patients", "description": "Percentage of patients with metastatic (stage 4) cancer who have a documented Advance Care Planning discussion in the first 6 months after metastatic diagnosis to inform treatment decisions and end-of-life care.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2018, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientEngagementExperience", "isHighPriority": true, "primarySteward": "Practice Insights by McKesson in Collaboration with The US Oncology Network - QCDR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8794712" ] }, { "category": "quality", "measureId": "PIMSH4", "title": "Oncology: Patient-Reported Pain Improvement", "description": "Percentage of cancer patients currently receiving chemotherapy or radiation therapy who report significant pain improvement (high to moderate, moderate to low, or high to low) within 30 days.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2019, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Practice Insights by McKesson in Collaboration with The US Oncology Network - QCDR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8794712" ] }, { "category": "quality", "measureId": "PIMSH9", "title": "Oncology: Supportive Care Drug Utilization in Last 14 Days of Life", "description": "Percentage of patients receiving supportive care drugs (including colony stimulating factors, bone health, supplemental iron medications, and neurokinin 1 (NK1) receptor antagonist antiemetics) during the 14 days prior to and including the date of death.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "efficiency", "isHighPriority": true, "primarySteward": "Practice Insights by McKesson in Collaboration with The US Oncology Network - QCDR", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8794712" ] }, { "category": "quality", "measureId": "PIMSH10", "title": "Oncology: Hepatitis B Serology Testing and Prophylactic Treatment Prior to Receiving Anti-CD20 Targeting Drugs", "description": "Percentage of patients tested for Hepatitis B prior to receiving anti-CD20 targeting treatment, including rituximab, ofatumumab, and obinutuzumab; patients testing positive for Hepatitis B receive prophylactic treatment.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Practice Insights by McKesson in Collaboration with The US Oncology Network - QCDR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8794712" ] }, { "category": "quality", "measureId": "PIMSH13", "title": "Oncology: Mutation Testing for Stage IV Lung Cancer Completed Prior to the Start of Targeted Therapy", "description": "Proportion of stage IV nsNSCLC patients tested for actionable biomarkers and received targeted therapy or chemotherapy based on biomarker results", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Practice Insights by McKesson in Collaboration with The US Oncology Network - QCDR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M0001" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8794712" ] }, { "category": "quality", "measureId": "PIMSH17", "title": "Oncology: Utilization of Prophylactic GCSF for Cancer Patients Receiving Low-Risk Chemotherapy (inverse measure)", "description": "Percentage of patients with cancer (solid tumors only) receiving any white cell growth factors with during the first cycle of low-risk chemotherapy.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "efficiency", "isHighPriority": true, "primarySteward": "Practice Insights by McKesson in Collaboration with The US Oncology Network - QCDR", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M0001" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8794712" ] }, { "category": "quality", "measureId": "PIMSH19", "title": "Antiemetic Therapy for Low- and Minimal-Emetic-Risk Antineoplastic Agents - Avoidance of Overuse (Lower Score - Better)", "description": "Percentage of cancer patients aged 18 years and older treated with low- or minimal-emetic-risk antineoplastic agents who are administered inappropriate pre-treatment antiemetic therapy", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Practice Insights by McKesson in Collaboration with The US Oncology Network - QCDR", "isInverse": true, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8794712", "2755787" ] }, { "category": "quality", "measureId": "PIMSH20", "title": "Appropriate Antiemetic Therapy for High- and Moderate-Emetic-Risk Antineoplastic Agents", "description": "Percentage of cancer patients aged 18 years and older treated with high- or moderate-emetic-risk antineoplastic agents who are administered appropriate pre-treatment antiemetic therapy", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "Practice Insights by McKesson in Collaboration with The US Oncology Network - QCDR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8794712", "2755787" ] }, { "category": "quality", "measureId": "PIMSH21", "title": "Oncology: Screening and Achieving Resolution or Improvement of Distress for Cancer Care", "description": "Percentage of patients 18 years and older with an active cancer diagnosis who are screened for distress AND if screen is positive, achieve resolution or improvement within 6 months for at least 1 of their concerns.\r\n\r\nTHERE ARE TWO SUBMISSION CRITERIA FOR THIS MEASURE:\r\n1) Patients 18 years and older with an active cancer diagnosis who are screened for distress using a comprehensive, standardized tool which assesses physical, emotional, social, practical, and spiritual concerns.\r\nAND\r\n2) Patients 18 years and older with an active cancer diagnosis who screen positive for distress using a comprehensive, standardized screening tool and achieve resolution or improvement within 6 months for at least 1 of their concerns.\r\n\r\nThe measure contains two submission criteria which aim to identify patients who were screened for distress (Submission Criteria 1) and of those patients who screened positive for distress, did corresponding interventions following a positive distress screening lead to meaningful improvement or resolution within 6 months (Submission Criteria 2). By separating this measure into various submission criteria, the MIPS eligible clinician or practice will be able to better ascertain where gaps in performance exist and identify opportunities for improvement. For accountability reporting in the CMS MIPS program, the rate for Submission Criteria 2 is used for performance.", "metricType": "registryMultiPerformanceRate", "overallAlgorithm": "overallStratumOnly", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Practice Insights by McKesson in Collaboration with The US Oncology Network - QCDR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "8794712" ], "strata": [ { "name": "screened", "description": "Performance Rate 1: Percentage of patients 18 years and older with an active cancer diagnosis who are screened for distress using a comprehensive, standardized tool which assesses physical, emotional, social, practical, and spiritual concerns." }, { "name": "overall", "description": "Performance Rate 2: Percentage of patients 18 years and older with an active cancer diagnosis who screen positive for distress using a comprehensive, standardized screening tool and achieve resolution or improvement within 6 months for at least 1 of their concerns." } ] }, { "category": "quality", "measureId": "PQRANES1", "title": "Use of Peripheral Nerve Block within the Emergency Department in Patients Admitted with Low Energy Hip Fracture", "description": "Percentage of patients aged 65 years and older that receive a peripheral nerve block for analgesia following diagnosis of isolated hip fracture within the Emergency Department", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "The PQR-ANES", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "7746687" ] }, { "category": "quality", "measureId": "QMM17", "title": "Appropriate Follow-up Recommendations for Ovarian-Adnexal Lesions using the Ovarian-Adnexal Reporting and Data System (O-RADS)", "description": "The percentage of final reports for female patients receiving a transvaginal ultrasound (US) examination of the pelvis (including transabdominal/transvaginal exams) where a lesion is detected, in which the radiologist describes the lesion using ORADS Lexicon Descriptors, provides ORADS score, and subsequently makes the correct clinical management recommendation based on the ORADS Risk Stratification and Management System.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "MSN Healthcare Solutions, LLC", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1498" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6394618", "5303416", "6704504" ] }, { "category": "quality", "measureId": "QMM18", "title": "Use of Breast Cancer Risk Score on Mammography", "description": "The percentage of final reports for screening mammograms which include the patient’s estimated numeric risk assessment based on a valid and published model**, and appropriate recommendations for supplemental screening based on the patient’s estimated risk and documentation of the source of recommendation.\n** Must be one of the models listed in the numerator instructions of this measure specification.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "MSN Healthcare Solutions, LLC", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1498" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6394618", "5303416", "6704504" ] }, { "category": "quality", "measureId": "QMM21", "title": "Incorporating results of concurrent studies into Final Reports for Bone Marrow Aspirate of patients with Leukemia, Myelodysplastic syndrome, or Chronic Anemia", "description": "The percentage of Final Bone Marrow Aspirate Reports of patients with Leukemia, Myelodysplastic syndrome, or Chronic Anemia with documentation of concurrent studies performed, their respective results, and interpretation of those results.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "MSN Healthcare Solutions QCDR II", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1501" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "7418330", "6704504" ] }, { "category": "quality", "measureId": "QMM23", "title": "Low dose cancer screening recommendation for computed tomography (CT) and computed tomography angiography (CTA) of chest with diagnosis of Emphysema.", "description": "Percentage of emphysema patients, aged 50-80 at the time of service, who undergo a CT/CTA of the chest in which the Final Report:\r\n1) Mentions that the presence of pulmonary emphysema on CT is an independent risk factor for lung cancer, AND\r\n2) Includes a recommendation to consider the patient for low dose CT (LDCT) lung cancer screening in the future (current chest CT serves as a baseline).", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "MSN Healthcare Solutions, LLC", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6394618", "5303416", "6704504" ] }, { "category": "quality", "measureId": "QMM25", "title": "Use of Structured Reporting for Urine Cytology Specimens", "description": "The percentage of Final Reports on Urine cytology specimens, for patients of any age, that utilize The Paris System (TPS) for reporting urinary cytology.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "MSN Healthcare Solutions QCDR II", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M1501" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "7418330", "6704504" ] }, { "category": "quality", "measureId": "QMM26", "title": "Screening Abdominal Aortic Aneurysm Reporting with Recommendations", "description": "Percentage of patients, aged 50-years-old or older, who have had a screening ultrasound for an abdominal aortic aneurysm (AAA), with positive or negative findings, that have recognized clinical follow-up recommendations documented in the final report and direct communication of findings greater than or equal to 5.5 cm in size made to the ordering provider.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "MSN Healthcare Solutions, LLC", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M1498" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6394618", "5303416", "6704504" ] }, { "category": "quality", "measureId": "QMM27", "title": "Appropriate Classification and Follow-up Imaging for Incidental Pancreatic Cysts", "description": "Percentage of final reports for computed tomography/computed tomography angiography (CT/CTA) of the abdomen or abdomen/pelvis or magnetic resonance imaging/magnetic resonance angiography (MRI/MRA) of the abdomen for patients 18 years of age and older with a pancreatic cyst incidentally noted that include documentation of cyst classification/morphology and follow-up imaging recommendation(s) in accordance with published guidelines and source of recommendation.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "MSN Healthcare Solutions, LLC", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6394618", "5303416", "6704504" ] }, { "category": "quality", "measureId": "QMM28", "title": "Reporting Breast Arterial Calcification (BAC) on Screening Mammography", "description": "Percentage of Final Screening Mammography Reports for female patients aged 40 years or older that include documentation of the presence or absence of Breast Arterial Calcification (BAC) and its clinical relevance.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "MSN Healthcare Solutions, LLC", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6394618", "5303416", "6704504" ] }, { "category": "quality", "measureId": "QMM29", "title": "Use of Appropriate Classification System for Lymphoma Specimen", "description": "Percentage of Final Lymphoma Specimen Pathology Reports, regardless of patient age, that classify the lymphoma using a validated and published model for lymphoma classification**. \n \n** Must be one of the models listed in the Numerator Instructions below.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "MSN Healthcare Solutions QCDR II", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M1501" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "7418330" ] }, { "category": "quality", "measureId": "QMM30", "title": "Appropriate Use of Bethesda System for Reporting Thyroid Cytopathology on Fine Needle Aspirations (FNA) of Thyroid Nodule(s)", "description": "Percentage of final pathology reports for thyroid nodule fine needle aspiration (FNA) specimens that include documentation of the diagnostic category, range of estimated risk of malignancy (ROM), and clinical management options in accordance with the Bethesda System for Reporting Cytopathology, 3rd edition (2023), and for thyroid nodule specimens of indeterminate cytology (Bethesda 3 or 4), documentation that direct communication was sent to patient and/or treating physician (if known) to inform them that molecular panel testing may be appropriate.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "MSN Healthcare Solutions QCDR II", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M1501" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "7418330", "6704504" ] }, { "category": "quality", "measureId": "QMM32", "title": "Intracerebral Hemorrhage (ICH) on Non-Contrast CT Head", "description": "All patients 18 years of age and older undergoing non-contrast CT (NCCT) Head with an initial diagnosis of intracerebral hemorrhage (ICH), also referred to as intra-axial or\r\nintraparenchymal hemorrhage (IPH), who have documentation of the location of ICH, ICH volume, and presence or absence of intraventricular hemorrhage (IVH) in the Final Report.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "MSN Healthcare Solutions, LLC", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6394618", "5303416" ] }, { "category": "quality", "measureId": "QMM33", "title": "Immunohistochemistry (IHC) and/or Molecular BRAF Testing Status in Metastatic Melanoma", "description": "Percentage of final immunohistochemical staining reports for patients with an initial diagnosis of metastatic melanoma that contain a recommendation for or the results of BRAF testing (either by immunohistochemistry (IHC) and/or molecular testing).", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "MSN Healthcare Solutions QCDR II", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "7418330" ] }, { "category": "quality", "measureId": "QMM34", "title": "Use of Appropriate Scoring System for Immunohistochemistry (IHC) for HER2/neu Testing for Invasive Breast Cancer", "description": "Percentage of final pathology reports for immunohistochemistry (IHC) for HER2/neu testing for invasive breast cancer that include interpretation of the results in accordance with the 2018, 2023 or later ASCO-CAP Guideline Update.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "MSN Healthcare Solutions QCDR II", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "7418330" ] }, { "category": "quality", "measureId": "QMM35", "title": "P16 Immunohistochemistry (IHC) Staining Status in Oropharyngeal Squamous Cell Carcinoma (OPSCC)", "description": "Percentage of final FNA or biopsy reports for patients with an initial diagnosis of primary oropharyngeal squamous cell carcinoma (OPSCC) that contain the results of P16 immunohistochemistry (IHC) staining.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "MSN Healthcare Solutions QCDR II", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "7418330" ] }, { "category": "quality", "measureId": "QMM36", "title": "P53 Immunohistochemistry (IHC) Staining Status in Endometrial Carcinoma", "description": "Percentage of final pathology reports for endometrial biopsy, dilation and curettage (D&C) material, or hysterectomy specimen with an initial diagnosis of primary endometrial carcinoma that contain the results of P53 immunohistochemistry (IHC) staining.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "MSN Healthcare Solutions QCDR II", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "7418330" ] }, { "category": "quality", "measureId": "QMM37", "title": "Hepatocellular Carcinoma (HCC) Screening Recommendation for Patients with Cirrhosis of the Liver", "description": "Percentage of patients, aged 18 years and older, with cirrhosis of the liver, regardless of etiology, who undergo CT/CTA of the abdomen or abdomen/pelvis, MRI of the abdomen, or abdominal US in which the final report:\r\nMentions that patients with cirrhosis of the liver have a higher risk of developing hepatocellular carcinoma (HCC), \r\nAND\r\nIncludes a recommendation to consider the patient for semi-annual hepatocellular carcinoma (HCC) screening/surveillance.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "MSN Healthcare Solutions, LLC", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6394618" ] }, { "category": "quality", "measureId": "RCOIR12", "title": "Tunneled Hemodialysis Catheter Clinical Success Rate", "description": "Percentage of tunneled central venous access catheter insertions or replacements that resulted in successful dialysis treatment in patients with end-stage renal disease (ESRD).", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2019, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Renal and Vascular Outcomes Improvement Program, powered by Forward Health Group in Collaboration with Renal Physicians Association (RPA)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1499", "M1503" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4302083" ] }, { "category": "quality", "measureId": "RCOIR13", "title": "Percutaneous Arteriovenous Fistula for Dialysis - Clinical Success Rate", "description": "Percentage of clinically successful percutaneously created arteriovenous fistulae (pAVF) for patients on maintenance hemodialysis.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Renal and Vascular Outcomes Improvement Program, powered by Forward Health Group in Collaboration with Renal Physicians Association (RPA)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1499", "M1503" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4302083" ] }, { "category": "quality", "measureId": "REGCLR1", "title": "Heel Pain Treatment Outcomes for Adults", "description": "Percentage of patients aged 18 and older with a diagnosis of heel pain who receive an intervention intended to treat the heel pain and experience a clinically significant decrease in heel pain.\r\nPatients who have had at least two visits during the reporting period", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2020, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Registry Clearinghouse in Collaboration with Ohio Foot and Ankle Medical Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1502" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4117893" ] }, { "category": "quality", "measureId": "REGCLR3", "title": "Bunion Outcome - Adult and Adolescent", "description": "Percentage of patients with a who have a hallux valgus (bunion) deformity causing pain that receive an intervention and have clinically significant reduction in pain as a result of that intervention.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Registry Clearinghouse in Collaboration with Ohio Foot and Ankle Medical Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1502" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4117893" ] }, { "category": "quality", "measureId": "REGCLR5", "title": "Offloading with Remote Monitoring", "description": "Percentage of patients with a plantar foot ulcer who were compliant with offloading and healed their ulcer in 10 (ten) weeks.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2021, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Registry Clearinghouse in Collaboration with Ohio Foot and Ankle Medical Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1502" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4117893" ] }, { "category": "quality", "measureId": "REGCLR8", "title": "Monitor and Improve Treatment Outcomes in Chronic Wound Healing", "description": "This measure is specifically for CHRONIC wounds. Those are wounds that have been present for an extended period of time and have not demonstrated healing. \nPercentage of patients presenting with a non-healing (chronic) wound (present for 6 weeks with no or limited response to treatment) who are currently visiting a provider responsible for their wound care, who performs a re-assessment of the wound (The use of digital imaging to monitor the wound is encouraged) , and has used the information learned from that re-assessment to implement a change in treatment plan, and whose wound healing rate has accelerated since implementation of the updated treatment plan.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Registry Clearinghouse in Collaboration with Ohio Foot and Ankle Medical Association", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M1502" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4117893" ] }, { "category": "quality", "measureId": "RPAQIR14", "title": "Arteriovenous Graft Thrombectomy Clinical Success Rate", "description": "Percentage of clinically successful arteriovenous graft (AVG) thrombectomies for patients on maintenance hemodialysis.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2016, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Renal and Vascular Outcomes Improvement Program, powered by Forward Health Group in Collaboration with Renal Physicians Association (RPA)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1499", "M1503" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4302083" ] }, { "category": "quality", "measureId": "RPAQIR15", "title": "Arteriovenous Fistulae Thrombectomy Clinical Success Rate", "description": "Percentage of clinically successful arteriovenous fistulae (AVF) thrombectomies for patients on maintenance hemodialysis.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2016, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "Renal and Vascular Outcomes Improvement Program, powered by Forward Health Group in Collaboration with Renal Physicians Association (RPA)", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1499", "M1503" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "4302083" ] }, { "category": "quality", "measureId": "THEPQR1", "title": "High Intensity Statin Prescribed for Acute and Subacute Ischemic Stroke and Transient Ischemic Attack (TIA)", "description": "Acute and subacute ischemic stroke and confirmed Transient Ischemic Attack (TIA) patients prescribed or continuing to take a high intensity statin at time of hospital discharge", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "The PQR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "1725296", "5133825" ] }, { "category": "quality", "measureId": "THEPQR2", "title": "Discontinuation of Proton Pump Inhibitors for patients who do not meet criteria for long-term utilization.", "description": "The percentage of patients on a Proton Pump Inhibitor with an appropriately documented indication or an order for discontinuation for not meeting criteria for long-term utilization.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "The PQR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "1725296", "5133825" ] }, { "category": "quality", "measureId": "THEPQR4", "title": "Consultation to Palliative Care for Patients with End Stage Conditions", "description": "The measure will identify patients with end stage diagnoses who meet any of the listed criteria for a palliative care consult", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": true, "primarySteward": "The PQR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "1725296" ] }, { "category": "quality", "measureId": "THEPQR5", "title": "Avoidance of Head CT Scans in Recurrent Seizure Episodes Without New Head Injury.", "description": "This quality measure aims to minimize the use of head computed tomography (CT) scans in both the Emergency Department (ED) and Hospital Medicine (HM) settings for patients presenting with seizures when they have a known history of seizure disorder and there is no new clinical evidence of head injury.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "efficiency", "isHighPriority": true, "primarySteward": "The PQR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "1725296", "3967247" ] }, { "category": "quality", "measureId": "THEPQR6", "title": "Timely and Effective Management of Pediatric Asthma Exacerbations in the Emergency Department", "description": "This measure evaluates the timely administration of both Short-Acting Beta Agonists (SABAs) and corticosteroids within 60 minutes of ED presentation in pediatric patients aged 2 to 18 years experiencing moderate to severe asthma exacerbations. It specifically assesses the prompt delivery of SABAs in conjunction with oral, intramuscular (IM), or intravenous (IV) corticosteroids to ensure effective management of asthma symptoms.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "The PQR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "1725296", "3967247" ] }, { "category": "quality", "measureId": "THEPQR7", "title": "Optimization of Short-term Dual Antiplatelet Therapy for High-risk Cerebrovascular Events", "description": "This measure assesses the proportion of adult patients who are prescribed short-term dual antiplatelet therapy upon discharge following a diagnosis of high-risk transient ischemic attack (TIA), minor non-embolic ischemic stroke, or intracranial large artery atherosclerosis. It encourages the use of evidence-based protocols to reduce the risk of recurrent stroke.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2025, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "The PQR", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "1725296", "3967247" ] }, { "category": "quality", "measureId": "UREQA8", "title": "Vitamin D level: Effective Control of Low Bone Mass/Osteopenia and Osteoporosis: Therapeutic Level Of 25 OH Vitamin D Level Achieved", "description": "Percentage of patients aged 65 years and older diagnosed with osteopenia or osteoporosis whose most recent serum 25 Hydroxy-Vitamin D results is greater than or equal to 30.0 ng/dL. \nReporting Frequency:\nThis measure is reported once per reporting period.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "UREQA (United Rheumatology Effectiveness and Quality Analytics) in Collaboration with HealthAdvanta", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1366" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "1649514" ] }, { "category": "quality", "measureId": "UREQA9", "title": "Screening for Osteoporosis for Men Aged 70 Years and Older", "description": "Percentage of male patients aged 70 years and older who had a central dual-energy X-ray absorptiometry (DXA) to screen for osteoporosis \n\n\nReporting Frequency:\nThis measure is reported once per reporting period", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "UREQA (United Rheumatology Effectiveness and Quality Analytics) in Collaboration with HealthAdvanta", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "G0053" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "1649514" ] }, { "category": "quality", "measureId": "UREQA10", "title": "Ankylosing Spondylitis: Controlled Disease Or Improved Disease Function", "description": "Percentage of qualifying visits for patients aged 18 years and older with a diagnosis of ankylosing spondylitis whose most recent BASDAI score is less than 4 OR who were in suboptimal disease control (BASDAI score >= 4.0) and who have seen an improvement by at least one point over the previous BASDAI score within the last 12 months.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2023, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "UREQA (United Rheumatology Effectiveness and Quality Analytics) in Collaboration with HealthAdvanta", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "G0053" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "1649514" ] }, { "category": "quality", "measureId": "USWR22", "title": "Nutritional Assessment and Intervention Plan in patients with Wounds and Ulcers", "description": "The percentage of patients in the denominator for whom an appropriate intervention plan is recommended by the practitioner based on the assessment results", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2017, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "U.S. Wound Registry in Collaboration with Intellicure, LLC", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6853338", "1718371" ] }, { "category": "quality", "measureId": "USWR30", "title": "Non-Invasive Arterial Assessment of patients with lower extremity wounds or ulcers for determination of healing potential", "description": "Percentage of patients aged 18 years or older with a non-healing lower extremity wound or ulcer that undergo a non-invasive arterial assessment once in a 12-month period", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "U.S. Wound Registry in Collaboration with Intellicure, LLC", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6853338", "1718371" ] }, { "category": "quality", "measureId": "USWR32", "title": "Adequate Compression at each visit for Patients with Venous Leg Ulcers (VLUs) appropriate to arterial supply", "description": "Percentage of venous leg ulcer visits among patients aged 18 years and older in which adequate compression is performed at each treatment visit during the 12-month reporting period. Arterial status must first be assessed to ensure that compression can be implemented safely.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2022, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "intermediateOutcome", "isHighPriority": true, "primarySteward": "U.S. Wound Registry in Collaboration with Intellicure, LLC", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "allowedPrograms": [ "mips", "M1502" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6853338", "1718371" ] }, { "category": "quality", "measureId": "USWR33", "title": "Diabetic Foot Ulcer (DFU) Healing or Closure", "description": "Percentage of diabetic foot ulcers that have achieved healing or closure within 6 months, stratified by the Wound Healing Index.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "U.S. Wound Registry in Collaboration with Intellicure, LLC", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": true, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M1502" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6853338" ] }, { "category": "quality", "measureId": "USWR34", "title": "Venous Leg Ulcer (VLU) Healing or Closure", "description": "Percentage of venous leg ulcers among patients aged 18 or older that have achieved healing or closure within 12 months, stratified by the Wound Healing Index. Healing or closure is defined as complete epithelialization without drainage or the need for a dressing over the closed ulceration, although venous compression would still be required.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "U.S. Wound Registry in Collaboration with Intellicure, LLC", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": true, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M1502" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6853338" ] }, { "category": "quality", "measureId": "USWR35", "title": "Adequate Off-loading of Diabetic Foot Ulcers performed at each visit, appropriate to location of ulcer", "description": "Percentage of visits in which diabetic foot ulcers received adequate off-loading during the 12-month reporting period, appropriate to the location of the ulcer. (Off-loading is not a simple documentation process but may include performing a procedure such as Total Contact Casting or special bandaging.)", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "U.S. Wound Registry in Collaboration with Intellicure, LLC", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips", "M1502" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6853338", "1718371" ] }, { "category": "quality", "measureId": "USWR36", "title": "Pressure Ulcer* (PU) Healing or Closure (ulcerations not on the lower extremity)", "description": "Percentage of Stage 2, 3, or 4 pressure ulcers* (not on the lower extremity) among patients aged 18 or older that achieve healing or closure within 6 months [Note: Because both CMS and ICD10-CM use the term \"pressure ulcer\" for open cutaneous lesions, we are using that term.]", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2024, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "outcome", "isHighPriority": true, "primarySteward": "U.S. Wound Registry in Collaboration with Intellicure, LLC", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": true, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6853338" ] }, { "category": "quality", "measureId": "USWR37", "title": "Objective Measurement of Wound Surface Area With AI-Based Imaging", "description": "Percentage of chronic wound/ulcer treatment visits in which wound surface area is measured objectively with an AI-based imaging tool, allowing for an objective evaluation of surface area reduction over time.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "U.S. Wound Registry in Collaboration with Intellicure, LLC", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "6853338" ] }, { "category": "quality", "measureId": "VHE1", "title": "Treatment of Symptoms of Autonomic Dysfunction for Patients with Parkinson's Disease", "description": "Percentage of all patients with a diagnosis of Parkinson's Disease who experienced symptoms of autonomic dysfunction during the measurement period and were provided follow-up care", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Verana Health - Evolve Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "2371980" ] }, { "category": "quality", "measureId": "VHE2", "title": "Cluster Headache: Preventive Treatment Prescribed", "description": "Percentage of patients greater than or equal to 18 years of age with a diagnosis of cluster headache (CH) who were prescribed or documented as receiving a short-term and/or long-term preventive treatment, including treatments prescribed or managed by a different clinician.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Verana Health - Evolve Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "2371980" ] }, { "category": "quality", "measureId": "VHE3", "title": "Appropriate Physical Activity Counseling for patients with Neurological Conditions", "description": "Percentage of patients with Multiple Sclerosis and Parkinson's disease who benefit from physical activity who are counseled on the benefits of the physical activity in the past 12 months.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Verana Health - Evolve Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "2371980" ] }, { "category": "quality", "measureId": "VHE4", "title": "Acute Migraine Attacks: Recommended Treatment", "description": "Percentage of patients age 6 years and older with a diagnosis of migraine who were prescribed a guideline recommended or FDA approved/cleared treatment for acute migraine attacks within the measurement period.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "process", "isHighPriority": false, "primarySteward": "Verana Health - Evolve Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "2371980" ] }, { "category": "quality", "measureId": "VHE5", "title": "Reduction of Polyneuropathy-Related Pain", "description": "Percentage of patients 18 years and older diagnosed with polyneuropathy whose pain score at 12 months (+/- 60 days) was improved from the index score.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Verana Health - Evolve Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "2371980" ] }, { "category": "quality", "measureId": "VHE6", "title": "Documentation of Seizure Frequency", "description": "Percentage of patients with epilepsy who had seizure frequency documented at each visit.", "metricType": "registrySinglePerformanceRate", "isRegistryMeasure": true, "firstPerformanceYear": 2026, "lastPerformanceYear": null, "eMeasureId": null, "nqfEMeasureId": null, "nqfId": null, "measureType": "patientReportedOutcome", "isHighPriority": true, "primarySteward": "Verana Health - Evolve Registry", "isInverse": false, "dataDisplayFormat": "percentage", "isRiskAdjusted": false, "isIcdImpacted": false, "icdImpacted": [], "isClinicalGuidelineChanged": false, "clinicalGuidelineChanged": [], "allowedPrograms": [ "mips" ], "submissionMethods": [ "registry" ], "measureSets": [], "isSevenPointCapRemoved": false, "sevenPointCapRemoved": [], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ], "allowedVendors": [ "2371980" ] }, { "category": "cost", "measureId": "COST_ACOPD_1", "title": "Asthma/Chronic Obstructive Pulmonary Disease (COPD)", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (\"episode\"). In all supplemental documentation, the term \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A, B, and D are used to construct this episode-based cost measure. The Asthma/COPD episode-based cost measure evaluates a clinician's or clinician group's risk-adjusted cost to Medicare for patients receiving medical care to manage and treat asthma or COPD. This chronic condition measure includes the costs of services that are clinically related to the attributed clinician's role in managing care during an Asthma/COPD episode.", "metricType": "costScore", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-chron-copd.pdf" }, "allowedPrograms": [ "mips", "M0005", "M1424" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_AKID_1", "title": "Acute Kidney Injury Requiring New Inpatient Dialysis", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (\"episode\"). In all supplemental documentation, \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Acute Kidney Injury Requiring New Inpatient Dialysis episode-based cost measure evaluates a clinician's risk-adjusted cost to Medicare for patients who receive their first inpatient dialysis service for acute kidney injury during the performance period. The measure score is the clinician's risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician's role in managing care during each episode from the clinical event that opens, or \"triggers,\" the episode through 30 days after the trigger.", "metricType": "costScore", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-aki-new-hd.pdf" }, "allowedPrograms": [ "mips", "M0002" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_CCLI_1", "title": "Revascularization for Lower Extremity Chronic Critical Limb Ischemia", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (\"episode\"). In all supplemental documentation, \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Revascularization for Lower Extremity Chronic Critical Limb Ischemia episode-based cost measure evaluates a clinician's risk-adjusted cost to Medicare for patients who undergo elective revascularization surgery for lower extremity chronic critical limb ischemia during the performance period. The measure score is the clinician's risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician's role in managing care during each episode from 30 days prior to the clinical event that opens, or \"triggers,\" the episode through 90 days after the trigger.", "metricType": "costScore", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-rleccli.pdf" }, "allowedPrograms": [ "mips", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_CKD_1", "title": "Chronic Kidney Disease (CKD) episode-based cost measure", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, the term “cost” generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A, B, and D are used to construct this episode-based cost measure.\nThe CKD episode-based cost measure evaluates a clinician’s or clinician group’s risk-adjusted and specialty-adjusted cost to Medicare for patients who receive medical care to manage and treat stage 4 or 5 chronic kidney disease. This chronic condition measure includes the costs of services that are clinically related to the attributed clinician’s role in managing care during a CKD episode.", "metricType": "costScore", "firstPerformanceYear": 2025, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-ckd.pdf" }, "allowedPrograms": [ "mips", "M0002" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_COPDE_1", "title": "Inpatient Chronic Obstructive Pulmonary Disease (COPD) Exacerbation", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (\"episode\"). In all supplemental documentation, \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Inpatient COPD Exacerbation episode-based cost measure evaluates a clinician's risk\u0002adjusted cost to Medicare for patients who receive inpatient treatment for an acute exacerbation of COPD during the performance period. The measure score is the clinician's risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This acute inpatient medical condition measure includes costs of services that are clinically related to the attributed clinician's role in managing care during each episode from the clinical event that opens, or \"triggers,\" the episode through 60 days after the trigger.", "metricType": "costScore", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-ip-copd.pdf" }, "allowedPrograms": [ "mips", "M1424" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_CRR_1", "title": "Colon and Rectal Resection", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (\"episode\"). In all supplemental documentation, \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Colon and Rectal Resection episode-based cost measure evaluates a clinician's risk-adjusted cost to Medicare for patients who receive colon or rectal resection for either benign or malignant indications during the performance period. The measure score is the clinician's risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician's role in managing care during each episode from 15 days prior to the clinical event that opens, or \"triggers,\" the episode through 90 days after the trigger.", "metricType": "costScore", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-colrec-rsct.pdf" }, "allowedPrograms": [ "mips", "M1425" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_D_1", "title": "Diabetes", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (\"episode\"). In all supplemental documentation, the term \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A, B, and D are used to construct this episode-based cost measure. The Diabetes episode-based cost measure evaluates a clinician's or clinician group's risk-adjusted cost to Medicare for patients receiving medical care to manage and treat diabetes. This chronic condition measure includes the costs of services that are clinically related to the attributed clinician's role in managing care during a Diabetes episode.", "metricType": "costScore", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-diabetes.pdf" }, "allowedPrograms": [ "mips", "M0005" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_DEP_1", "title": "Depression", "description": "Patients receiving medical care to manage and treat depression. This chronic condition measure includes the costs of services that are clinically related to the attributed clinician’s role in managing care during a Depression episode.", "metricType": "costScore", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-depression.pdf" }, "allowedPrograms": [ "mips", "M0005", "M1369" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_EDV_1", "title": "Emergency Medicine", "description": "Patients who have an Emergency Department (ED) during the year.", "metricType": "costScore", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-emergency.pdf" }, "allowedPrograms": [ "mips", "G0057" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_EOPCI_1", "title": "Elective Outpatient Percutaneous Coronary Intervention (PCI)", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (\"episode\"). In all supplemental documentation, \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Elective Outpatient PCI episode-based cost measure evaluates a clinician's risk-adjusted cost to Medicare for patients who undergo elective outpatient PCI surgery to place a coronary stent for heart disease during the performance period. The measure score is the clinician's risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician's role in managing care during each episode from the clinical event that opens, or \"triggers,\" the episode through 30 days after the trigger.", "metricType": "costScore", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-op-pci.pdf" }, "allowedPrograms": [ "mips", "G0055" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_ESRD_1", "title": "End-Stage Renal Disease (ESRD) episode-based cost measure", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, the term “cost” generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A, B, and D are used to construct this episode-based cost measure.\nThe ESRD episode-based cost measure evaluates a clinician’s or clinician group’s risk-adjusted and specialty-adjusted cost to Medicare for patients who receive medical care to manage ESRD. This chronic condition measure includes the costs of services that are clinically related to the attributed clinician’s role in managing care during an ESRD episode.", "metricType": "costScore", "firstPerformanceYear": 2025, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-esrd.pdf" }, "allowedPrograms": [ "mips", "M0002" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_FIHR_1", "title": "Femoral or Inguinal Hernia Repair", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (\"episode\"). In all supplemental documentation, \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Femoral or Inguinal Hernia Repair episode-based cost measure evaluates a clinician's risk\u0002adjusted cost to Medicare for patients who undergo surgical procedure to repair a femoral or inguinal hernia during the performance period. The measure score is the clinician's risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician's role in managing care during each episode from 30 days prior to the clinical event that opens, or \"triggers,\" the episode through 90 days after the trigger.", "metricType": "costScore", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-fihr.pdf" }, "allowedPrograms": [ "mips", "M1425" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_HAC_1", "title": "Hemodialysis Access Creation", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (\"episode\"). In all supplemental documentation, \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Hemodialysis Access Creation episode-based cost measure evaluates a clinician's risk\u0002adjusted cost to Medicare for patients who undergo a procedure for the creation of graft or fistula access for long-term hemodialysis during the performance period. The measure score is the clinician's risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician's role in managing care during each episode from 60 days prior to the clinical event that opens, or \"triggers,\" the episode through 90 days after the trigger.", "metricType": "costScore", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-hd-access.pdf" }, "allowedPrograms": [ "mips", "M1499", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_HF_1", "title": "Heart Failure", "description": "Patients receiving medical care to manage and treat heart failure. This chronic condition measure includes the costs of services that are clinically related to the attributed clinician’s role in managing care during a Heart Failure episode.", "metricType": "costScore", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-heart-fail.pdf" }, "allowedPrograms": [ "mips", "G0055", "M0005" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_IHCI_1", "title": "Intracranial Hemorrhage or Cerebral Infarction", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (\"episode\"). In all supplemental documentation, \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Intracranial Hemorrhage or Cerebral Infarction episode-based cost measure evaluates a clinician's risk-adjusted cost to Medicare for patients who receive inpatient treatment for cerebral infarction or intracranial hemorrhage during the performance period. The measure score is the clinician's risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This acute inpatient medical condition measure includes costs of services that are clinically related to the attributed clinician's role in managing care during each episode from the clinical event that opens, or \"triggers,\" the episode through 90 days after the trigger.", "metricType": "costScore", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-ich-cva.pdf" }, "allowedPrograms": [ "mips", "G0054", "M1499" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_IOL_1", "title": "Cataract Removal with Intraocular Lens (IOL) Implantation episode-based cost measure", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized Medicare allowed amount and claims data from Medicare Parts A and B are used to construct the episode-based cost measures.\nThe Cataract Removal with IOL Implantation episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for patients who undergo a procedure for cataract removal with IOL implantation during the performance period. The measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 60 days prior to the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.", "metricType": "costScore", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-cataract1.pdf" }, "allowedPrograms": [ "mips", "M1420" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_KA_1", "title": "Knee Arthroplasty", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (\"episode\"). In all supplemental documentation, \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Knee Arthroplasty episode-based cost measure evaluates a clinician's risk-adjusted cost to Medicare for patients who receive an elective knee arthroplasty during the performance period. The measure score is the clinician's risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician's role in managing care during each episode from 30 days prior to the clinical event that opens, or \"triggers,\" the episode through 90 days after the trigger.", "metricType": "costScore", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-knee-arthro.pdf" }, "allowedPrograms": [ "mips", "G0058" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_KTM_1", "title": "Kidney Transplant Management episode-based cost measure", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, the term “cost” generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A, B, and D3 are used to construct this episode-based cost measure.\nThe Kidney Transplant Management episode-based cost measure evaluates a clinician’s or clinician group’s risk-adjusted and specialty-adjusted cost to Medicare for patients who receive medical care related to kidney transplant, beginning 90 days post-transplant. This chronic condition measure includes the costs of services that are clinically related to the attributed clinician’s role in managing care during a Kidney Transplant Management episode.", "metricType": "costScore", "firstPerformanceYear": 2025, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-kidney-tplt.pdf" }, "allowedPrograms": [ "mips", "M0002" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_LBP_1", "title": "Low Back Pain", "description": "Patients receiving medical care to manage and treat low back pain. This chronic condition measure includes the costs of services that are clinically related to the attributed clinician’s role in managing care during a Low Back Pain episode.", "metricType": "costScore", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-low-back.pdf" }, "allowedPrograms": [ "mips", "M1370" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_LGH_1", "title": "Lower Gastrointestinal Hemorrhage (groups only)", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (\"episode\"). In all supplemental documentation, \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Lower Gastrointestinal Hemorrhage episode-based cost measure evaluates a clinician's risk-adjusted cost to Medicare for patients who receive inpatient non-surgical treatment for acute bleeding in the lower gastrointestinal tract during the performance period. The measure score is the clinician's risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This acute inpatient medical condition measure includes costs of services that are clinically related to the attributed clinician's role in managing care during each episode from the clinical event that opens, or \"triggers,\" the episode through 35 days after the trigger.", "metricType": "costScore", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-lgi-bleed.pdf" }, "allowedPrograms": [ "mips", "M1422" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_LPMSM_1", "title": "Lumpectomy, Partial Mastectomy, Simple Mastectomy", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (\"episode\"). In all supplemental documentation, \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Lumpectomy, Partial Mastectomy, Simple Mastectomy episode-based cost measure evaluates a clinician's risk-adjusted cost to Medicare for patients who undergo partial or total mastectomy for breast cancer during the performance period. The measure score is the clinician's risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician's role in managing care during each episode from 30 days prior to the clinical event that opens, or \"triggers,\" the episode through 90 days after the trigger.", "metricType": "costScore", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-lump-mast.pdf" }, "allowedPrograms": [ "mips", "M1425" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_LSFDD_1", "title": "Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (\"episode\"). In all supplemental documentation, \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels episode-based cost measure evaluates a clinician's risk-adjusted cost to Medicare for patients who undergo surgery for lumbar spine fusion during the performance period. The measure score is the clinician's risk\u0002adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician's role in managing care during each episode from 30 days prior to the clinical event that opens, or \"triggers,\" the episode through 90 days after the trigger.", "metricType": "costScore", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-l-fusion.pdf" }, "allowedPrograms": [ "mips", "M1425" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_MR_1", "title": "Melanoma Resection", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (\"episode\"). In all supplemental documentation, \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Melanoma Resection episode-based cost measure evaluates a clinician's risk-adjusted cost to Medicare for patients who undergo an excision procedure to remove a cutaneous melanoma during the performance period. The measure score is the clinician's risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician's role in managing care during each episode from 30 days prior to the clinical event that opens, or \"triggers,\" the episode through 90 days after the trigger.", "metricType": "costScore", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-mel-rsct.pdf" }, "allowedPrograms": [ "mips", "M1421" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_NECABG_1", "title": "Non-Emergent Coronary Artery Bypass Graft (CABG)", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (\"episode\"). In all supplemental documentation, \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Non-Emergent CABG episode-based cost measure evaluates a clinician's risk-adjusted cost to Medicare for patients who undergo a CABG procedure during the performance period. The measure score is the clinician's risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician's role in managing care during each episode from 30 days prior to the clinical event that opens, or \"triggers,\" the episode through 90 days after the trigger.", "metricType": "costScore", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-ne-cabg.pdf" }, "allowedPrograms": [ "mips", "M1425" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_PC_1", "title": "Prostate Cancer episode-based cost measure", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, the term “cost” generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A, B, and D are used to construct this episode-based cost measure.\nThe Prostate Cancer episode-based cost measure evaluates a clinician’s or clinician group’s risk-adjusted and specialty-adjusted cost to Medicare for patients who receive medical care to manage and treat prostate cancer. This chronic condition measure includes the costs of services that are clinically related to the attributed clinician’s role in managing care during a Prostate Cancer episode.", "metricType": "costScore", "firstPerformanceYear": 2025, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-prost-ca.pdf" }, "allowedPrograms": [ "mips", "M0001", "M1423" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_PHA_1", "title": "Elective Primary Hip Arthroplasty", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (\"episode\"). In all supplemental documentation, \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Elective Primary Hip Arthroplasty episode-based cost measure evaluates a clinician's risk\u0002adjusted cost to Medicare for patients who receive an elective primary hip arthroplasty during the performance period. The measure score is the clinician's risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician's role in managing care during each episode from 30 days prior to the clinical event that opens, or \"triggers,\" the episode through 90 days after the trigger.", "metricType": "costScore", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-el-ha.pdf" }, "allowedPrograms": [ "mips", "G0058" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_PRC_1", "title": "Psychoses and Related Conditions", "description": "Patients who receive inpatient treatment for psychoses or related conditions during the performance period. Acute IP hospitals and inpatient psychiatric facilities (IPFs).", "metricType": "costScore", "firstPerformanceYear": 2024, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-psych.pdf" }, "allowedPrograms": [ "mips", "M1369" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_RA_1", "title": "Rheumatoid Arthritis episode-based cost measure", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, the term “cost” generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A, B, and D are used to construct this episode-based cost measure.\nThe Rheumatoid Arthritis episode-based cost measure evaluates a clinician’s or clinician group’s risk-adjusted and specialty-adjusted cost to Medicare for patients who receive medical care to manage and treat rheumatoid arthritis. This chronic condition measure includes the costs of services that are clinically related to the attributed clinician’s role in managing care during a Rheumatoid Arthritis episode", "metricType": "costScore", "firstPerformanceYear": 2025, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-rheum-arth.pdf" }, "allowedPrograms": [ "mips", "G0053" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_RIH_1", "title": "Respiratory Infection Hospitalization episode-based cost measure", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures.\nThe Respiratory Infection Hospitalization episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for patients who receive inpatient treatment for a respiratory infection during the performance period. The measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This acute inpatient medical condition measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from the clinical event that opens, or “triggers,” the episode through 30 days after the trigger.", "metricType": "costScore", "firstPerformanceYear": 2025, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-resp-infxn.pdf" }, "allowedPrograms": [ "mips", "M1368" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_RUSST_1", "title": "Renal or Ureteral Stone Surgical Treatment", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (\"episode\"). In all supplemental documentation, \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Renal or Ureteral Stone Surgical Treatment episode-based cost measure evaluates a clinician's risk-adjusted cost to Medicare for patients who receive surgical treatment for renal or ureteral stones during the performance period. The measure score is the clinician's risk\u0002adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician's role in managing care during each episode from 90 days prior to the clinical event that opens, or \"triggers,\" the episode through 30 days after the trigger.", "metricType": "costScore", "firstPerformanceYear": 2020, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-rn-stone.pdf" }, "allowedPrograms": [ "mips", "M1423" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_S_1", "title": "Sepsis", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (\"episode\"). In all supplemental documentation, \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A, B, and D are used to construct the episode-based cost measures. The Sepsis episode-based cost measure evaluates a clinician's risk-adjusted cost to Medicare for patients who receive inpatient medical treatment for sepsis during the performance period. The measure score is the clinician's risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This acute inpatient medical condition measure includes costs of services that are clinically related to the attributed clinician's role in managing care during each episode from the clinical event that opens, or \"triggers,\" the episode through 45 days after the trigger.", "metricType": "costScore", "firstPerformanceYear": 2022, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-sepsis.pdf" }, "allowedPrograms": [ "mips", "M1368" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_SSC_1", "title": "Screening/Surveillance Colonoscopy", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (\"episode\"). In all supplemental documentation, \"cost\" generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures. The Screening/Surveillance Colonoscopy episode-based cost measure evaluates a clinician's risk-adjusted cost to Medicare for patients who undergo a screening or surveillance colonoscopy procedure during the performance period. The measure score is the clinician's risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician's role in managing care during each episode from the clinical event that opens, or \"triggers,\" the episode through 14 days after the trigger.", "metricType": "costScore", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-ss-clnscpy.pdf" }, "allowedPrograms": [ "mips", "M1422" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "COST_STEMI_1", "title": "Inpatient Percutaneous Coronary Intervention (PCI) episode-based cost measure", "description": "Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, “cost” generally means the standardized Medicare allowed amount, and claims data from Medicare Parts A and B are used to construct the episode-based cost measures.\nThe Inpatient PCI episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for patients who present with a cardiac event and emergently receive PCI as treatment during the performance period. The measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This acute inpatient medical condition measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from the clinical event that opens, or “triggers,” the episode through 30 days after the trigger.", "metricType": "costScore", "firstPerformanceYear": 2019, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-ebcm-ip-pci.pdf" }, "allowedPrograms": [ "mips", "G0055" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "MSPB_1", "title": "Medicare Spending Per Beneficiary (MSPB) Clinician", "description": "The MSPB Clinician measure assesses the risk-adjusted cost to Medicare for services performed as a result of a clinician's care for a patient's inpatient hospital stay during the period 3 days prior to a hospital stay (also known as the \"index admission\" for the episode) through 30 days after discharge. The measure excludes costs from a defined list of services that are unlikely to be influenced by the clinician's care decisions and are thus considered unrelated to the index admission. In all supplemental documentation, the term \"cost\" generally means the standardized Medicare allowed amount.", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-mspb-clinician.pdf" }, "allowedPrograms": [ "mips", "G0055", "G0059", "M0004", "M1366", "M1367", "M1368", "M1369", "M1423", "M1425", "M1498", "M1499", "M1500", "M1501", "M1502", "M1503" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] }, { "category": "cost", "measureId": "TPCC_1", "title": "Total Per Capita Cost (TPCC)", "description": "The TPCC measure assesses the overall cost of care delivered to a patient with a focus on the primary care they receive from their provider(s). The measure is payment-standardized, risk-adjusted, and specialty-adjusted. In all supplemental documentation, the term \"cost\" generally means the standardized Medicare allowed amount.", "metricType": "costScore", "firstPerformanceYear": 2017, "lastPerformanceYear": null, "isInverse": true, "dataDisplayFormat": "currency", "submissionMethods": [ "administrativeClaims" ], "measureSpecification": { "default": "https://qpp.cms.gov/docs/cost_specifications/2025-12-py2026-mif-tpcc.pdf" }, "allowedPrograms": [ "mips", "G0053", "G0055", "M0001", "M0002", "M0005", "M1366", "M1368", "M1422", "M1500" ], "allowedRegistrationTypes": [ "apm", "group", "subgroup", "individual" ] } ]