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Selected Measures
Disclaimer
*MIPS eligible clinicians or groups are expected to report on applicable measures. “Applicable” is defined as measures relevant to a particular MIPS eligible clinician’s services or care rendered. MIPS eligible clinicians can refer to the measures specifications to verify which measures are applicable. Not all measures in each Specialty Measure Set will be applicable to all clinicians in a given specialty. If the set includes less than six applicable measures, the eligible clinician should only report the measures that are applicable.
Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0654
- Quality ID: 093
NQS Domain
Efficiency and Cost Reduction
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Specialty Measure Set
- Emergency Medicine
- Otolaryngology
- General Practice/Family Medicine
- Pediatrics
Primary Measure Steward
American Academy of Otolaryngology-Head and Neck Surgery
Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0653
- Quality ID: 091
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Specialty Measure Set
- Emergency Medicine
- Otolaryngology
- Pediatrics
Primary Measure Steward
American Academy of Otolaryngology-Head and Neck Surgery
Percentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported. a. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase. b. Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.
Measure Number
- eMeasure ID: CMS136v6
- eMeasure NQF: N/A
- NQF: 0108
- Quality ID: 366
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Specialty Measure Set
- Mental/Behavioral Health
- Pediatrics
Primary Measure Steward
National Committee for Quality Assurance
Percentage of individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months)
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 1879
- Quality ID: 383
NQS Domain
Patient Safety
Measure Type
Intermediate Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Mental/Behavioral Health
Primary Measure Steward
Health Services Advisory Group
Percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (stage 3, 4, or 5, not receiving Renal Replacement Therapy [RRT]) with a blood pressure < 140/90 mmHg OR >= 140/90 mmHg with a documented plan of care
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 122
NQS Domain
Effective Clinical Care
Measure Type
Intermediate Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
N/A
Primary Measure Steward
Renal Physicians Association
Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) who initiate maintenance hemodialysis during the measurement period, whose mode of vascular access is a catheter at the time maintenance hemodialysis is initiated
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 329
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
N/A
Primary Measure Steward
Renal Physicians Association
Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) receiving maintenance hemodialysis for greater than or equal to 90 days whose mode of vascular access is a catheter
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 330
NQS Domain
Patient Safety
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
N/A
Primary Measure Steward
Renal Physicians Association
Percentage of patients aged 18 years and older with a diagnosis of ESRD who withdraw from hemodialysis or peritoneal dialysis who are referred to hospice care
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 403
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
N/A
Primary Measure Steward
Renal Physicians Association
Percentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Renal Disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 325
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Mental/Behavioral Health
Primary Measure Steward
American Psychiatric Association
Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified
Measure Number
- eMeasure ID: CMS161v5
- eMeasure NQF: N/A
- NQF: 0104
- Quality ID: 107
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Specialty Measure Set
N/A
Primary Measure Steward
Physician Consortium for Performance Improvement
Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment who did not require a return to the operating room within 90 days of surgery
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 384
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Ophthalmology
Primary Measure Steward
American Academy of Ophthalmology
Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment and achieved an improvement in their visual acuity, from their preoperative level, within 90 days of surgery in the operative eye
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 385
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Ophthalmology
Primary Measure Steward
American Academy of Ophthalmology
Percentage of patients, aged 18 years and older, with a diagnosis of acute sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 331
NQS Domain
Efficiency and Cost Reduction
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Allergy/Immunology
- Internal Medicine
- Otolaryngology
- General Practice/Family Medicine
Primary Measure Steward
American Academy of Otolaryngology-Head and Neck Surgery
Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosis
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 332
NQS Domain
Efficiency and Cost Reduction
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Allergy/Immunology
- Internal Medicine
- Otolaryngology
- General Practice/Family Medicine
Primary Measure Steward
American Academy of Otolaryngology-Head and Neck Surgery
Percentage of patients aged 18 years and older, with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 333
NQS Domain
Efficiency and Cost Reduction
Measure Type
Efficiency
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Allergy/Immunology
- Internal Medicine
- Otolaryngology
- General Practice/Family Medicine
Primary Measure Steward
American Academy of Otolaryngology-Head and Neck Surgery
Percentage of patients aged 18 years and older with a diagnosis of chronic sinusitis who had more than one CT scan of the paranasal sinuses ordered or received within 90 days after the date of diagnosis
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 334
NQS Domain
Efficiency and Cost Reduction
Measure Type
Efficiency
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Allergy/Immunology
- Internal Medicine
- Otolaryngology
- General Practice/Family Medicine
Primary Measure Steward
American Academy of Otolaryngology-Head and Neck Surgery
The percentage of patients greater than 85 years of age who received a screening colonoscopy from January 1 to December 31
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 439
NQS Domain
Efficiency and Cost Reduction
Measure Type
Efficiency
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Gastroenterology
Primary Measure Steward
American Gastroenterological Association
Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) or their caregiver(s) who were counseled within 12 months on the benefits and/or risks of the Age-Related Eye Disease Study (AREDS) formulation for preventing progression of AMD
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0566
- Quality ID: 140
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- Registry
Specialty Measure Set
- Ophthalmology
Primary Measure Steward
American Academy of Ophthalmology
Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or hemorrhage AND the level of macular degeneration severity during one or more office visits within 12 months
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0087
- Quality ID: 014
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- Registry
Specialty Measure Set
- Ophthalmology
Primary Measure Steward
American Academy of Ophthalmology
The 30-day All-Cause Hospital Readmission measure is a risk-standardized readmission rate for beneficiaries age 65 or older who were hospitalized at a short-stay acute care hospital and experienced an unplanned readmission for any cause to an acute care hospital within 30 days of discharge.
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 1789
- Quality ID: 458
NQS Domain
Communication and Care Coordination
Measure Type
Outcome
High Priority Measure
No
Data Submission Method
- Administrative Claims
Specialty Measure Set
N/A
Primary Measure Steward
Yale University
Percentage of patients diagnosed with Amyotrophic Lateral Sclerosis (ALS) who were offered assistance in planning for end of life issues (e.g., advance directives, invasive ventilation, hospice) at least once annually
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 386
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Neurology
Primary Measure Steward
American Academy of Neurology
Percentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 354
NQS Domain
Patient Safety
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- General Surgery
Primary Measure Steward
American College of Surgeons
The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 404
NQS Domain
Effective Clinical Care
Measure Type
Intermediate Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Anesthesiology
Primary Measure Steward
American Society of Anesthesiologists
Percentage of patients, regardless of age, who are active injection drug users who received screening for HCV infection within the 12 month reporting period
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 387
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Specialty Measure Set
- Internal Medicine
- General Practice/Family Medicine
Primary Measure Steward
Physician Consortium for Performance Improvement
Percentage of patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported. a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks). b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months).
Measure Number
- eMeasure ID: CMS128v5
- eMeasure NQF: N/A
- NQF: 0105
- Quality ID: 009
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Specialty Measure Set
- Internal Medicine
- Mental/Behavioral Health
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
Percentage of patients in whom a retrievable IVC filter is placed who, within 3 months post-placement, have a documented assessment for the appropriateness of continued filtration, device removal or the inability to contact the patient with at least two attempts
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 421
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Specialty Measure Set
N/A
Primary Measure Steward
Society of Interventional Radiology
Percentage of final reports for abdominal imaging studies for asymptomatic patients aged 18 years and older with one or more of the following noted incidentally with follow-up imaging recommended: Liver lesion <= 0.5 cm Cystic kidney lesion < 1.0 cm Adrenal lesion <= 1.0 cm
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 405
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Specialty Measure Set
- Diagnostic Radiology
Primary Measure Steward
American College of Radiology
Percentage of final reports for computed tomography (CT), CT angiography (CTA) or magnetic resonance imaging (MRI) or magnetic resonance angiogram (MRA) studies of the chest or neck or ultrasound of the neck for patients aged 18 years and older with no known thyroid disease with a thyroid nodule < 1.0 cm noted incidentally with follow-up imaging recommended
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 406
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Specialty Measure Set
- Diagnostic Radiology
Primary Measure Steward
American College of Radiology
Percentage of patients aged 50 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0658
- Quality ID: 320
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Specialty Measure Set
- Gastroenterology
Primary Measure Steward
American Gastroenterological Association
Percentage of children 3-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode
Measure Number
- eMeasure ID: CMS146v5
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 066
NQS Domain
Efficiency and Cost Reduction
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- EHR
- Registry
Specialty Measure Set
- Emergency Medicine
- General Practice/Family Medicine
- Pediatrics
Primary Measure Steward
National Committee for Quality Assurance
Percentage of children 3 months-18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode
Measure Number
- eMeasure ID: CMS154v5
- eMeasure NQF: N/A
- NQF: 0069
- Quality ID: 065
NQS Domain
Efficiency and Cost Reduction
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- EHR
- Registry
Specialty Measure Set
- General Practice/Family Medicine
- Pediatrics
Primary Measure Steward
National Committee for Quality Assurance
Percentage of patients with sepsis due to MSSA bacteremia who received beta-lactam antibiotic (e.g. nafcillin, oxacillin or cefazolin) as definitive therapy
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 407
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Specialty Measure Set
- Hospitalists
Primary Measure Steward
Infectious Diseases Society of America
Percentage of women, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy before undergoing an endometrial ablation
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0567
- Quality ID: 448
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Obstetrics/Gynecology
Primary Measure Steward
Centers for Medicare & Medicaid Services
Percentage of patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation (AF) or atrial flutter whose assessment of the specified thromboembolic risk factors indicate one or more high-risk factors or more than one moderate risk factor, as determined by CHADS2 risk stratification, who are prescribed warfarin OR another oral anticoagulant drug that is FDA approved for the prevention of thromboembolism
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 1525
- Quality ID: 326
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- Registry
Specialty Measure Set
- Internal Medicine
- Cardiology
- General Practice/Family Medicine
Primary Measure Steward
American College of Cardiology
The percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0058
- Quality ID: 116
NQS Domain
Efficiency and Cost Reduction
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Internal Medicine
- Emergency Medicine
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
Percentage of esophageal biopsy reports that document the presence of Barrett's mucosa that also include a statement about dysplasia
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 1854
- Quality ID: 249
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- Registry
Specialty Measure Set
- Pathology
Primary Measure Steward
College of American Pathologists
Basal Cell Carcinoma (BCC)/Squamous Cell Carcinoma: Biopsy Reporting Time - Pathologist to Clinician
Percentage of biopsies with a diagnosis of cutaneous Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC) (including in situ disease) in which the pathologist communicates results to the clinician within 7 days of biopsy date
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 440
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
N/A
Primary Measure Steward
American Academy of Dermatology
Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient by the performing physician
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 265
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Dermatology
- Interventional Radiology
- Obstetrics/Gynecology
- Urology
Primary Measure Steward
American Academy of Dermatology
Percentage of patients with depression or bipolar disorder with evidence of an initial assessment that includes an appraisal for alcohol or chemical substance use
Measure Number
- eMeasure ID: CMS169v5
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 367
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Specialty Measure Set
N/A
Primary Measure Steward
Center for Quality Assessment and Improvement in Mental Health
Percentage of breast cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes), and the histologic grade
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0391
- Quality ID: 099
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- Registry
Specialty Measure Set
- Pathology
Primary Measure Steward
College of American Pathologists
Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer.
Measure Number
- eMeasure ID: CMS125v5
- eMeasure NQF: N/A
- NQF: 2372
- Quality ID: 112
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- CMS Web Interface
- EHR
- Registry
Specialty Measure Set
- Internal Medicine
- Obstetrics/Gynecology
- Preventive Medicine
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
Getting timely care, appointments, and information; How well providers Communicate; Patient's Rating of Provider; Access to Specialists; Health Promotion & Education; Shared Decision Making; Health Status/Functional Status; Courteous and Helpful Office Staff; Care Coordination; Between Visit Communication; Helping Your to Take Medication as Directed; and Stewardship of Patient Resources
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0006 & 0005
- Quality ID: 321
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Patient Engagement/Experience
High Priority Measure
Yes
Data Submission Method
- CSV
Specialty Measure Set
- General Practice/Family Medicine
Primary Measure Steward
Agency for Healthcare Research & Quality
Percentage of patients evaluated in an outpatient setting who within the previous 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the qualifying event/diagnosis who were referred to a CR program
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0643
- Quality ID: 243
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
N/A
Primary Measure Steward
American College of Cardiology Foundation
Percentage of stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), or cardiac magnetic resonance (CMR) performed in low risk surgery patients 18 years or older for preoperative evaluation during the 12-month reporting period
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 322
NQS Domain
Efficiency and Cost Reduction
Measure Type
Efficiency
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Cardiology
Primary Measure Steward
American College of Cardiology
Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in patients aged 18 years and older routinely after percutaneous coronary intervention (PCI), with reference to timing of test after PCI and symptom status
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 323
NQS Domain
Efficiency and Cost Reduction
Measure Type
Efficiency
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Cardiology
Primary Measure Steward
American College of Cardiology
Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in asymptomatic, low coronary heart disease (CHD) risk patients 18 years and older for initial detection and risk assessment
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 324
NQS Domain
Efficiency and Cost Reduction
Measure Type
Efficiency
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Cardiology
Primary Measure Steward
American College of Cardiology
Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0326
- Quality ID: 047
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Specialty Measure Set
- Internal Medicine
- Cardiology
- Emergency Medicine
- Gastroenterology
- General Surgery
- General Oncology
- Hospitalists
- Neurology
- Obstetrics/Gynecology
- Ophthalmology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Preventive Medicine
- Rheumatology
- Thoracic Surgery
- Urology
- Vascular Surgery
- Mental/Behavioral Health
- Plastic Surgery
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following the cataract surgery
Measure Number
- eMeasure ID: CMS133v5
- eMeasure NQF: N/A
- NQF: 0565
- Quality ID: 191
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- EHR
- Registry
Specialty Measure Set
- Ophthalmology
Primary Measure Steward
Physician Consortium for Performance Improvement
Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and had any of a specified list of surgical procedures in the 30 days following cataract surgery which would indicate the occurrence of any of the following major complications: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence
Measure Number
- eMeasure ID: CMS132v5
- eMeasure NQF: N/A
- NQF: 0564
- Quality ID: 192
NQS Domain
Patient Safety
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- EHR
- Registry
Specialty Measure Set
- Ophthalmology
Primary Measure Steward
Physician Consortium for Performance Improvement
Percentage of patients aged 18 years and older who had cataract surgery and had improvement in visual function achieved within 90 days following the cataract surgery, based on completing a pre-operative and post-operative visual function survey
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 1536
- Quality ID: 303
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Ophthalmology
Primary Measure Steward
American Academy of Ophthalmology
Percentage of patients aged 18 years and older who had cataract surgery and were satisfied with their care within 90 days following the cataract surgery, based on completion of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 304
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Ophthalmology
Primary Measure Steward
American Academy of Ophthalmology
Percentage of patients aged 18 years and older who had cataract surgery performed and who achieved a final refraction within +/- 1.0 diopters of their planned (target) refraction
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 389
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Ophthalmology
Primary Measure Steward
American Academy of Ophthalmology
Percentage of patients aged 18 years and older who had cataract surgery performed and had an unplanned rupture of the posterior capsule requiring vitrectomy
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 388
NQS Domain
Patient Safety
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Ophthalmology
Primary Measure Steward
American Academy of Ophthalmology
Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria: * Women age 21-64 who had cervical cytology performed every 3 years * Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years
Measure Number
- eMeasure ID: CMS124v5
- eMeasure NQF: N/A
- NQF: 0032
- Quality ID: 309
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Specialty Measure Set
- Obstetrics/Gynecology
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk
Measure Number
- eMeasure ID: CMS177v5
- eMeasure NQF: N/A
- NQF: 1365
- Quality ID: 382
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- EHR
Specialty Measure Set
- Mental/Behavioral Health
- Pediatrics
Primary Measure Steward
Physician Consortium for Performance Improvement
Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday
Measure Number
- eMeasure ID: CMS117v5
- eMeasure NQF: N/A
- NQF: 0038
- Quality ID: 240
NQS Domain
Community/Population Health
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Specialty Measure Set
- Pediatrics
Primary Measure Steward
National Committee for Quality Assurance
Percentage of children, age 0-20 years, who have had tooth decay or cavities during the measurement period
Measure Number
- eMeasure ID: CMS75v5
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 378
NQS Domain
Community/Population Health
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- EHR
Specialty Measure Set
N/A
Primary Measure Steward
Centers for Medicare & Medicaid Services
The percentage of female adolescents 16 years of age who had a chlamydia screening test with proper follow-up during the measurement period
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 447
NQS Domain
Community/Population Health
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Specialty Measure Set
- Obstetrics/Gynecology
Primary Measure Steward
National Committee for Quality Assurance
Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period
Measure Number
- eMeasure ID: CMS153v5
- eMeasure NQF: N/A
- NQF: 0033
- Quality ID: 310
NQS Domain
Community/Population Health
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Specialty Measure Set
- Obstetrics/Gynecology
- Pediatrics
Primary Measure Steward
National Committee for Quality Assurance
Percentage of patients aged 18 years and older with a diagnosis of COPD (FEV1/FVC < 70%) and who have an FEV1 less than 60% predicted and have symptoms who were prescribed an long-acting inhaled bronchodilator
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0102
- Quality ID: 052
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- Registry
Specialty Measure Set
N/A
Primary Measure Steward
American Thoracic Society
Percentage of patients aged 18 years and older with a diagnosis of COPD who had spirometry results documented
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0091
- Quality ID: 051
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- Registry
Specialty Measure Set
N/A
Primary Measure Steward
American Thoracic Society
Percentage of patients with a mRs score of 0 to 2 at 90 days following endovascular stroke intervention
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 409
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
N/A
Primary Measure Steward
Society of Interventional Radiology
Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred
Measure Number
- eMeasure ID: CMS50v5
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 374
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- EHR
Specialty Measure Set
- Allergy/Immunology
- Cardiology
- Dermatology
- Emergency Medicine
- Gastroenterology
- General Surgery
- General Oncology
- Hospitalists
- Neurology
- Obstetrics/Gynecology
- Ophthalmology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Preventive Medicine
- Rheumatology
- Thoracic Surgery
- Urology
- Vascular Surgery
- Mental/Behavioral Health
- Plastic Surgery
Primary Measure Steward
Centers for Medicare & Medicaid Services
Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior adenomatous polyp(s) in previous colonoscopy findings, which had an interval of 3 or more years since their last colonoscopy
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0659
- Quality ID: 185
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Specialty Measure Set
- Gastroenterology
Primary Measure Steward
American Gastroenterological Association
Percentage of colon and rectum cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes) and the histologic grade
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0392
- Quality ID: 100
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- Registry
Specialty Measure Set
- Pathology
Primary Measure Steward
College of American Pathologists
Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer.
Measure Number
- eMeasure ID: CMS130v5
- eMeasure NQF: N/A
- NQF: 0034
- Quality ID: 113
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- CMS Web Interface
- EHR
- Registry
Specialty Measure Set
- Internal Medicine
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
Percentage of patients aged 50 years and older treated for a fracture with documentation of communication, between the physician treating the fracture and the physician or other clinician managing the patient's on-going care, that a fracture occurred and that the patient was or should be considered for osteoporosis treatment or testing. This measure is reported by the physician who treats the fracture and who therefore is held accountable for the communication
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0045
- Quality ID: 024
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Specialty Measure Set
- Preventive Medicine
Primary Measure Steward
National Committee for Quality Assurance
Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period
Measure Number
- eMeasure ID: CMS165v5
- eMeasure NQF: N/A
- NQF: 0018
- Quality ID: 236
NQS Domain
Effective Clinical Care
Measure Type
Intermediate Outcome
High Priority Measure
Yes
Data Submission Method
- Claims
- CMS Web Interface
- EHR
- Registry
Specialty Measure Set
- Internal Medicine
- Cardiology
- Obstetrics/Gynecology
- Preventive Medicine
- Thoracic Surgery
- Vascular Surgery
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who, within 30 days postoperatively, develop deep sternal wound infection involving muscle, bone, and/or mediastinum requiring operative intervention
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0130
- Quality ID: 165
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Thoracic Surgery
Primary Measure Steward
Society of Thoracic Surgeons
Percentage of patients aged 18 years and older undergoing isolated CABG surgery (without pre-existing renal failure) who develop postoperative renal failure or require dialysis
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0114
- Quality ID: 167
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Thoracic Surgery
Primary Measure Steward
Society of Thoracic Surgeons
Percentage of isolated Coronary Artery Bypass Graft (CABG) surgeries for patients aged 18 years and older who received a beta-blocker within 24 hours prior to surgical incision
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0236
- Quality ID: 044
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Specialty Measure Set
- Anesthesiology
Primary Measure Steward
Centers for Medicare & Medicaid Services
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation > 24 hours
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0129
- Quality ID: 164
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Thoracic Surgery
Primary Measure Steward
Society of Thoracic Surgeons
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who have a postoperative stroke (i.e., any confirmed neurological deficit of abrupt onset caused by a disturbance in blood supply to the brain) that did not resolve within 24 hours
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0131
- Quality ID: 166
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Thoracic Surgery
Primary Measure Steward
Society of Thoracic Surgeons
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require a return to the operating room (OR) during the current hospitalization for mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction, or other cardiac reason
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0115
- Quality ID: 168
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Thoracic Surgery
Primary Measure Steward
Society of Thoracic Surgeons
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who received an IMA graft
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0134
- Quality ID: 043
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Specialty Measure Set
N/A
Primary Measure Steward
Society of Thoracic Surgeons
Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0066
- Quality ID: 118
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Specialty Measure Set
- Cardiology
Primary Measure Steward
American Heart Association
Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12 month period who were prescribed aspirin or clopidogrel
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0067
- Quality ID: 006
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Specialty Measure Set
- Cardiology
Primary Measure Steward
American Heart Association
Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have a prior MI or a current or prior LVEF <40% who were prescribed beta-blocker therapy
Measure Number
- eMeasure ID: CMS145v5
- eMeasure NQF: N/A
- NQF: 0070
- Quality ID: 007
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
- Registry
Specialty Measure Set
- Cardiology
- General Practice/Family Medicine
Primary Measure Steward
Physician Consortium for Performance Improvement
Percentage of patients, regardless of age, with a diagnosis of dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND referred to additional resources for support within a 12 month period
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 288
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Neurology
- Mental/Behavioral Health
Primary Measure Steward
American Academy of Neurology
Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12 month period
Measure Number
- eMeasure ID: CMS149v5
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 281
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Specialty Measure Set
- Neurology
- Mental/Behavioral Health
Primary Measure Steward
Physician Consortium for Performance Improvement
Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled or referred for counseling regarding safety concerns within a 12 month period
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 286
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Neurology
- Mental/Behavioral Health
Primary Measure Steward
American Academy of Neurology
Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of functional status is performed and the results reviewed at least once within a 12 month period
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 282
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Specialty Measure Set
- Neurology
- Mental/Behavioral Health
Primary Measure Steward
American Academy of Neurology
Percentage of patients, regardless of age, with a diagnosis of dementia who have one or more neuropsychiatric symptoms who received or were recommended to receive an intervention for neuropsychiatric symptoms within a 12 month period
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 284
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Specialty Measure Set
- Neurology
- Mental/Behavioral Health
Primary Measure Steward
American Academy of Neurology
Percentage of patients, regardless of age, with a diagnosis of dementia and for whom an assessment of neuropsychiatric symptoms is performed and results reviewed at least once in a 12 month period
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 283
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Specialty Measure Set
- Neurology
- Mental/Behavioral Health
Primary Measure Steward
American Academy of Neurology
Adult patients age 18 years and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at six months defined as a PHQ-9 score less than 5. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment. This measure additionally promotes ongoing contact between the patient and provider as patients who do not have a follow-up PHQ-9 score at six months (+/- 30 days) are also included in the denominator
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0711
- Quality ID: 411
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Mental/Behavioral Health
Primary Measure Steward
Minnesota Community Measurement
Patients age 18 and older with major depression or dysthymia and an initial Patient Health Questionnaire (PHQ-9) score greater than nine who demonstrate remission at twelve months (+/- 30 days after an index visit) defined as a PHQ-9 score less than five. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment.
Measure Number
- eMeasure ID: CMS159v5
- eMeasure NQF: N/A
- NQF: 0710
- Quality ID: 370
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- CMS Web Interface
- EHR
- Registry
Specialty Measure Set
- Mental/Behavioral Health
- General Practice/Family Medicine
Primary Measure Steward
Minnesota Community Measurement
Patients age 18 and older with the diagnosis of major depression or dysthymia who have a Patient Health Questionnaire (PHQ-9) tool administered at least once during a 4-month period in which there was a qualifying visit
Measure Number
- eMeasure ID: CMS160v5
- eMeasure NQF: N/A
- NQF: 0712
- Quality ID: 371
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Specialty Measure Set
- Mental/Behavioral Health
Primary Measure Steward
Minnesota Community Measurement
Percentage of patients 18-75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal exam (no evidence of retinopathy) in the 12 months prior to the measurement period
Measure Number
- eMeasure ID: CMS131v5
- eMeasure NQF: N/A
- NQF: 0055
- Quality ID: 117
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- CMS Web Interface
- EHR
- Registry
Specialty Measure Set
- Internal Medicine
- Ophthalmology
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a foot exam (visual inspection and sensory exam with mono filament and a pulse exam) during the measurement year
Measure Number
- eMeasure ID: CMS123v5
- eMeasure NQF: N/A
- NQF: 0056
- Quality ID: 163
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Specialty Measure Set
- Internal Medicine
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period
Measure Number
- eMeasure ID: CMS122v5
- eMeasure NQF: N/A
- NQF: 0059
- Quality ID: 001
NQS Domain
Effective Clinical Care
Measure Type
Intermediate Outcome
High Priority Measure
Yes
Data Submission Method
- Claims
- CMS Web Interface
- EHR
- Registry
Specialty Measure Set
- Internal Medicine
- Preventive Medicine
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period.
Measure Number
- eMeasure ID: CMS134v5
- eMeasure NQF: N/A
- NQF: 0062
- Quality ID: 119
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
- Registry
Specialty Measure Set
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 months
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0417
- Quality ID: 126
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Specialty Measure Set
N/A
Primary Measure Steward
American Podiatric Medical Association
Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0416
- Quality ID: 127
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Specialty Measure Set
N/A
Primary Measure Steward
American Podiatric Medical Association
Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months
Measure Number
- eMeasure ID: CMS142v5
- eMeasure NQF: N/A
- NQF: 0089
- Quality ID: 019
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- EHR
- Registry
Specialty Measure Set
- Ophthalmology
Primary Measure Steward
Physician Consortium for Performance Improvement
Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy and the presence or absence of macular edema during one or more office visits within 12 months
Measure Number
- eMeasure ID: CMS167v5
- eMeasure NQF: N/A
- NQF: 0088
- Quality ID: 018
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Specialty Measure Set
- Ophthalmology
Primary Measure Steward
Physician Consortium for Performance Improvement
Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration.
Measure Number
- eMeasure ID: CMS68v6
- eMeasure NQF: N/A
- NQF: 0419
- Quality ID: 130
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- EHR
- Registry
Specialty Measure Set
- Allergy/Immunology
- Internal Medicine
- Anesthesiology
- Cardiology
- Dermatology
- Emergency Medicine
- Gastroenterology
- General Surgery
- General Oncology
- Hospitalists
- Neurology
- Obstetrics/Gynecology
- Ophthalmology
- Orthopedic Surgery
- Otolaryngology
- Physical Medicine
- Preventive Medicine
- Rheumatology
- Thoracic Surgery
- Urology
- Vascular Surgery
- Mental/Behavioral Health
- Plastic Surgery
- General Practice/Family Medicine
Primary Measure Steward
Centers for Medicare & Medicaid Services
All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record.
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 412
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Specialty Measure Set
- Internal Medicine
- Neurology
- Physical Medicine
- General Practice/Family Medicine
Primary Measure Steward
American Academy of Neurology
Percentage of patients undergoing endovascular stroke treatment who have a door to puncture time of less than two hours
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 413
NQS Domain
Effective Clinical Care
Measure Type
Intermediate Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
N/A
Primary Measure Steward
Society of Interventional Radiology
Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening tool on the date of encounter AND a documented follow-up plan on the date of the positive screen
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 181
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Specialty Measure Set
- Internal Medicine
- Mental/Behavioral Health
- General Practice/Family Medicine
Primary Measure Steward
Centers for Medicare & Medicaid Services
Percentage of emergency department visits for patients aged 18 years and older who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 415
NQS Domain
Efficiency and Cost Reduction
Measure Type
Efficiency
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Specialty Measure Set
- Emergency Medicine
Primary Measure Steward
American College of Emergency Physicians
Percentage of emergency department visits for patients aged 2 through 17 years who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the Pediatric Emergency Care Applied Research Network (PECARN) prediction rules for traumatic brain injury
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 416
NQS Domain
Efficiency and Cost Reduction
Measure Type
Efficiency
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Specialty Measure Set
- Emergency Medicine
Primary Measure Steward
American College of Emergency Physicians
All female patients of childbearing potential (12 - 44 years old) diagnosed with epilepsy who were counseled or referred for counseling for how epilepsy and its treatment may affect contraception OR pregnancy at least once a year
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 1814
- Quality ID: 268
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- Registry
Specialty Measure Set
- Neurology
Primary Measure Steward
American Academy of Neurology
All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical record
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 414
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Specialty Measure Set
- Internal Medicine
- Neurology
- Physical Medicine
- General Practice/Family Medicine
Primary Measure Steward
American Academy of Neurology
Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0101
- Quality ID: 155
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Specialty Measure Set
- Internal Medicine
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0101
- Quality ID: 154
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Specialty Measure Set
- Internal Medicine
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period.
Measure Number
- eMeasure ID: CMS139v5
- eMeasure NQF: N/A
- NQF: 0101
- Quality ID: 318
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- CMS Web Interface
- EHR
Specialty Measure Set
N/A
Primary Measure Steward
National Committee for Quality Assurance
The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported: The percentage of discharges for which the patient received follow-up within 30 days of discharge. The percentage of discharges for which the patient received follow-up within 7 days of discharge
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0576
- Quality ID: 391
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Mental/Behavioral Health
- Pediatrics
Primary Measure Steward
National Committee for Quality Assurance
Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 2624
- Quality ID: 182
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Specialty Measure Set
- Physical Medicine
Primary Measure Steward
Centers for Medicare & Medicaid Services
Percentage of patients 18 years of age and older with primary total hip arthroplasty (THA) who completed baseline and follow-up patient-reported functional status assessments
Measure Number
- eMeasure ID: CMS56v5
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 376
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- EHR
Specialty Measure Set
- Orthopedic Surgery
Primary Measure Steward
Centers for Medicare & Medicaid Services
Percentage of patients 18 years of age and older with primary total knee arthroplasty (TKA) who completed baseline and follow-up patient-reported functional status assessments
Measure Number
- eMeasure ID: CMS66v5
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 375
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- EHR
Specialty Measure Set
- Orthopedic Surgery
Primary Measure Steward
Centers for Medicare & Medicaid Services
Percentage of patients 65 years of age and older with congestive heart failure who completed initial and follow-up patient-reported functional status assessments
Measure Number
- eMeasure ID: CMS90v6
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 377
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- EHR
Specialty Measure Set
N/A
Primary Measure Steward
Centers for Medicare & Medicaid Services
A self-report outcome measure of functional status (FS) for patients 14 years+ with elbow, wrist or hand impairments. The change in FS assessed using FOTO (elbow, wrist and hand) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0427
- Quality ID: 222
NQS Domain
Communication and Care Coordination
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
N/A
Primary Measure Steward
Focus on Therapeutic Outcomes, Inc.
A self-report measure of change in functional status (FS) for patients 14 years+ with foot and ankle impairments. The change in functional status (FS) assessed using FOTO's (foot and ankle) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0424
- Quality ID: 219
NQS Domain
Communication and Care Coordination
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
N/A
Primary Measure Steward
Focus on Therapeutic Outcomes, Inc.
A self-report outcome measure of functional status (FS) for patients 14 years+ with general orthopaedic impairments (neck, cranium, mandible, thoracic spine, ribs or other general orthopaedic impairment). The change in FS assessed using FOTO (general orthopaedic) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level by to assess quality
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0428
- Quality ID: 223
NQS Domain
Communication and Care Coordination
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
N/A
Primary Measure Steward
Focus on Therapeutic Outcomes, Inc.
A self-report measure of change in functional status (FS) for patients 14 years+ with hip impairments. The change in functional status (FS) assessed using FOTO's (hip) PROM (patient- reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0423
- Quality ID: 218
NQS Domain
Communication and Care Coordination
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
N/A
Primary Measure Steward
Focus on Therapeutic Outcomes, Inc.
A self-report measure of change in functional status for patients 14 year+ with knee impairments. The change in functional status (FS) assessed using FOTO's (knee ) PROM (patient-reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0422
- Quality ID: 217
NQS Domain
Communication and Care Coordination
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
N/A
Primary Measure Steward
Focus on Therapeutic Outcomes, Inc.
A self-report outcome measure of change in functional status for patients 14 years+ with lumbar impairments. The change in functional status (FS) assessed using FOTO (lumbar) PROM (patient reported outcome measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level by to assess quality
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0425
- Quality ID: 220
NQS Domain
Communication and Care Coordination
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
N/A
Primary Measure Steward
Focus on Therapeutic Outcomes, Inc.
A self-report outcome measure of change in functional status (FS) for patients 14 years+ with shoulder impairments. The change in functional status (FS) assessed using FOTO's (shoulder) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0426
- Quality ID: 221
NQS Domain
Communication and Care Coordination
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
N/A
Primary Measure Steward
Focus on Therapeutic Outcomes, Inc.
Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge
Measure Number
- eMeasure ID: CMS135v5
- eMeasure NQF: 2907
- NQF: 0081
- Quality ID: 005
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
- Registry
Specialty Measure Set
- Internal Medicine
- Cardiology
- Hospitalists
- General Practice/Family Medicine
Primary Measure Steward
Physician Consortium for Performance Improvement
Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge
Measure Number
- eMeasure ID: CMS144v5
- eMeasure NQF: 2908
- NQF: 0083
- Quality ID: 008
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
- Registry
Specialty Measure Set
- Cardiology
- Hospitalists
- General Practice/Family Medicine
Primary Measure Steward
Physician Consortium for Performance Improvement
Percentage of patients aged 18 years and older, seen within a 12 month reporting period, with a diagnosis of chronic lymphocytic leukemia (CLL) made at any time during or prior to the reporting period who had baseline flow cytometry studies performed and documented in the chart
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0379
- Quality ID: 070
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Specialty Measure Set
N/A
Primary Measure Steward
Physician Consortium for Performance Improvement
Percentage of patients aged 18 years and older with a diagnosis of multiple myeloma, not in remission, who were prescribed or received intravenous bisphosphonate therapy within the 12 month reporting period
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0380
- Quality ID: 069
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Specialty Measure Set
N/A
Primary Measure Steward
American Society of Hematology
Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) or an acute leukemia who had baseline cytogenetic testing performed on bone marrow
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0377
- Quality ID: 067
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Specialty Measure Set
N/A
Primary Measure Steward
American Society of Hematology
Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) who are receiving erythropoietin therapy with documentation of iron stores within 60 days prior to initiating erythropoietin therapy
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0378
- Quality ID: 068
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Specialty Measure Set
N/A
Primary Measure Steward
American Society of Hematology
Percentage of patients aged 18 years and older with a diagnosis of hepatitis C with whom a physician or other qualified healthcare professional reviewed the range of treatment options appropriate to their genotype and demonstrated a shared decision making approach with the patient. To meet the measure, there must be documentation in the patient record of a discussion between the physician or other qualified healthcare professional and the patient that includes all of the following: treatment choices appropriate to genotype, risks and benefits, evidence of effectiveness, and patient preferences toward treatment
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 390
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Gastroenterology
Primary Measure Steward
American Gastroenterological Association
Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12 month reporting period
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 401
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Specialty Measure Set
- Internal Medicine
- Gastroenterology
- General Practice/Family Medicine
Primary Measure Steward
American Gastroenterological Association
Proportion of female patients (aged 18 years and older) with breast cancer who are human epidermal growth factor receptor 2 (HER2)/neu negative who are not administered HER2-targeted therapies
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 1857
- Quality ID: 449
NQS Domain
Efficiency and Cost Reduction
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- General Oncology
Primary Measure Steward
American Society of Clinical Oncology
Percentage of patients aged 6 weeks and older with a diagnosis of HIV/AIDS who were prescribed Pneumocystis jiroveci pneumonia (PCP) prophylaxis
Measure Number
- eMeasure ID: CMS52v5
- eMeasure NQF: N/A
- NQF: 0405
- Quality ID: 160
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Specialty Measure Set
- Allergy/Immunology
- Pediatrics
Primary Measure Steward
National Committee for Quality Assurance
Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia, gonorrhea, and syphilis screenings were performed at least once since the diagnosis of HIV infection
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0409
- Quality ID: 205
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Specialty Measure Set
- Pediatrics
Primary Measure Steward
National Committee for Quality Assurance
Percentage of patients, regardless of age with a diagnosis of HIV who had at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical visits
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 2079
- Quality ID: 340
NQS Domain
Efficiency and Cost Reduction
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
N/A
Primary Measure Steward
Health Resources and Services Administration
The percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 2082
- Quality ID: 338
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- General Practice/Family Medicine
Primary Measure Steward
Health Resources and Services Administration
Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation This measure is reported as four rates stratified by age and gender: Reporting Age Criteria 1: Females 18-64years of age Reporting Age Criteria 2: Males 18-64 years of age Reporting Age Criteria 3: Females 65 years of age and older Reporting Age Criteria 4: Males 65 years of age and older
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 2474
- Quality ID: 392
NQS Domain
Patient Safety
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Electrophysiology Cardiac Specialist
Primary Measure Steward
The Heart Rhythm Society
Patients with physician-specific risk-standardized rates of procedural complications following the first time implantation of an ICD
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 348
NQS Domain
Patient Safety
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Electrophysiology Cardiac Specialist
Primary Measure Steward
The Heart Rhythm Society
Infection rate following CIED device implantation, replacement, or revision
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 393
NQS Domain
Patient Safety
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Electrophysiology Cardiac Specialist
Primary Measure Steward
The Heart Rhythm Society
Percentage of patients aged 18-85 years of age with a diagnosis of hypertension whose blood pressure improved during the measurement period.
Measure Number
- eMeasure ID: CMS65v6
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 373
NQS Domain
Effective Clinical Care
Measure Type
Intermediate Outcome
High Priority Measure
Yes
Data Submission Method
- EHR
Specialty Measure Set
N/A
Primary Measure Steward
Centers for Medicare & Medicaid Services
Image confirmation of lesion(s) targeted for image guided excisional biopsy or image guided partial mastectomy in patients with nonpalpable, image-detected breast lesion(s). Lesions may include: microcalcifications, mammographic or sonographic mass or architectural distortion, focal suspicious abnormalities on magnetic resonance imaging (MRI) or other breast imaging amenable to localization such as positron emission tomography (PET) mammography, or a biopsy marker demarcating site of confirmed pathology as established by previous core biopsy
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 262
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
N/A
Primary Measure Steward
American Society of Breast Surgeons
The percentage of adolescents 13 years of age who had the recommended immunizations by their 13th birthday
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 1407
- Quality ID: 394
NQS Domain
Community/Population Health
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Specialty Measure Set
- General Practice/Family Medicine
- Pediatrics
Primary Measure Steward
National Committee for Quality Assurance
Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status assessed and results interpreted within one year prior to receiving a first course of anti-TNF (tumor necrosis factor) therapy
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 275
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Specialty Measure Set
- Gastroenterology
Primary Measure Steward
American Gastroenterological Association
Percentage of patients aged 18 years and older with an inflammatory bowel disease encounter who were prescribed prednisone equivalents greater than or equal to 10 mg/day for 60 or greater consecutive days or a single prescription equating to 600 mg prednisone or greater for all fills and were documented for risk of bone loss once during the reporting year or the previous calendar year
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 271
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Specialty Measure Set
- Gastroenterology
Primary Measure Steward
American Gastroenterological Association
Percentage of patients 13 years of age and older with a new episode of alcohol and other drug (AOD) dependence who received the following. Two rates are reported. a. Percentage of patients who initiated treatment within 14 days of the diagnosis. b. Percentage of patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit.
Measure Number
- eMeasure ID: CMS137v5
- eMeasure NQF: N/A
- NQF: 0004
- Quality ID: 305
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Specialty Measure Set
N/A
Primary Measure Steward
National Committee for Quality Assurance
The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization's total IVD denominator. All-or-None Outcome Measure (Optimal Control) - Using the IVD denominator optimal results include: Most recent blood pressure (BP) measurement is less than 140/90 mm Hg -- And Most recent tobacco status is Tobacco Free -- And Daily Aspirin or Other Antiplatelet Unless Contraindicated -- And Statin Use
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 441
NQS Domain
Effective Clinical Care
Measure Type
Intermediate Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
N/A
Primary Measure Steward
Wisconsin Collaborative for Healthcare Quality
Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antiplatelet during the measurement period.
Measure Number
- eMeasure ID: CMS164v5
- eMeasure NQF: N/A
- NQF: 0068
- Quality ID: 204
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Claims
- CMS Web Interface
- EHR
- Registry
Specialty Measure Set
- Internal Medicine
- Cardiology
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy for whom KRAS gene mutation testing was performed
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 1859
- Quality ID: 451
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Specialty Measure Set
- General Oncology
Primary Measure Steward
American Society of Clinical Oncology
Pathology reports based on biopsy and/or cytology specimens with a diagnosis of primary non-small cell lung cancer classified into specific histologic type or classified as NSCLC-NOS with an explanation included in the pathology report
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 395
NQS Domain
Communication and Care Coordination
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Specialty Measure Set
- Pathology
Primary Measure Steward
College of American Pathologists
Pathology reports based on resection specimens with a diagnosis of primary lung carcinoma that include the pT category, pN category and for non-small cell lung cancer, histologic type
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 396
NQS Domain
Communication and Care Coordination
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Specialty Measure Set
- Pathology
Primary Measure Steward
College of American Pathologists
The percentage of children who turned 6 months of age during the measurement year, who had a face-to-face visit between the clinician and the child during child's first 6 months, and who had a maternal depression screening for the mother at least once between 0 and 6 months of life.
Measure Number
- eMeasure ID: CMS82v4
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 372
NQS Domain
Community/Population Health
Measure Type
Process
High Priority Measure
No
Data Submission Method
- EHR
Specialty Measure Set
N/A
Primary Measure Steward
National Committee for Quality Assurance
Percentage of patients, regardless of age, who gave birth during a 12-month period who delivered a live singleton at >= 37 and < 39 weeks of gestation completed who had elective deliveries or early inductions without medical indication
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 335
NQS Domain
Patient Safety
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
N/A
Primary Measure Steward
Centers for Medicare & Medicaid Services
Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for post-partum care within 8 weeks of giving birth who received a breast feeding evaluation and education, post-partum depression screening, post-partum glucose screening for gestational diabetes patients, and family and contraceptive planning
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 336
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
N/A
Primary Measure Steward
Centers for Medicare & Medicaid Services
The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment period
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 1799
- Quality ID: 444
NQS Domain
Efficiency and Cost Reduction
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Allergy/Immunology
- General Practice/Family Medicine
- Pediatrics
Primary Measure Steward
National Committee for Quality Assurance
The percentage of discharges from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years and older of age seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record. This measure is reported as three rates stratified by age group: Reporting Criteria 1: 18-64 years of age Reporting Criteria 2: 65 years and older Total Rate: All patients 18 years of age and older
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0097
- Quality ID: 046
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- CMS Web Interface
- Registry
Specialty Measure Set
N/A
Primary Measure Steward
National Committee for Quality Assurance
Percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered, at least once within a 12 month period, into a recall system that includes: A target date for the next complete physical skin exam, AND A process to follow up with patients who either did not make an appointment within the specified timeframe or who missed a scheduled appointment
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0650
- Quality ID: 137
NQS Domain
Communication and Care Coordination
Measure Type
Structure
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Dermatology
Primary Measure Steward
American Academy of Dermatology
Percentage of patient visits, regardless of age, with a new occurrence of melanoma who have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 138
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Dermatology
Primary Measure Steward
American Academy of Dermatology
Percentage of patients, regardless of age, with a current diagnosis of Stage 0 through IIC melanoma or a history of melanoma of any stage, without signs or symptoms suggesting systemic spread, seen for an office visit during the one-year measurement period, for whom no diagnostic imaging studies were ordered
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0562
- Quality ID: 224
NQS Domain
Efficiency and Cost Reduction
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Dermatology
Primary Measure Steward
American Academy of Dermatology
Pathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness and ulceration and for pT1, mitotic rate
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 397
NQS Domain
Communication and Care Coordination
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Specialty Measure Set
- Pathology
Primary Measure Steward
College of American Pathologists
The percentage of adolescent females 16-20 years of age who were screened unnecessarily for cervical cancer
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 443
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Obstetrics/Gynecology
- General Practice/Family Medicine
Primary Measure Steward
National Committee for Quality Assurance
Percentage of final reports for all patients, regardless of age, undergoing bone scintigraphy that include physician documentation of correlation with existing relevant imaging studies (e.g., x-ray, MRI, CT, etc.) that were performed
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 147
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Specialty Measure Set
- Diagnostic Radiology
Primary Measure Steward
Society of Nuclear Medicine and Molecular Imaging
Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified
Measure Number
- eMeasure ID: CMS157v5
- eMeasure NQF: N/A
- NQF: 0384
- Quality ID: 143
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- EHR
- Registry
Specialty Measure Set
- General Oncology
- Radiation Oncology
Primary Measure Steward
Physician Consortium for Performance Improvement
Percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0383
- Quality ID: 144
NQS Domain
Person and Caregiver-Centered Experience and Outcomes
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Radiation Oncology
Primary Measure Steward
American Society of Clinical Oncology
Percentage of patients, regardless of age, with a diagnosis of breast, rectal, pancreatic or lung cancer receiving 3D conformal radiation therapy who had documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0382
- Quality ID: 156
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Claims
- Registry
Specialty Measure Set
- Radiation Oncology
Primary Measure Steward
American Society for Radiation Oncology
Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945-1965 who received one-time screening for hepatitis C virus (HCV) infection
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 400
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Specialty Measure Set
- Internal Medicine
- General Practice/Family Medicine
Primary Measure Steward
Physician Consortium for Performance Improvement
Percent of patients undergoing index pediatric and/or congenital heart surgery who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days (including patients transferred to other acute care facilities), and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, stratified by the five STAT Mortality Levels, a multi-institutional validated complexity stratification tool
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: 0733
- Quality ID: 446
NQS Domain
Patient Safety
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
N/A
Primary Measure Steward
Society of Thoracic Surgeons
All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 408
NQS Domain
Effective Clinical Care
Measure Type
Process
High Priority Measure
No
Data Submission Method
- Registry
Specialty Measure Set
- Internal Medicine
- Neurology
- Physical Medicine
- General Practice/Family Medicine
Primary Measure Steward
American Academy of Neurology
Composite measure of the percentage of pediatric and adult patients whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools and not at risk for exacerbation
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 398
NQS Domain
Effective Clinical Care
Measure Type
Outcome
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Allergy/Immunology
- General Practice/Family Medicine
Primary Measure Steward
Minnesota Community Measurement
Percentage of final reports for computed tomography (CT) imaging studies of the thorax for patients aged 18 years and older with documented follow-up recommendations for incidentally detected pulmonary nodules (e.g., follow-up CT imaging studies needed or that no follow-up is needed) based at a minimum on nodule size AND patient risk factors
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 364
NQS Domain
Communication and Care Coordination
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Diagnostic Radiology
Primary Measure Steward
American College of Radiology
Percentage of final reports for computed tomography (CT) studies performed for all patients, regardless of age, which document that Digital Imaging and Communications in Medicine (DICOM) format image data are available to non-affiliated external healthcare facilities or entities on a secure, media free, reciprocally searchable basis with patient authorization for at least a 12-month period after the study
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 362
NQS Domain
Communication and Care Coordination
Measure Type
Structure
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Diagnostic Radiology
Primary Measure Steward
American College of Radiology
Percentage of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion studies) imaging reports for all patients, regardless of age, that document a count of known previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion) studies that the patient has received in the 12-month period prior to the current study
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 360
NQS Domain
Patient Safety
Measure Type
Process
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Diagnostic Radiology
Primary Measure Steward
American College of Radiology
Percentage of total computed tomography (CT) studies performed for all patients, regardless of age, that are reported to a radiation dose index registry that is capable of collecting at a minimum selected data elements
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 361
NQS Domain
Patient Safety
Measure Type
Structure
High Priority Measure
Yes
Data Submission Method
- Registry
Specialty Measure Set
- Diagnostic Radiology
Primary Measure Steward
American College of Radiology
Percentage of final reports of computed tomography (CT) studies performed for all patients, regardless of age, which document that a search for Digital Imaging and Communications in Medicine (DICOM) format images was conducted for prior patient CT imaging studies completed at non-affiliated external healthcare facilities or entities within the past 12-months and are available through a secure, authorized, media-free, shared archive prior to an imaging study being performed
Measure Number
- eMeasure ID: N/A
- eMeasure NQF: N/A
- NQF: N/A
- Quality ID: 363