Diabetes Mellitus

This measure group may be submitted via registry only.

Includes the following individual measures:

#1Diabetes: Hemoglobin A1c Poor Control

Report via: Claim, Registry, EHR, GPRO/ACO, Measure Group

#2Diabetes: Low Density Lipoprotein (LDL-C) Control (<100 mg/dL)

Report via: Claim, Registry, EHR, Measure Group

#117Diabetes: Eye Exam

Report via: Claim, Registry, EHR, Measure Group

#119Diabetes: Medical Attention for Nephropathy

Report via: Claim, Registry, EHR, Measure Group

#163Diabetes: Foot Exam

Report via: Claim, Registry, EHR, Measure Group

Chronic Kidney Disease (CKD)

This measure group may be submitted via registry only.

Includes the following individual measures:

#110Preventive Care and Screening: Influenza Immunization

Report via: Claim, Registry, EHR, GPRO/ACO, Measure Group

#121Adult Kidney Disease: Laboratory Testing (Lipid Profile)

Report via: Claim, Registry, Measure Group

#122Adult Kidney Disease: Blood Pressure Management

Report via: Claim, Registry, Measure Group

#123Adult Kidney Disease: Patients On Erythropoiesis-Stimulating Agent (ESA) - Hemoglobin Level > 12.0 g/dL

Report via: Claim, Registry, Measure Group

Preventive Care

This measure group may be submitted via registry only.

Includes the following individual measures:

#39Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older

Report via: Claim, Registry, Measure Group

#48Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older

Report via: Claim, Registry, Measure Group

#110Preventive Care and Screening: Influenza Immunization

Report via: Claim, Registry, EHR, GPRO/ACO, Measure Group

#111Pneumonia Vaccination Status for Older Adults

Report via: Claim, Registry, EHR, GPRO/ACO, Measure Group

#112Breast Cancer Screening

Report via: Claim, Registry, EHR, GPRO/ACO, Measure Group

#113Colorectal Cancer Screening

Report via: Claim, Registry, EHR, GPRO/ACO, Measure Group

#128Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up

Report via: Claim, Registry, EHR, GPRO/ACO, Measure Group

#173Community/Preventive Care and Screening: Unhealthy Alcohol Use - Screening

Report via: Registry, Measure Group

#226Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Report via: Claim, Registry, EHR, GPRO/ACO, Measure Group

Coronary Artery Bypass Graft (CABG)

This measure group may be submitted via registry only.

Includes the following individual measures:

#43Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery

Report via: Claim, Registry, Measure Group

#44Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery

Report via: Claim, Registry, Measure Group

#164Coronary Artery Bypass Graft (CABG): Prolonged Intubation

Report via: Registry, Measure Group

#165Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate

Report via: Registry, Measure Group

#166Coronary Artery Bypass Graft (CABG): Stroke

Report via: Registry, Measure Group

#167Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure

Report via: Registry, Measure Group

#168Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration

Report via: Registry, Measure Group

#169Coronary Artery Bypass Graft (CABG): Antiplatelet Medications at Discharge

Report via: Registry, Measure Group

#170Coronary Artery Bypass Graft (CABG): Beta-Blockers Administered at Discharge

Report via: Registry, Measure Group

#171Coronary Artery Bypass Graft (CABG): Anti-Lipid Treatment at Discharge

Report via: Registry, Measure Group

Rheumatoid Arthritis

This measure group may be submitted via registry only.

Includes the following individual measures:

#108Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug (DMARD) Therapy

Report via: Claim, Registry, Measure Group

#176Rheumatoid Arthritis (RA): Tuberculosis Screening

Report via: Registry, Measure Group

#177Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity

Report via: Registry, Measure Group

#178Rheumatoid Arthritis (RA): Functional Status Assessment

Report via: Registry, Measure Group

#179Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis

Report via: Registry, Measure Group

#180Rheumatoid Arthritis (RA): Glucocorticoid Management

Report via: Registry, Measure Group

Perioperative Care

This measure group may be submitted via registry only.

Includes the following individual measures:

#20Perioperative Care: Timing of Prophylactic Parenteral Antibiotic - Ordering Physician

Report via: Claim, Registry, Measure Group

#21Perioperative Care: Selection of Prophylactic Antibiotic - First OR Second Generation Cephalosporin

Report via: Claim, Registry, Measure Group

#22Perioperative Care: Discontinuation of Prophylactic Parenteral Antibiotics (Non-Cardiac Procedures)

Report via: Claim, Registry, Measure Group

#23Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)

Report via: Claim, Registry, Measure Group

Back Pain

This measure group may be submitted via registry only.

Includes the following individual measures:

#148Back Pain: Initial Visit

This measure may be submitted via Measure Group only

#149Back Pain: Physical Exam

This measure may be submitted via Measure Group only

#150Back Pain: Advice for Normal Activities

This measure may be submitted via Measure Group only

#151Back Pain: Advice Against Bed Rest

This measure may be submitted via Measure Group only

Hepatitis C

This measure group may be submitted via registry only.

Includes the following individual measures:

#84Hepatitis C: Ribonucleic Acid (RNA) Testing Before Initiating Treatment

Report via: Registry, Measure Group

#85Hepatitis C: HCV Genotype Testing Prior to Treatment

Report via: Registry, Measure Group

#87Hepatitis C: Hepatitis C Virus (HCV) Ribonucleic Acid (RNA) Testing Between 4-12 Weeks After Initiation of Treatment

Report via: Registry, Measure Group

#183Hepatitis C: Hepatitis A Vaccination in Patients with Hepatitis C Virus (HCV)

Report via: Registry, Measure Group

Heart Failure (HF)

This measure group may be submitted via registry only.

Includes the following individual measures:

#5Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)

Report via: Registry, EHR, Measure Group

#8Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)

Report via: Registry, EHR, GPRO/ACO, Measure Group

#198Heart Failure: Left Ventricular Ejection Fraction (LVEF) Assessment

Report via: Registry, Measure Group

#226Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Report via: Claim, Registry, EHR, GPRO/ACO, Measure Group

Coronary Artery Disease (CAD)

This measure group may be submitted via registry only.

Includes the following individual measures:

#6Coronary Artery Disease (CAD): Antiplatelet Therapy

Report via: Claim, Registry, Measure Group

#197Coronary Artery Disease (CAD): Lipid Control

Report via: Registry, GPRO/ACO, Measure Group

#226Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Report via: Claim, Registry, EHR, GPRO/ACO, Measure Group

#242Coronary Artery Disease (CAD): Symptom Management

Report via: Registry, Measure Group

Ischemic Vascular Disease (IVD)

This measure group may be submitted via registry only.

Includes the following individual measures:

#204Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic

Report via: Claim, Registry, EHR, GPRO/ACO, Measure Group

#226Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Report via: Claim, Registry, EHR, GPRO/ACO, Measure Group

#236Controlling High Blood Pressure

Report via: Claim, Registry, EHR, GPRO/ACO, Measure Group

#241Ischemic Vascular Disease (IVD): Complete Lipid Profile and LDL-C Control (<100 mg/dL)

Report via: Claim, Registry, EHR, GPRO/ACO, Measure Group

HIV/AIDS

This measure group may be submitted via registry only.

Includes the following individual measures:

#159HIV/AIDS: CD4+ Cell Count or CD4+ Percentage Performed

Report via: Registry, Measure Group

#160HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis

Report via: Registry, EHR, Measure Group

#205HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis

Report via: Registry, Measure Group

#338HIV Viral Load Suppression

Report via: Registry, Measure Group

#339Prescription of HIV Antiretroviral Therapy

Report via: Registry, Measure Group

#340HIV Medical Visit Frequency

Report via: Registry, Measure Group

#341Gap in HIV Medical Visits

Report via: Registry, Measure Group

Asthma

This measure group may be submitted via registry only.

Includes the following individual measures:

#53Asthma: Pharmacologic Therapy for Persistent Asthma - Ambulatory Care Setting

Report via: Registry, Measure Group

#64Asthma: Assessment of Asthma Control - Ambulatory Care Setting

Report via: Registry, Measure Group

#231Asthma: Tobacco Use: Screening - Ambulatory Care Setting

Report via: Claim, Registry, Measure Group

#232Asthma: Tobacco Use: Intervention - Ambulatory Care Setting

Report via: Claim, Registry, Measure Group

Chronic Obstructive Pulmonary Disease (COPD)

This measure group may be submitted via registry only.

Includes the following individual measures:

#51Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation

Report via: Claim, Registry, Measure Group

#52Chronic Obstructive Pulmonary Disease (COPD): Inhaled Bronchodilator Therapy

Report via: Claim, Registry, Measure Group

#110Preventive Care and Screening: Influenza Immunization

Report via: Claim, Registry, EHR, GPRO/ACO, Measure Group

#111Pneumonia Vaccination Status for Older Adults

Report via: Claim, Registry, EHR, GPRO/ACO, Measure Group

#226Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Report via: Claim, Registry, EHR, GPRO/ACO, Measure Group

Inflammatory Bowel Disease (IBD)

This measure group may be submitted via registry only.

Includes the following individual measures:

#226Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Report via: Claim, Registry, EHR, GPRO/ACO, Measure Group

#269Inflammatory Bowel Disease (IBD): Type, Anatomic Location and Activity All Documented

This measure may be submitted via Measure Group only

#270Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Sparing Therapy

This measure may be submitted via Measure Group only

#271Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury - Bone Loss Assessment

This measure may be submitted via Measure Group only

#272Inflammatory Bowel Disease (IBD): Preventive Care: Influenza Immunization

This measure may be submitted via Measure Group only

#273Inflammatory Bowel Disease (IBD): Preventive Care: Pneumococcal Immunization

This measure may be submitted via Measure Group only

#274Inflammatory Bowel Disease (IBD): Testing for Latent Tuberculosis (TB) Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy

This measure may be submitted via Measure Group only

#275Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy

This measure may be submitted via Measure Group only

Sleep Apnea

This measure group may be submitted via registry only.

Includes the following individual measures:

#276Sleep Apnea: Assessment of Sleep Symptoms

This measure may be submitted via Measure Group only

#277Sleep Apnea: Severity Assessment at Initial Diagnosis

This measure may be submitted via Measure Group only

#278Sleep Apnea: Positive Airway Pressure Therapy Prescribed

This measure may be submitted via Measure Group only

#279Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy

This measure may be submitted via Measure Group only

Dementia

This measure group may be submitted via registry only.

Includes the following individual measures:

#280Dementia: Staging of Dementia

This measure may be submitted via Measure Group only

#281Dementia: Cognitive Assessment

Report via: EHR, Measure Group

#282Dementia: Functional Status Assessment

This measure may be submitted via Measure Group only

#283Dementia: Neuropsychiatric Symptom Assessment

This measure may be submitted via Measure Group only

#284Dementia: Management of Neuropsychiatric Symptoms

This measure may be submitted via Measure Group only

#285Dementia: Screening for Depressive Symptoms

This measure may be submitted via Measure Group only

#286Dementia: Counseling Regarding Safety Concerns

This measure may be submitted via Measure Group only

#287Dementia: Counseling Regarding Risks of Driving

This measure may be submitted via Measure Group only

#288Dementia: Caregiver Education and Support

This measure may be submitted via Measure Group only

Parkinson's Disease

This measure group may be submitted via registry only.

Includes the following individual measures:

#289Parkinson's Disease: Annual Parkinson's Disease Diagnosis Review

This measure may be submitted via Measure Group only

#290Parkinson's Disease: Psychiatric Disorders or Disturbances Assessment

This measure may be submitted via Measure Group only

#291Parkinson's Disease: Cognitive Impairment or Dysfunction Assessment

This measure may be submitted via Measure Group only

#292Parkinson's Disease: Querying about Sleep Disturbances

This measure may be submitted via Measure Group only

#293Parkinson's Disease: Rehabilitative Therapy Options

This measure may be submitted via Measure Group only

#294Parkinson's Disease: Parkinson's Disease Medical and Surgical Treatment Options Reviewed

This measure may be submitted via Measure Group only

Hypertension (HTN)

This measure group may be submitted via registry only.

Includes the following individual measures:

#295Hypertension: Use of Aspirin or Other Antithrombotic Therapy

This measure may be submitted via Measure Group only

#296Hypertension: Complete Lipid Profile

This measure may be submitted via Measure Group only

#297Hypertension: Urine Protein Test

This measure may be submitted via Measure Group only

#298Hypertension: Annual Serum Creatinine Test

This measure may be submitted via Measure Group only

#299Hypertension: Diabetes Mellitus Screening Test

This measure may be submitted via Measure Group only

#300Hypertension: Blood Pressure Control

This measure may be submitted via Measure Group only

#301Hypertension: Low Density Lipoprotein (LDL-C) Control

This measure may be submitted via Measure Group only

#302Hypertension: Dietary and Physical Activity Modifications Appropriately Prescribed

This measure may be submitted via Measure Group only

Cardiovascular Prevention

This measure group may be submitted via registry only.

Includes the following individual measures:

#2Diabetes: Low Density Lipoprotein (LDL-C) Control (<100 mg/dL)

Report via: Claim, Registry, EHR, Measure Group

#204Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic

Report via: Claim, Registry, EHR, GPRO/ACO, Measure Group

#226Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Report via: Claim, Registry, EHR, GPRO/ACO, Measure Group

#236Controlling High Blood Pressure

Report via: Claim, Registry, EHR, GPRO/ACO, Measure Group

#241Ischemic Vascular Disease (IVD): Complete Lipid Profile and LDL-C Control (<100 mg/dL)

Report via: Claim, Registry, EHR, GPRO/ACO, Measure Group

#317Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

Report via: Claim, Registry, EHR, GPRO/ACO, Measure Group

Cataracts

This measure group may be submitted via registry only.

Includes the following individual measures:

#191Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery

Report via: Registry, EHR, Measure Group

#192Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures

Report via: Registry, EHR, Measure Group

#303Cataracts: Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery

Report via: Registry, Measure Group

#304Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery

Report via: Registry, Measure Group

Oncology

This measure group may be submitted via registry only.

Includes the following individual measures:

#71Breast Cancer: Hormonal Therapy for Stage IC - IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer

Report via: Claim, Registry, EHR, Measure Group

#72Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients

Report via: Claim, Registry, EHR, Measure Group

#110Preventive Care and Screening: Influenza Immunization

Report via: Claim, Registry, EHR, GPRO/ACO, Measure Group

#130Documentation of Current Medications in the Medical Record

Report via: Claim, Registry, EHR, Measure Group

#143Oncology: Medical and Radiation - Pain Intensity Quantified

Report via: Registry, EHR, Measure Group

#144Oncology: Medical and Radiation - Plan of Care for Pain

Report via: Registry, Measure Group

#194Oncology: Cancer Stage Documented

Report via: Claim, Registry, Measure Group

#226Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Report via: Claim, Registry, EHR, GPRO/ACO, Measure Group

Total Knee Replacement

This measure group may be submitted via registry only.

Includes the following individual measures:

#350Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy

This measure may be submitted via Measure Group only

#351Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation

This measure may be submitted via Measure Group only

#352Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet

This measure may be submitted via Measure Group only

#353Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report

This measure may be submitted via Measure Group only

General Surgery

This measure group may be submitted via registry only.

Includes the following individual measures:

#354Anastomotic Leak Intervention

This measure may be submitted via Measure Group only

#355Unplanned Reoperation within the 30 Day Postoperative Period

This measure may be submitted via Measure Group only

#356Unplanned Hospital Readmission within 30 Days of Principal Procedure

This measure may be submitted via Measure Group only

#357Surgical Site Infection (SSI)

This measure may be submitted via Measure Group only

#358Patient-Centered Surgical Risk Assessment and Communications

Report via: Registry, Measure Group

Optimizing Patient Exposure to Ionizing Radiation

This measure group may be submitted via registry only.

Includes the following individual measures:

#359Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computerized Tomography (CT) Imaging Description

This measure may be submitted via Measure Group only

#360Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies

This measure may be submitted via Measure Group only

#361Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index

This measure may be submitted via Measure Group only

#362Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison Purposes

This measure may be submitted via Measure Group only

#363Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Imaging Studies Through a Secure, Authorized, Media-Free, Shared Archive

This measure may be submitted via Measure Group only

#364Optimizing Patient Exposure to Ionizing Radiation: Appropriateness

This measure may be submitted via Measure Group only