#Measure TitleSubmission Methods
IA_EPA_1Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record
IA_EPA_2Use of telehealth services that expand practice access
IA_EPA_3Collection and use of patient experience and satisfaction data on access
IA_EPA_4Additional improvements in access as a result of QIN/QIO TA
IA_EPA_5Participation in User Testing of the Quality Payment Program Website (https://qpp.cms.gov/)
IA_PM_2Anticoagulant Management Improvements
IA_PM_3RHC, IHS or FQHC quality improvement activities
IA_PM_4Glycemic management services
IA_PM_5Engagement of community for health status improvement
IA_PM_6Use of toolsets or other resources to close healthcare disparities across communities
IA_PM_7Use of QCDR for feedback reports that incorporate population health
IA_PM_11Regular Review Practices in Place on Targeted Patient Population Needs
IA_PM_12Population empanelment
IA_PM_13Chronic Care and Preventative Care Management for Empaneled Patients
IA_PM_14Implementation of methodologies for improvements in longitudinal care management for high risk patients
IA_PM_15Implementation of episodic care management practice improvements
IA_PM_16Implementation of medication management practice improvements
IA_PM_17Participation in Population Health Research
IA_PM_18Provide Clinical-Community Linkages
IA_PM_19Glycemic Screening Services
IA_PM_20Glycemic Referring Services
IA_PM_21Advance Care Planning
IA_CC_1Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop
IA_CC_2Implementation of improvements that contribute to more timely communication of test results
IA_CC_7Regular training in care coordination
IA_CC_8Implementation of documentation improvements for practice/process improvements
IA_CC_9Implementation of practices/processes for developing regular individual care plans
IA_CC_10Care transition documentation practice improvements
IA_CC_11Care transition standard operational improvements
IA_CC_12Care coordination agreements that promote improvements in patient tracking across settings
IA_CC_13Practice Improvements for Bilateral Exchange of Patient Information
IA_CC_14Practice Improvements that Engage Community Resources to Support Patient Health Goals
IA_CC_15PSH Care Coordination
IA_CC_16Primary Care Physician and Behavioral Health Bilateral Electronic Exchange of Information for Shared Patients
IA_CC_17Patient Navigator Program
IA_CC_18Relationship-Centered Communication
IA_CC_19Tracking of clinician’s relationship to and responsibility for a patient by reporting MACRA patient relationship codes.
IA_BE_1Use of certified EHR to capture patient reported outcomes
IA_BE_3Engagement with QIN-QIO to implement self-management training programs
IA_BE_4Engagement of patients through implementation of improvements in patient portal
IA_BE_5Enhancements/regular updates to practice websites/tools that also include considerations for patients with cognitive disabilities
IA_BE_6Collection and follow-up on patient experience and satisfaction data on beneficiary engagement
IA_BE_7Participation in a QCDR, that promotes use of patient engagement tools.
IA_BE_8Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive.
IA_BE_12Use evidence-based decision aids to support shared decision-making.
IA_BE_13Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms.
IA_BE_14Engage Patients and Families to Guide Improvement in the System of Care
IA_BE_15Engagement of Patients, Family, and Caregivers in Developing a Plan of Care
IA_BE_16Evidenced-based techniques to promote self-management into usual care
IA_BE_17Use of tools to assist patient self-management
IA_BE_18Provide peer-led support for self-management.
IA_BE_19Use group visits for common chronic conditions (e.g., diabetes).
IA_BE_20Implementation of condition-specific chronic disease self-management support programs
IA_BE_21Improved Practices that Disseminate Appropriate Self-Management Materials
IA_BE_22Improved Practices that Engage Patients Pre-Visit
IA_BE_23Integration of patient coaching practices between visits
IA_BE_24Financial Navigation Program
IA_BE_25Drug Cost Transparency
IA_PSPA_1Participation in an AHRQ-listed patient safety organization.
IA_PSPA_2Participation in MOC Part IV
IA_PSPA_3Participate in IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS or Other Similar Activity
IA_PSPA_4Administration of the AHRQ Survey of Patient Safety Culture
IA_PSPA_6Consultation of the Prescription Drug Monitoring Program
IA_PSPA_7Use of QCDR data for ongoing practice assessment and improvements
IA_PSPA_8Use of Patient Safety Tools
IA_PSPA_9Completion of the AMA STEPS Forward program
IA_PSPA_10Completion of training and receipt of approved waiver for provision opioid medication-assisted treatments
IA_PSPA_11Participation in CAHPS or other supplemental questionnaire
IA_PSPA_12Participation in private payer CPIA
IA_PSPA_13Participation in Joint Commission Evaluation Initiative
IA_PSPA_15Implementation of an ASP
IA_PSPA_16Use of decision support and standardized treatment protocols
IA_PSPA_17Implementation of analytic capabilities to manage total cost of care for practice population
IA_PSPA_18Measurement and Improvement at the Practice and Panel Level
IA_PSPA_19Implementation of formal quality improvement methods, practice changes, or other practice improvement processes
IA_PSPA_20Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes
IA_PSPA_21Implementation of fall screening and assessment programs
IA_PSPA_22CDC Training on CDC's Guideline for Prescribing Opioids for Chronic Pain
IA_PSPA_23Completion of CDC Training on Antibiotic Stewardship
IA_PSPA_25Cost Display for Laboratory and Radiographic Orders
IA_PSPA_26Communication of Unscheduled Visit for Adverse Drug Event and Nature of Event
IA_PSPA_27Invasive Procedure or Surgery Anticoagulation Medication Management
IA_PSPA_28Completion of an Accredited Safety or Quality Improvement Program
IA_PSPA_29Consulting AUC Using Clinical Decision Support when Ordering Advanced
IA_PSPA_30PCI Bleeding Campaign
IA_PSPA_31Patient Medication Risk Education
IA_PSPA_32Use of CDC Guideline for Clinical Decision Support to Prescribe Opioids for Chronic Pain via Clinical Decision Support
IA_AHE_1Engagement of New Medicaid Patients and Follow-up
IA_AHE_3Promote Use of Patient-Reported Outcome Tools
IA_AHE_5MIPS Eligible Clinician Leadership in Clinical Trials or CBPR
IA_AHE_6Provide Education Opportunities for New Clinicians
IA_AHE_7Comprehensive Eye Exams
IA_ERP_1Participation on Disaster Medical Assistance Team, registered for 6 months.
IA_ERP_2Participation in a 60-day or greater effort to support domestic or international humanitarian needs.
IA_ERP_3COVID-19 Clinical Data Reporting with or without Clinical Trial
IA_BMH_1Diabetes screening
IA_BMH_2Tobacco use
IA_BMH_4Depression screening
IA_BMH_5MDD prevention and treatment interventions
IA_BMH_6Implementation of co-location PCP and MH services
IA_BMH_7Implementation of Integrated Patient Centered Behavioral Health Model
IA_BMH_8Electronic Health Record Enhancements for BH data capture
IA_BMH_9Unhealthy Alcohol Use for Patients with Co-occurring Conditions of Mental Health and Substance Abuse and Ambulatory Care Patients
IA_BMH_10Completion of Collaborative Care Management Training Program
IA_PCMHElectronic submission of Patient Centered Medical Home accreditation
PI_PPHI_1Security Risk Analysis
PI_ONCDIR_1ONC Direct Review Attestation
PI_INFBLO_1Prevention of Information Blocking Attestation
PI_ONCACB_1ONC-ACB Surveillance Attestation
PI_EP_1e-Prescribing
PI_LVPP_1e-Prescribing Exclusion
PI_EP_2Query of the Prescription Drug Monitoring Program (PDMP)
PI_HIE_1Support Electronic Referral Loops By Sending Health Information
PI_LVOTC_1Support Electronic Referral Loops By Sending Health Information Exclusion
PI_HIE_4Support Electronic Referral Loops By Receiving and Reconciling Health Information
PI_LVITC_2Support Electronic Referral Loops By Receiving and Reconciling Health Information Exclusion
PI_HIE_5Health Information Exchange(HIE) Bi-Directional Exchange
PI_PEA_1Provide Patients Electronic Access to Their Health Information
PI_PHCDRR_2Syndromic Surveillance Reporting
PI_PHCDRR_2_MULTISyndromic Surveillance Reporting for Multiple Registry Engagement
PI_PHCDRR_2_EX_1Syndromic Surveillance Reporting Exclusion
PI_PHCDRR_2_EX_2Syndromic Surveillance Reporting Exclusion
PI_PHCDRR_2_EX_3Syndromic Surveillance Reporting Exclusion
PI_PHCDRR_1Immunization Registry Reporting
PI_PHCDRR_1_MULTIImmunization Registry Reporting for Multiple Registry Engagement
PI_PHCDRR_1_EX_1Immunization Registry Reporting Exclusion
PI_PHCDRR_1_EX_2Immunization Registry Reporting Exclusion
PI_PHCDRR_1_EX_3Immunization Registry Reporting Exclusion
PI_PHCDRR_3Electronic Case Reporting
PI_PHCDRR_3_MULTIElectronic Case Reporting for Multiple Registry Engagement
PI_PHCDRR_3_EX_1Electronic Case Reporting Exclusion
PI_PHCDRR_3_EX_2Electronic Case Reporting Exclusion
PI_PHCDRR_3_EX_3Electronic Case Reporting Exclusion
PI_PHCDRR_4Public Health Registry Reporting
PI_PHCDRR_4_MULTIPublic Health Registry Reporting for Multiple Registry Engagement
PI_PHCDRR_4_EX_1Public Health Registry Reporting Exclusion
PI_PHCDRR_4_EX_2Public Health Registry Reporting Exclusion
PI_PHCDRR_4_EX_3Public Health Registry Reporting Exclusion
PI_PHCDRR_5Clinical Data Registry Reporting
PI_PHCDRR_5_MULTIClinical Data Registry Reporting for Multiple Registry Engagement
PI_PHCDRR_5_EX_1Clinical Data Registry Reporting Exclusion
PI_PHCDRR_5_EX_2Clinical Data Registry Reporting Exclusion
PI_PHCDRR_5_EX_3Clinical Data Registry Reporting Exclusion
001Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)Claims, Electronic Health Record, Cms Web Interface, Registry
005Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)Electronic Health Record, Registry
006Coronary Artery Disease (CAD): Antiplatelet TherapyRegistry
007Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%)Electronic Health Record, Registry
008Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)Electronic Health Record, Registry
009Anti-Depressant Medication ManagementElectronic Health Record
012Primary Open-Angle Glaucoma (POAG): Optic Nerve EvaluationElectronic Health Record
014Age-Related Macular Degeneration (AMD): Dilated Macular ExaminationClaims, Registry
019Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes CareElectronic Health Record, Registry
021Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second-Generation CephalosporinClaims, Registry
023Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)Claims, Registry
024Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and OlderClaims, Registry
039Screening for Osteoporosis for Women Aged 65-85 Years of AgeClaims, Registry
044Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG SurgeryRegistry
047Advance Care PlanClaims, Registry
048Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and OlderRegistry
050Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and OlderClaims, Registry
052Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator TherapyRegistry
065Appropriate Treatment for Upper Respiratory Infection (URI)Electronic Health Record, Registry
066Appropriate Testing for PharyngitisElectronic Health Record, Registry
067Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone MarrowRegistry
070Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow CytometryRegistry
076Prevention of Central Venous Catheter (CVC) - Related Bloodstream InfectionsClaims, Registry
093Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate UseClaims, Registry
102Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer PatientsElectronic Health Record, Registry
104Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate CancerRegistry
107Adult Major Depressive Disorder (MDD): Suicide Risk AssessmentElectronic Health Record
110Preventive Care and Screening: Influenza ImmunizationClaims, Electronic Health Record, Cms Web Interface, Registry
111Pneumococcal Vaccination Status for Older AdultsClaims, Electronic Health Record, Registry
112Breast Cancer ScreeningClaims, Electronic Health Record, Cms Web Interface, Registry
113Colorectal Cancer ScreeningClaims, Electronic Health Record, Cms Web Interface, Registry
116Avoidance of Antibiotic Treatment for Acute Bronchitis/BronchiolitisRegistry
117Diabetes: Eye ExamClaims, Electronic Health Record, Registry
118Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)Registry
119Diabetes: Medical Attention for NephropathyElectronic Health Record, Registry
126Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological EvaluationRegistry
127Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of FootwearRegistry
128Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up PlanClaims, Electronic Health Record, Registry
130Documentation of Current Medications in the Medical RecordClaims, Electronic Health Record, Registry
134Preventive Care and Screening: Screening for Depression and Follow-Up PlanClaims, Electronic Health Record, Cms Web Interface, Registry
137Melanoma: Continuity of Care – Recall SystemRegistry
138Melanoma: Coordination of CareRegistry
141Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of CareClaims, Registry
143Oncology: Medical and Radiation – Pain Intensity QuantifiedElectronic Health Record, Registry
144Oncology: Medical and Radiation - Plan of Care for PainRegistry
145Radiology: Exposure Dose Indices or Exposure Time and Number of Images Reported for Procedures Using FluoroscopyClaims, Registry
147Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone ScintigraphyClaims, Registry
154Falls: Risk AssessmentClaims, Registry
155Falls: Plan of CareClaims, Registry
164Coronary Artery Bypass Graft (CABG): Prolonged IntubationRegistry
167Coronary Artery Bypass Graft (CABG): Postoperative Renal FailureRegistry
168Coronary Artery Bypass Graft (CABG): Surgical Re-ExplorationRegistry
176Tuberculosis Screening Prior to First Course Biologic TherapyRegistry
177Rheumatoid Arthritis (RA): Periodic Assessment of Disease ActivityRegistry
178Rheumatoid Arthritis (RA): Functional Status AssessmentRegistry
180Rheumatoid Arthritis (RA): Glucocorticoid ManagementRegistry
181Elder Maltreatment Screen and Follow-Up PlanClaims, Registry
182Functional Outcome AssessmentClaims, Registry
185Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate UseRegistry
187Stroke and Stroke Rehabilitation: Thrombolytic TherapyRegistry
191Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract SurgeryElectronic Health Record, Registry
195Radiology: Stenosis Measurement in Carotid Imaging ReportsClaims, Registry
205HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and SyphilisRegistry
217Functional Status Change for Patients with Knee ImpairmentsRegistry
218Functional Status Change for Patients with Hip ImpairmentsRegistry
219Functional Status Change for Patients with Lower Leg, Foot or Ankle ImpairmentsRegistry
220Functional Status Change for Patients with Low Back ImpairmentsRegistry
221Functional Status Change for Patients with Shoulder ImpairmentsRegistry
222Functional Status Change for Patients with Elbow, Wrist or Hand ImpairmentsRegistry
225Radiology: Reminder System for Screening MammogramsClaims, Registry
226Preventive Care and Screening: Tobacco Use: Screening and Cessation InterventionClaims, Electronic Health Record, Cms Web Interface, Registry
236Controlling High Blood PressureClaims, Electronic Health Record, Cms Web Interface, Registry
238Use of High-Risk Medications in Older AdultsElectronic Health Record, Registry
239Weight Assessment and Counseling for Nutrition and Physical Activity for Children and AdolescentsElectronic Health Record
240Childhood Immunization StatusElectronic Health Record
243Cardiac Rehabilitation Patient Referral from an Outpatient SettingRegistry
249Barrett’s EsophagusClaims, Registry
250Radical Prostatectomy Pathology ReportingClaims, Registry
254Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal PainClaims, Registry
258Rate of Open Repair of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7)Registry
259Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #2)Registry
260Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2)Registry
261Referral for Otologic Evaluation for Patients with Acute or Chronic DizzinessClaims, Registry
264Sentinel Lymph Node Biopsy for Invasive Breast CancerRegistry
265Biopsy Follow-UpRegistry
268Epilepsy: Counseling for Women of Childbearing Potential with EpilepsyRegistry
275Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) TherapyRegistry
277Sleep Apnea: Severity Assessment at Initial DiagnosisRegistry
279Sleep Apnea: Assessment of Adherence to Positive Airway Pressure TherapyRegistry
281Dementia: Cognitive AssessmentElectronic Health Record
282Dementia: Functional Status AssessmentRegistry
283Dementia Associated Behavioral and Psychiatric Symptoms Screening and ManagementRegistry
286Dementia: Safety Concern Screening and Follow-Up for Patients with DementiaRegistry
288Dementia: Education and Support of Caregivers for Patients with DementiaRegistry
290Parkinson’s Disease: Psychiatric Symptoms Assessment for Patients with Parkinson’s DiseaseRegistry
291Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment for Patients with Parkinson's DiseaseRegistry
293Parkinson’s Disease: Rehabilitative Therapy OptionsRegistry
303Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract SurgeryRegistry
304Cataracts: Patient Satisfaction within 90 Days Following Cataract SurgeryRegistry
305Initiation and Engagement of Alcohol and Other Drug Dependence TreatmentElectronic Health Record
309Cervical Cancer ScreeningElectronic Health Record
310Chlamydia Screening for WomenElectronic Health Record
317Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up DocumentedClaims, Electronic Health Record, Registry
318Falls: Screening for Future Fall RiskElectronic Health Record, Cms Web Interface
320Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk PatientsClaims, Registry
321CAHPS for MIPs Clinician/Group SurveyCertified Survey Vendor
322Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery PatientsRegistry
323Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI)Registry
324Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk PatientsRegistry
326Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation TherapyClaims, Registry
331Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)Registry
332Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)Registry
335Maternity Care: Elective Delivery or Early Induction Without Medical Indication at < 39 Weeks (Overuse)Registry
336Maternity Care: Postpartum Follow-up and Care CoordinationRegistry
337Psoriasis: Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis on a Biological Immune Response ModifierRegistry
338HIV Viral Load SuppressionRegistry
340HIV Medical Visit FrequencyRegistry
342Pain Brought Under Control Within 48 HoursRegistry
344Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)Registry
350Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) TherapyRegistry
351Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk EvaluationRegistry
354Anastomotic Leak InterventionRegistry
355Unplanned Reoperation within the 30 Day Postoperative PeriodRegistry
356Unplanned Hospital Readmission within 30 Days of Principal ProcedureRegistry
357Surgical Site Infection (SSI)Registry
358Patient-Centered Surgical Risk Assessment and CommunicationRegistry
360Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine StudiesRegistry
364Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended GuidelinesRegistry
366Follow-Up Care for Children Prescribed ADHD Medication (ADD)Electronic Health Record
370Depression Remission at Twelve MonthsElectronic Health Record, Cms Web Interface, Registry
374Closing the Referral Loop: Receipt of Specialist ReportElectronic Health Record, Registry
375Functional Status Assessment for Total Knee ReplacementElectronic Health Record
376Functional Status Assessment for Total Hip ReplacementElectronic Health Record
377Functional Status Assessments for Congestive Heart FailureElectronic Health Record
378Children Who Have Dental Decay or CavitiesElectronic Health Record
379Primary Caries Prevention Intervention as Offered by Primary Care Providers, including DentistsElectronic Health Record
382Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk AssessmentElectronic Health Record
383Adherence to Antipsychotic Medications For Individuals with SchizophreniaRegistry
384Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of SurgeryRegistry
385Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of SurgeryRegistry
386Amyotrophic Lateral Sclerosis (ALS) Patient Care PreferencesRegistry
387Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug UsersRegistry
389Cataract Surgery: Difference Between Planned and Final RefractionRegistry
391Follow-Up After Hospitalization for Mental Illness (FUH)Registry
392Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation AblationRegistry
393Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or RevisionRegistry
394Immunizations for AdolescentsRegistry
395Lung Cancer Reporting (Biopsy/Cytology Specimens)Claims, Registry
396Lung Cancer Reporting (Resection Specimens)Claims, Registry
397Melanoma ReportingClaims, Registry
398Optimal Asthma ControlRegistry
400One-Time Screening for Hepatitis C Virus (HCV) for Patients at RiskRegistry
401Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with CirrhosisRegistry
402Tobacco Use and Help with Quitting Among AdolescentsRegistry
404Anesthesiology Smoking AbstinenceRegistry
405Appropriate Follow-up Imaging for Incidental Abdominal LesionsClaims, Registry
406Appropriate Follow-up Imaging for Incidental Thyroid Nodules in PatientsClaims, Registry
409Clinical Outcome Post Endovascular Stroke TreatmentRegistry
410Psoriasis: Clinical Response to Systemic MedicationsRegistry
413Door to Puncture Time for Endovascular Stroke TreatmentRegistry
415Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and OlderRegistry
416Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 YearsClaims, Registry
418Osteoporosis Management in Women Who Had a FractureClaims, Registry
419Overuse of Imaging for the Evaluation of Primary HeadacheRegistry
420Varicose Vein Treatment with Saphenous Ablation: Outcome SurveyRegistry
421Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for RemovalRegistry
422Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract InjuryClaims, Registry
424Perioperative Temperature ManagementRegistry
425Photodocumentation of Cecal IntubationClaims, Registry
429Pelvic Organ Prolapse: Preoperative Screening for Uterine MalignancyClaims, Registry
430Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination TherapyRegistry
431Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief CounselingRegistry
432Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse RepairRegistry
433Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse RepairRegistry
434Proportion of Patients Sustaining a Ureter Injury at the Time of Pelvic Organ Prolapse RepairRegistry
436Radiation Consideration for Adult CT: Utilization of Dose Lowering TechniquesClaims, Registry
438Statin Therapy for the Prevention and Treatment of Cardiovascular DiseaseElectronic Health Record, Cms Web Interface, Registry
439Age Appropriate Screening ColonoscopyRegistry
440Skin Cancer: Biopsy Reporting Time – Pathologist to ClinicianRegistry
441Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)Registry
443Non-Recommended Cervical Cancer Screening in Adolescent FemalesRegistry
444Medication Management for People with AsthmaRegistry
445Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)Registry
448Appropriate Workup Prior to Endometrial AblationRegistry
450Appropriate Treatment for Patients with Stage I (T1c) - III HER2 Positive Breast CancerRegistry
451RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody TherapyRegistry
452Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal AntibodiesRegistry
453Percentage of Patients Who Died from Cancer Receiving Chemotherapy in the Last 14 Days of Life (lower score – better)Registry
455Percentage of Patients Who Died from Cancer Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life (lower score – better)Registry
457Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score – better)Registry
459Back Pain After Lumbar Discectomy/LaminectomyRegistry
460Back Pain After Lumbar FusionRegistry
461Leg Pain After Lumbar Discectomy/LaminectomyRegistry
462Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation TherapyElectronic Health Record
463Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics)Registry
464Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate UseRegistry
465Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian ArteriesRegistry
468Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)Registry
469Functional Status After Lumbar FusionRegistry
470Functional Status After Primary Total Knee ReplacementRegistry
471Functional Status After Lumbar Discectomy/LaminectomyRegistry
472Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic FractureElectronic Health Record
473Leg Pain After Lumbar FusionRegistry
475HIV ScreeningElectronic Health Record
476Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic HyperplasiaElectronic Health Record
477Multimodal Pain ManagementRegistry
478Functional Status Change for Patients with Neck ImpairmentsRegistry
479Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) GroupsAdministrative Claims
480Risk-standardized complication rate (RSCR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) for Merit-based Incentive Payment System (MIPS)Administrative Claims
MCC1All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions for ACOs (MCC)Administrative Claims
MSPB_1Medicare Spending Per Beneficiary (MSPB)Administrative Claims
TPCC_1Total Per Capita Costs (TPCC)Administrative Claims
COST_IOL_1Routine Cataract Removal with Intraocular Lens (IOL) ImplantationAdministrative Claims
COST_IHCI_1Intracranial Hemorrhage or Cerebral InfarctionAdministrative Claims
COST_KA_1Knee ArthroplastyAdministrative Claims
COST_EOPCI_1Elective Outpatient Percutaneous Coronary Intervention (PCI)Administrative Claims
COST_SPH_1Simple Pneumonia with HospitalizationAdministrative Claims
COST_CCLI_1Revascularization for Lower Extremity Chronic Critical Limb IschemiaAdministrative Claims
COST_SSC_1Screening/Surveillance ColonoscopyAdministrative Claims
COST_STEMI_1ST-Elevation Myocardial Infarction (STEMI) with Percutaneous Coronary Intervention (PCI)Administrative Claims
COST_AKID_1Acute Kidney Injury Requiring New Inpatient DialysisAdministrative Claims
COST_PHA_1Elective Primary Hip ArthroplastyAdministrative Claims
COST_FIHR_1Femoral or Inguinal Hernia RepairAdministrative Claims
COST_HAC_1Hemodialysis Access CreationAdministrative Claims
COST_COPDE_1Inpatient Chronic Obstructive Pulmonary Disease (COPD) ExacerbationAdministrative Claims
COST_LGH_1Lower Gastrointestinal Hemorrhage (groups only)Administrative Claims
COST_LSFDD_1Lumbar Spine Fusion for Degenerative Disease, 1-3 LevelsAdministrative Claims
COST_LPMSM_1Lumpectomy Partial Mastectomy, Simple MastectomyAdministrative Claims
COST_NECABG_1Non-Emergent Coronary Artery Bypass Graft (CABG)Administrative Claims
COST_RUSST_1Renal or Ureteral Stone Surgical TreatmentAdministrative Claims
CAHPS_1CAHPS for MIPS SSM: Getting Timely Care, Appointments, and InformationCertified Survey Vendor
CAHPS_2CAHPS for MIPS SSM: How Well Providers CommunicateCertified Survey Vendor
CAHPS_3CAHPS for MIPS SSM: Patient’s Rating of ProviderCertified Survey Vendor
CAHPS_4CAHPS for MIPS SSM: Access to SpecialistsCertified Survey Vendor
CAHPS_5CAHPS for MIPS SSM: Health Promotion and EducationCertified Survey Vendor
CAHPS_6CAHPS for MIPS SSM: Shared Decision MakingCertified Survey Vendor
CAHPS_7CAHPS for MIPS SSM: Health Status and Functional StatusCertified Survey Vendor
CAHPS_8CAHPS for MIPS SSM: Care CoordinationCertified Survey Vendor
CAHPS_9CAHPS for MIPS SSM: Courteous and Helpful Office StaffCertified Survey Vendor
CAHPS_11CAHPS for MIPS SSM: Stewardship of Patient ResourcesCertified Survey Vendor
AAAAI17Asthma Control: Minimal Important Difference ImprovementRegistry
AAAAI18Penicillin Allergy: Appropriate Removal or ConfirmationRegistry
AAAAI2Asthma: Assessment of Asthma Control – Ambulatory Care SettingRegistry
AAAAI6Documentation of Clinical Response to Allergen Immunotherapy within One YearRegistry
AAAAI8Achievement of Projected Effective Dose of Standardized Allergens for Patient Treated With Allergen Immunotherapy for at Least One YearRegistry
AAD10Dermatitis – Improvement in Patient-Reported Itch SeverityRegistry
AAD11Skin Cancer Surgery: Post-Operative ComplicationsRegistry
AAD12Melanoma: – Appropriate Surgical MarginsRegistry
AAD6Skin Cancer: Biopsy Reporting Time - Clinician to PatientRegistry
AAD7Psoriasis: Screening for Psoriatic ArthritisRegistry
AAD8Chronic Skin Conditions: Patient Reported Quality-of-LifeRegistry
AAD9Psoriasis – Improvement in Patient-Reported Itch SeverityRegistry
AAN22Quality of Life Outcome for Patients with Neurologic ConditionsRegistry
AAN25Pediatric Medication reconciliationRegistry
AAN26Activity counseling for back painRegistry
AAN28Diabetes/Pre-Diabetes Screening for Patients with DSPRegistry
AAN29Comprehensive Epilepsy Care Center Referral or Discussion for Patients with EpilepsyRegistry
AAN30Migraine Preventive Therapy ManagementRegistry
AAN31Acute Treatment Prescribed for Cluster HeadacheRegistry
AAN32Preventive Treatment Prescribed for Cluster HeadacheRegistry
AAN33Fatigue Screening and Follow-Up for Patients with MSRegistry
AAN34Patient reported falls and plan of careRegistry
AAN5Medication Prescribed For Acute Migraine AttackRegistry
AAN8Exercise and Appropriate Physical Activity Counseling for Patients with MSRegistry
AAN9Querying About Symptoms of Autonomic Dysfunction for Patients with Parkinson's DiseaseRegistry
AAO12Tympanostomy Tubes: Topical Ear Drop Monotherapy Acute OtorrheaRegistry
AAO13Bell's Palsy: Inappropriate Use of Magnetic Resonance Imaging or Computed Tomography Scan (Inverse Measure)Registry
AAO16Age-related Hearing Loss: Audiometric EvaluationRegistry
AAO20Tympanostomy Tubes: Hearing TestRegistry
AAO21Otitis Media with Effusion: Hearing Test for Chronic OME > 3 monthsRegistry
AAO23Allergic Rhinitis: Intranasal Corticosteroids or Oral AntihistaminesRegistry
AAO24Allergic Rhinitis: Avoidance of Leukotriene InhibitorsRegistry
AAO29Quality of Life for Patients with Neurotology DisordersRegistry
AAO31Otitis Media with Effusion (OME): Avoidance of Inappropriate Use of MedicationsRegistry
AAO32Standard BPPV ManagementRegistry
AAO34Dysphonia: Postoperative Laryngeal ExaminationRegistry
AAO35Benign Positional Paroxysmal Vertigo (BPPV): Dix-Hallpike and Canalith RepositioningRegistry
AAO36Tympanostomy Tubes: Resolution of Otitis Media with Effusion in Adults and ChildrenRegistry
AASM1Pediatric OSA: Objective Assessment of Positive Airway Pressure Therapy AdherenceRegistry
AASM2Pediatric OSA: Objective Assessment of OSA Signs and Symptoms in Children with Complex Medical ConditionsRegistry
AASM3Adult OSA: Screening for Adult OSA by Primary Care PhysiciansRegistry
ABFM11Person-Centered Primary Care Measure Performance Measure (PCPCM PRO-PM)Registry
ABFM9Measuring the Value-Functions of Primary Care: Provider Level Continuity MeasureRegistry
ABG40Hypotension Prevention After Spinal Placement for Elective Cesarean SectionRegistry
ABG41Upper Extremity Nerve Blockade in Shoulder SurgeryRegistry
ABG42Known or Suspected Difficult Airway Mitigation StrategiesRegistry
ACCPIN11Heart Failure: Patient Self Care EducationRegistry
ACCPIN7Peripheral Artery Disease: Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular RiskRegistry
ACCPIN8Hypertension Control (Stage 1 or 2)Registry
ACEP19Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and OlderRegistry
ACEP21Coagulation Studies in Patients Presenting with Chest Pain with No Coagulopathy or BleedingRegistry
ACEP22Appropriate Emergency Department Utilization of CT for Pulmonary EmbolismRegistry
ACEP25Tobacco Use: Screening and Cessation Intervention for Patients with Asthma and COPDRegistry
ACEP30Sepsis Management: Septic Shock: Lactate Clearance Rate of ≥ 10%Registry
ACEP31Appropriate Foley catheter use in the emergency departmentRegistry
ACEP48Sepsis Management: Septic Shock: Lactate Level Measurement, Antibiotics Ordered, and Fluid ResuscitationRegistry
ACEP50ED Median Time from ED arrival to ED departure for all Adult PatientsRegistry
ACEP51ED Median Time from ED arrival to ED departure for all Pediatric PatientsRegistry
ACEP52Appropriate Emergency Department Utilization of Lumbar Spine Imaging for Atraumatic Low Back PainRegistry
ACEP53Appropriate Use of Imaging for Recurrent Renal ColicRegistry
ACEP54Appropriate Utilization of FAST Exam in the Emergency DepartmentRegistry
ACEP55Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 YearsRegistry
ACEP56Follow-Up Care Coordination Documented in Discharge SummaryRegistry
ACEP57Avoidance of Opioid therapy for migraine, low back pain, dental painRegistry
ACEP58Appropriate Treatment for Adults with Upper Respiratory Infection (URI)Registry
ACMS2Closing the Mohs Surgery Referral Loop: Transmission of Surgical ReportRegistry
ACMS3Antibiotic Prophylaxis for High Risk Cardiac / Orthopedic Cases prior to Mohs micrographic surgery - Prevention of OveruseRegistry
ACMS4Surgical Site Infection Rate - Mohs Micrographic SurgeryRegistry
ACMS5Documentation of High-Risk Squamous Cell Carcinoma Stage in Mohs Micrographic Surgery RecordRegistry
ACMS8Limit quantity of opioids prescribed for pain management in patients following Mohs micrographic surgeryRegistry
ACQR12ABCDEF Bundle - Early mobility for ICU patientsRegistry
ACQR13Sepsis: Hour One bundleRegistry
ACQR15Use of a risk stratification tool in patients with CAPRegistry
ACQR16COPD Exacerbation or CHF Exacerbation requiring Hospital Admission: Palliative Care EvaluationRegistry
ACQR3COPD: Steroids for no more than 5 days in COPD ExacerbationRegistry
ACQR9Use of ACE-I or ARB and beta blockade in CHFRegistry
ACR10Hepatitis B Safety ScreeningRegistry
ACR12Disease Activity Measurement for Patients with PsARegistry
ACR14Gout: Serum Urate TargetRegistry
ACR15Safe Hydroxychloroquine DosingRegistry
ACR16Rheumatoid Arthritis Patients with Low Disease Activity or RemissionRegistry
ACRAD15Report Turnaround Time: RadiographyRegistry
ACRAD16Report Turnaround Time: Ultrasound (Excluding Breast US)Registry
ACRAD17Report Turnaround Time: MRIRegistry
ACRAD18Report Turnaround Time: CTRegistry
ACRAD19Report Turnaround Time: PETRegistry
ACRAD25Report Turnaround Time: MammographyRegistry
ACRAD34Multi-strata weighted average for 3 CT Exam Types: Overall Percent of CT exams for which Dose Length Product is at or below the size-specific diagnostic reference level (for CT Abdomen-pelvis with contrast/single phase scan, CT Chest without contrast/single phase scan and CT Head/Brain without contrast/single phase scan)Registry
ACRAD36Incidental Coronary Artery Calcification Reported on Chest CTRegistry
ACRAD37Interpretation of CT Pulmonary Angiography (CTPA) for Pulmonary EmbolismRegistry
ACRAD38Use of Low Dose Cranial CT or MRI Examinations for Patients with Ventricular ShuntsRegistry
ACRAD39Use of Low Dose CT Studies for Adults with Suspicion of Urolithiasis or NephrolithiasisRegistry
ACRAD40Use of Structured Reporting in Prostate MRIRegistry
ACRAD41Use of Quantitative Criteria for Oncologic FDG PET ImagingRegistry
ACRAD42Surveillance Imaging for Liver Nodules <10mm in Patients at Risk for Hepatocellular Carcinoma (HCC)Registry
AHSQC10Ventral Hernia Repair: Pain and Functional Status AssessmentRegistry
AHSQC6Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative PeriodRegistry
AJRR3Hip Arthroplasty: Shared Decision-Making: Trial of Conservative (Non-surgical) TherapyRegistry
AJRR4Hip Arthroplasty: Venous Thromboembolic and Cardiovascular Risk EvaluationRegistry
AJRR6Hip/Knee Arthroplasty: Unplanned Readmission within 90 Days Following the Primary ProcedureRegistry
AJRR7Hip/Knee Replacement: Postoperative AmbulationRegistry
AQI18Coronary Artery Bypass Graft (CABG): Prolonged Intubation – Inverse MeasureRegistry
AQI48Patient-Reported Experience with AnesthesiaRegistry
AQI49Adherence to Blood Conservation Guidelines for Cardiac Operations using Cardiopulmonary Bypass (CPB) – CompositeRegistry
AQI55Team-Based Implementation of a Care-and-Communication Bundle for ICU PatientsRegistry
AQI56Use of Neuraxial Techniques and/or Peripheral Nerve Blocks for Total Knee Arthroplasty (TKA)Registry
AQI57Safe Opioid Prescribing PracticesRegistry
AQI62Obstructive Sleep Apnea: Patient EducationRegistry
AQI65Avoidance of Cerebral Hyperthermia for Procedures Involving Cardiopulmonary BypassRegistry
AQI67Consultation for Frail PatientsRegistry
AQI68Obstructive Sleep Apnea: Mitigation StrategiesRegistry
AQI69Intraoperative Antibiotic RedosingRegistry
AQI70Prevention of Arterial Line-Related Bloodstream InfectionsRegistry
AQI71Ambulatory Glucose ManagementRegistry
AQI72Perioperative Anemia ManagementRegistry
AQUA14Stones: Inappropriate Repeat Shock Wave Lithotripsy (SWL) Within 6 Months of Initial TreatmentRegistry
AQUA15Stones: Urinalysis Performed Before Surgical Stone ProceduresRegistry
AQUA16Non-Muscle Invasive Bladder Cancer: Repeat Transurethral Resection of Bladder Tumor (TURBT) for T1 diseaseRegistry
AQUA18Non-Muscle Invasive Bladder Cancer: Early Surveillance Cystoscopy for Non-Muscle Invasive Bladder CancerRegistry
AQUA26Benign Prostate Hyperplasia (BPH): Inappropriate Lab & Imaging Services for Patients with BPHRegistry
AQUA8Hospital admissions/complications within 30 days of TRUS BiopsyRegistry
ASPS10Patient Satisfaction with Information Provided during Breast ReconstructionRegistry
ASPS16Airway Assessment for patients undergoing RhinoplastyRegistry
ASPS17Patient Satisfaction with Rhinoplasty ProcedureRegistry
ASPS18Shared-decision making for post-operative management of discomfort following RhinoplastyRegistry
ASPS22Coordination of Care for Anticoagulated Patients Undergoing Reconstruction After Skin Cancer ResectionRegistry
ASPS24Visits to the ER or Urgent Care Following Reconstruction After Skin Cancer ResectionRegistry
ASPS26Patient Satisfaction with Information Prior to Facial Reconstruction After Skin Cancer Resection ProceduresRegistry
ASPS27Avoidance of Post-operative Systemic Antibiotics for Office-based Closures and Reconstruction After Skin Cancer ProceduresRegistry
ASPS28Continuation of Anticoagulation Therapy in the Office-based Setting for Closure and Reconstruction After Skin Cancer Resection ProceduresRegistry
ASPS29Avoidance of Opioid Prescriptions for Closure and Reconstruction After Skin Cancer ResectionRegistry
ASPS5Breast Reconstruction: Return to ORRegistry
CAP22Turnaround Time (TAT) - BiopsiesRegistry
CAP28Helicobacter pylori Status and Turnaround TimeRegistry
CAP30Urinary Bladder Biopsy Diagnostic Requirements For Appropriate Patient ManagementRegistry
CAP32Prostate Cancer Gleason Pattern, Score, and Grade GroupRegistry
CAP33Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status in Colorectal Carcinoma, Endometrial, Gastroesophageal, or Small Bowel CarcinomaRegistry
CAP34Biomarker Status to Inform Clinical Management and Treatment Decisions in Patients with Non-small Cell Lung CancerRegistry
CAP35Cancer Protocol and Turnaround Time for Gastrointestinal Carcinomas: Gastric, Esophageal, Colorectal and Hepatocellular CarcinomasRegistry
CAP36p16 Immunohistochemistry Reporting for Human Papillomavirus in Patients with Oropharyngeal Squamous Cell Carcinoma (OPSCC)Registry
CAP37Cancer Protocol and Turnaround Time for Gynecologic and Genitourinary Carcinomas: Carcinoma of the Endometrium, Prostate, and Renal Tubular OriginRegistry
CCOME1Patient-Reported Pain and/or Function Improvement after Total Knee ArthroplastyRegistry
CCOME4Patient-Reported Pain and/or Function Improvement after ACLR SurgeryRegistry
CCOME5Extent of Osteoarthritis Observed in Arthroscopic Partial MeniscectomyRegistry
CCOME6Patient-Reported Pain and/or Function Improvement after APM SurgeryRegistry
CCOME7Patient-Reported Pain and/or Function Improvement after Total Hip ArthroplastyRegistry
CCOME8Patient-Reported Pain and/or Function Improvement after Total Shoulder ArthroplastyRegistry
CDR1Adequate Off-loading of Diabetic Foot Ulcer at each visitRegistry
CDR2Diabetic Foot Ulcer (DFU) Healing or ClosureRegistry
CDR5Adequate Compression at each visit for Patients with VLUsRegistry
CDR6Venous Leg Ulcer (VLU) outcome measure: Healing or ClosureRegistry
CDR8Appropriate Use of hyperbaric oxygen therapy for patients with diabetic foot ulcersRegistry
CESQIP1Post operative hypocalcemia after thyroidectomy surgeryRegistry
CESQIP3Pre operative ultrasound exam of patients with thyroid cancerRegistry
CESQIP5Related readmission for adrenal related problemsRegistry
CESQIP9qPTH >50% Reduction at End of ProcedureRegistry
ECPR39Avoid Head CT for Patients with Uncomplicated SyncopeRegistry
ECPR40Initiation of the Initial Sepsis BundleRegistry
ECPR41Rh Status Evaluation and Treatment of Pregnant Women at Risk of Fetal Blood ExposureRegistry
ECPR46Avoidance of Opiates for Low Back Pain or MigrainesRegistry
ECPR50Door to Diagnostic Evaluation by a Provider Within 30 Minutes – Urgent Care PatientsRegistry
ECPR51Discharge Prescription of Naloxone after Opioid Poisoning or OverdoseRegistry
ECPR52Appropriate Treatment of Psychosis and Agitation in the Emergency DepartmentRegistry
ECPR53Clinician Reporting of Loss of Consciousness to State Department of Public Health or Department of Motor VehiclesRegistry
ECPR54Avoidance of Co-Prescribing of Opioid Analgesic and BenzodiazepineRegistry
ECPR55Avoidance of Long-Acting (LA) or Extended-Release (ER) Opiate Prescriptions and Opiate Prescriptions for Greater Than 3 Days Duration for Acute PainRegistry
ECPR56Opioid Withdrawal: Initiation of Medication-Assisted Treatment (MAT) and Referral to Outpatient Opioid TreatmentRegistry
EPREOP30Ultrasound Guidance for Peripheral Nerve Block with Patient ExperienceRegistry
EPREOP31Intraoperative Hypotension among Non-Emergent Noncardiac Surgical CasesRegistry
FORCE21Review of Pain Status Assessment for Patients with OsteoarthritisRegistry
FOTO2Functional Status Change for Patients Post Stroke: Lower BodyRegistry
FOTO3Functional Status Change for Patients Post Stroke: Upper BodyRegistry
FOTO4Functional Status Changes for Patients with Upper or Lower Extremity Regional SwellingRegistry
GIQIC10Appropriate management of anticoagulation in the peri-procedural period rate – EGDRegistry
GIQIC22Screening Colonoscopy Adenoma Detection RateRegistry
GIQIC23Appropriate follow-up interval based on pathology findings in screening colonoscopyRegistry
HCPR14Venous Thromboembolism (VTE) ProphylaxisRegistry
HCPR16Physician’s Orders for Life-Sustaining Treatment (POLST) FormRegistry
HCPR17Pressure Ulcers – Risk Assessment and Plan of CareRegistry
HCPR18Unintentional Weight Loss – Risk Assessment and Plan of CareRegistry
HCPR20Clostridium Difficile – Risk Assessment and Plan of CareRegistry
HCPR22Critical Care Transfer of Care – Use of Verbal Checklist or ProtocolRegistry
HCPR23Avoidance of Echocardiogram and Carotid Ultrasound for SyncopeRegistry
HM10Outcomes of Hearing Loss TreatmentRegistry
HM11Outcomes of Treatment of Subjective TinnitusRegistry
HM12Outcomes of Treatment of Benign Paroxysmal Positional VertigoRegistry
HM4Functional Status Change for Patients With Upper-limb Functional Status DeficitRegistry
HM5Functional Status Change for Patients With Neck Functional Status DeficitRegistry
HM6Functional Status Change for Patients With Low Back Functional Status DeficitRegistry
HM7Functional Status Change for Patients with Vestibular DysfunctionRegistry
HM8Functional Status Change for Patients With Lower Extremity Functional Status DeficitRegistry
HM9Functional Benefit of a Cochlear ImplantRegistry
IGR1Comprehensive TTE studies reporting a measured value of LVEF AND wall motion findings with LVEF < 50%Registry
IGR10Transthoracic Echo (TTE) performance per ASE guidelinesRegistry
IGR12Appropriate diagnosis verification and severity grading for valve disease through transthoracic echocardiography (TTE) quantitative parameters.Registry
IGR14Appropriate Evaluation of Left Ventricular Structure and Systolic Function with Transthoracic Echocardiography (TTE) to Guide Heart Failure and Cardiomyopathy ManagementRegistry
IGR15Myocardial Perfusion Imaging (MPI) or Stress Echocardiography Imaging Studies - Adequate Exercise ProtocolRegistry
IGR16Myocardial Perfusion Imaging (MPI) Studies, Transthoracic Echo (TTE), or Stress Echocardiography Imaging Studies - Adequate Reporting for Appropriate InterventionsRegistry
IGR17Myocardial Perfusion Imaging (MPI) studies - Radiation Reduction StrategiesRegistry
IGR18Myocardial Perfusion Imaging (MPI) or Stress Echocardiography imaging studies - Improving Image QualityRegistry
IGR2Parameters in stress echocardiography dobutamine testing for low flow, low gradient aortic stenosisRegistry
IGR9Stress echo performance for shortness of breath per ASE guidelinesRegistry
IRIS1Endothelial Keratoplasty - Post-operative improvement in best corrected visual acuity to 20/40 or betterRegistry
IRIS13Diabetic Macular Edema - Loss of Visual AcuityRegistry
IRIS17Acute Anterior Uveitis: Post-treatment Grade 0 anterior chamber cellsRegistry
IRIS2Glaucoma – Intraocular Pressure ReductionRegistry
IRIS23Refractive Surgery: Patients with a postoperative uncorrected visual acuity (UCVA) of 20/20 or better within 30 daysRegistry
IRIS24Refractive Surgery: Patients with a postoperative correction within + or - 0.5 Diopter (D) of the intended correctionRegistry
IRIS26Avoidance of Routine Antibiotic Use in Patients Before or After Intravitreal InjectionsRegistry
IRIS35Improvement of Macular Edema in Patients with UveitisRegistry
IRIS38Endothelial Keratoplasty – Dislocation Requiring Surgical InterventionRegistry
IRIS39Intraocular Pressure Reduction Following Trabeculectomy or an Aqueous Shunt ProcedureRegistry
IRIS41Improved visual acuity after epiretinal membrane treatment within 120 daysRegistry
IRIS43Intraocular Pressure Reduction Following Laser TrabeculoplastyRegistry
IRIS44Visual Field Progression in GlaucomaRegistry
IRIS45Exudative Age-Related Macular Degeneration: Loss of Visual AcuityRegistry
IRIS46Evidence of anatomic closure of macular hole within 90 days after surgery as documented by OCTRegistry
IRIS48Adult Surgical Esotropia: Postoperative alignmentRegistry
IRIS49Surgical Pediatric Esotropia: Postoperative alignmentRegistry
IRIS5Surgery for Acquired Involutional Ptosis: Patients with an improvement of marginal reflex distance (MRD)Registry
IRIS50Amblyopia: Interocular visual acuityRegistry
IRIS51Acute Anterior Uveitis: Post-treatment visual acuityRegistry
IRIS52Post-operative opioid management following ocular surgeryRegistry
IRIS53Chronic Anterior Uveitis - Post-treatment visual acuityRegistry
IRIS54Complications After Cataract SurgeryRegistry
IRIS55Visual Acuity Improvement Following Cataract Surgery and Minimally Invasive Glaucoma SurgeryRegistry
IRIS56Adult Diplopia: Improvement of ocular deviation or absence of diplopia or functional improvementRegistry
IRIS57Idiopathic Intracranial Hypertension: Improvement of mean deviation or stability of mean deviationRegistry
IRIS58Improved Visual Acuity after Vitrectomy for Complications of Diabetic Retinopathy within 120 DaysRegistry
IRIS59Regaining Vision After Cataract SurgeryRegistry
IRIS6Acquired Involutional Entropion: Normalized lid position after surgical repairRegistry
IRIS60Visual Acuity Improvement Following Cataract Surgery Combined with a Trabeculectomy or an Aqueous Shunt ProcedureRegistry
IROMS11Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in knee rehabilitation of patients with knee injury measured via their validated Knee Outcome Survey (KOS) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCID.Registry
IROMS12Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with knee injury pain.Registry
IROMS13Failure to Progress (FTP): Proportion of patients not achieving a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with hip, leg or ankle injuries using the validated Lower Extremity Function Scale (LEFS) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCID.Registry
IROMS14Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with hip, leg or ankle (lower extremity except knee) injury.Registry
IROMS15Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with neck pain/injury measured via the validated Neck Disability Index (NDI).Registry
IROMS16Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with neck pain/injury.Registry
IROMS17Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation patients with low back pain measured via the validated Modified Low Back Pain Disability Questionnaire (MDQ) score.Registry
IROMS18Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with low back pain.Registry
IROMS19Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with arm, shoulder, and hand injury measured via the validated Disability of Arm Shoulder and Hand (DASH) score, Quick Disability of Arm Shoulder and Hand (QDASH) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCID.Registry
IROMS20Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with arm, shoulder, or hand injury.Registry
MBHR1Use of Anxiety Severity MeasureRegistry
MBHR10Symptom Improvement in adults with ADHDRegistry
MBHR11Cognitive Assessment with Counseling on Safety and Potential RiskRegistry
MBHR12Patient Feedback of Test Results Following Cognitive or Mental Status AssessmentRegistry
MBHR2Anxiety Response at 6-monthsRegistry
MBHR3Pain Interference Response utilizing PROMISRegistry
MBHR4Social Role Functioning Outcome utilizing PROMISRegistry
MBHR5Screening and monitoring for psychosocial problems among children and youthRegistry
MBHR6Sleep Quality Assessment and Sleep Response at 3-monthsRegistry
MBHR7Posttraumatic Stress Disorder (PTSD) Outcome Assessment for Adults and ChildrenRegistry
MBHR8Alcohol Use Disorder Outcome ResponseRegistry
MBHR9Outcome monitoring of ADHD functional impairment in children and youthRegistry
MEDNAX53Use of Capnography for Non-Operating Room AnesthesiaRegistry
MEDNAX54Labor Epidural Failure when Converting from Labor Analgesia to Cesarean Section AnesthesiaRegistry
MEDNAX55Use of ASPECTS (Alberta Stroke Program Early CT Score) for non-contrast CT Head performed for suspected acute stroke.Registry
MEDNAX56Use of a “PEG Test” to Manage Patients Receiving OpioidsRegistry
MEX5Hammer Toe OutcomeRegistry
MSN13Screening Coronary Calcium Scoring for Cardiovascular Risk Assessment Including Coronary Artery Calcification Regional Distribution ScoringRegistry
MSN15Use of Thyroid Imaging Reporting & Data System (TI-RADS) in Final Report to Stratify Thyroid Nodule RiskRegistry
MSN16Screening Abdominal Aortic Aneurysm Reporting with RecommendationsRegistry
MUSIC10Prostate Cancer: Confirmation Testing in low risk AS eligible patientsRegistry
MUSIC11Prostate Cancer: Follow-Up Testing for patients on active surveillance for at least 30 monthsRegistry
MUSIC12Kidney Stones: ED visit within 30 days of ureteroscopyRegistry
MUSIC15Kidney Stones: SWL in patients with largest renal stone > 2 cm or lower pole stone > 1 cmRegistry
MUSIC17Kidney Stones: Opioid utilization after ureteroscopy and shockwave lithotripsyRegistry
MUSIC18Kidney Stones: Alpha-blockers at discharge for patients undergoing ureteroscopy or shockwave lithotripsyRegistry
MUSIC19Kidney Stones: Readmission within 30 days of ureteroscopyRegistry
MUSIC20Prostate Cancer: Complications within 30 days of radical prostatectomyRegistry
MUSIC21Prostate Cancer: Opioid utilization after radical prostatectomyRegistry
MUSIC22Prostate Cancer: Urinary continence at 12 months post-radical prostatectomyRegistry
MUSIC23Renal Mass: Documentation of the RENAL score for patients with small renal mass diagnosesRegistry
MUSIC24Kidney Stones: Post-ureteroscopy and shockwave lithotripsy imaging for any stonesRegistry
MUSIC25Renal Mass: ED visit or Readmission within 30 days of radical nephrectomyRegistry
MUSIC26Renal Mass: ED Visit or Readmission within 30 days of partial nephrectomyRegistry
MUSIC4Prostate Cancer: Active Surveillance/Watchful Waiting for Low Risk Prostate Cancer PatientsRegistry
MUSIC5Prostate Cancer: Radical Prostatectomy Cases LOSRegistry
NHCR4Repeat screening or surveillance colonoscopy recommended within one year due to inadequate/poor bowel preparationRegistry
NIPM18CHANGE IN PATIENT REPORTED QUALITY OF LIFE FOLLOWING EPIDURAL LYSIS OF ADHESIONSRegistry
NIPM19CHANGE IN PATIENT REPORTED QUALITY OF LIFE AND FUNCTIONAL STATUS FOLLOWING MEDIAL BRANCH RADIOFREQUENCY ABLATIONRegistry
NIPM20CHANGE IN PATIENT REPORTED PAIN AND FUNCTIONAL STATUS FOLLOWING SPINAL CORD STIMULATOR IMPLANTATIONRegistry
NIPM22CHANGE IN PATIENT REPORTED QUALITY OF LIFE FOLLOWING EPIDURAL CORTICOSTEROID INJECTIONRegistry
NIPM23CHANGE IN PATIENT REPORTED QUALITY OF LIFE FOLLOWING MAJOR JOINT CORTICOSTEROID INJECTIONRegistry
NIPM24CHANGE IN PATIENT REPORTED QUALITY OF LIFE FOLLOWING INTRATHECAL PUMP IMPLANTATIONRegistry
NIPM25CHANGE IN PATIENT REPORTED QUALITY OF LIFE FOLLOWING INTERSPINOUS INDIRECT DECOMPRESSION (SPACER)Registry
NPQR1Notification to the ordering provider requesting myoglobin or CK-MB in the diagnosis of suspected acute myocardial infarction (AMI)Registry
NPQR11Rate of communicating results of an amended report with a major discrepancy to the responsible providerRegistry
NPQR13Rate of notification to clinical provider of a new diagnosis of malignancyRegistry
NPQR15Non-small cell lung carcinoma (NSCLC) ancillary biomarker testing status and turnaround time (TAT) from point of specimen accession date to ancillary biomarker testing completion and reporting date should be ≤ 10 daysRegistry
NPQR16Notification to the provider ordering repeat blood chemistry panels in clinically stable patients within four days.Registry
NPQR17Notification to the provider ordering repeat C. difficile stool toxin testing within seven daysRegistry
NPQR18Notification to the provider ordering repeat CBCs in clinically stable patients within four daysRegistry
NPQR19Notification to the provider ordering repeat Hepatitis C serology testing on a patient with previously positive resultsRegistry
NPQR2Notification to the ordering provider requesting thyroid screening tests other than only a Thyroid Stimulating Hormone (TSH) test in the initial screening of a patient with a suspected thyroid disorderRegistry
NPQR3Notification to the ordering provider requesting amylase testing in the diagnosis of suspected acute pancreatitisRegistry
NPQR4Time interval: critical value reporting for chemistryRegistry
NPQR5Time interval: critical value reporting for cerebrospinal fluid - white blood cell (CSF - WBC)Registry
NPQR6Time interval: critical value reporting for toxicologyRegistry
NPQR7Time interval: critical value reporting for troponinRegistry
OBERD32Quality of Life - Physical Health OutcomesRegistry
OEIS6Appropriate non-invasive arterial testing for patients with intermittent claudication who are undergoing a LE peripheral vascular interventionRegistry
OEIS7Structured Walking Program Prior to Intervention for ClaudicationRegistry
OEIS8Use of ultrasound guidance for vascular accessRegistry
ONSQIR21Patient Reported Health-Related Quality of Life (HRQoL) during Treatment for Advanced CancerRegistry
ONSQIR22PCR Test with MR2 or greater result (BCR-ABL1 transcript level <= 1% [IS]) for patients receiving TKI for at least 6 months for Chronic Myelogenous LeukemiaRegistry
ONSQIR23Assessment for and management of immune-related adverse events during cancer treatment with checkpoint inhibitors (ICPi)Registry
PIMSH1Oncology: Advance Care Planning in metastatic cancer patientsRegistry
PIMSH10Oncology: Hepatitis B serology testing and prophylactic treatment prior to receiving anti-CD20 targeting drugsRegistry
PIMSH11Oncology: Utilization of PET, PET/CT, or CT scans for breast cancer stage 0, I, or II at any time during the course of evaluation and treatmentRegistry
PIMSH2Oncology: Utilization of GCSF in metastatic colorectal cancerRegistry
PIMSH3Oncology: Combination chemotherapy recommended or received within 4 months of diagnosis by women under 70 with AJCC stage T1cN0M0 to Stage 1B-III ER/PR negative breast cancerRegistry
PIMSH4Oncology: Patient-reported pain improvementRegistry
PIMSH8Oncology: Mutation testing for lung cancer completed prior to start of targeted therapyRegistry
PIMSH9Oncology: Supportive care drug utilization in last 14 days of lifeRegistry
PINC55Appropriate Documentation of a Malnutrition DiagnosisRegistry
PINC56Assessment of Nutritionally At-Risk Patients for Malnutrition and Development of Nutrition Recommendations/Interventions by a Registered Dietitian NutritionistRegistry
PP8Measurement-based Care Processes: Baseline Assessment, Monitoring and Treatment AdjustmentRegistry
PP9Improvement or Maintenance of Functioning for Individuals with a Mental Health and/or Substance Use DisorderRegistry
QMM16IVC Filter Management ConfirmationRegistry
QMM17Appropriate Follow-up Recommendations for Ovarian-Adnexal Lesions using the Ovarian-Adnexal Reporting and Data System (O-RADS)Registry
QMM18Use of Breast Cancer Risk Score on MammographyRegistry
QMM19DEXA/DXA and Fracture Risk Assessment for Patients with OsteopeniaRegistry
QMM20Opening Pressure in Lumbar PunctureRegistry
QOPI23Concurrent Chemo radiation for Patients with a Diagnosis of Stage IIIB NSCLCRegistry
QOPI26Sentinel Lymph Node (SLN) Biopsies for Patients AJCC T1b-T4 MelanomaRegistry
QOPI27Appropriate Antiemetic Therapy for High- and Moderate Emetic Risk Antineoplastic AgentsRegistry
QUANTUM31Central Line Ultrasound GuidanceRegistry
RCOIR10Upper Extremity Edema ImprovementRegistry
RCOIR12Tunneled Hemodialysis Catheter SuccessRegistry
RCOIR13Percutaneous Arteriovenous Fistula for Dialysis - Clinical Success RateRegistry
RCOIR5End Stage Renal Disease (ESRD) Initiation of Home Dialysis or Self-CareRegistry
RCOIR7Improved Access Site BleedingRegistry
REGCLR1Heel Pain Treatment Outcomes for AdultsRegistry
REGCLR2Tendinitis/ Enthesopathy- Injection Treatment Outcomes for AdultsRegistry
REGCLR3Bunion Outcome - Adult and AdolescentRegistry
REGCLR4Heel Pain Treatment Outcomes for Pediatric PatientsRegistry
REGCLR5Offloading with Remote MonitoringRegistry
REGCLR6Use of Digital Imaging to Monitor and Improve Treatment Outcomes in Chronic Wound HealingRegistry
REGCLR7Use of Ankle Foot Orthotics to improve patient functionRegistry
RPAQIR13Rate of Timely Documentation Transmission to Dialysis Unit/Referring PhysicianRegistry
RPAQIR14Arteriovenous Graft Thrombectomy Success RateRegistry
RPAQIR15Arteriovenous Fistulae Thrombectomy Success RateRegistry
RPAQIR16Peritoneal Dialysis Catheter Success RateRegistry
RPAQIR18Advance Directives CompletedRegistry
RPAQIR5Transplant ReferralRegistry
SPINETRACK4Percent of patients meeting SCB thresholds for back or neck painRegistry
SPINETRACK5Percent of patients meeting SCB thresholds for leg or arm painRegistry
SPINETRACK6Percent of patients meeting SCB thresholds for pain-related disability (ODI/NDI)Registry
SPINETRACK8Patient satisfaction following spinal fusion surgeryRegistry
SPINETRACK9Unplanned hospital readmission following spinal fusion surgery.Registry
STS1Prolonged Length of Stay Following Coronary Artery Bypass GraftingRegistry
STS7Patient Centered Surgical Risk Assessment and Communication for Cardiac SurgeryRegistry
UREQA1Ankylosing Spondylitis: Controlled DiseaseRegistry
UREQA2Ankylosing Spondylitis: Appropriate Pharmacologic TherapyRegistry
UREQA4Folic or Folinic Acid Therapy for Patients Treated with MethotrexateRegistry
USWR22Patient Reported Nutritional Assessment in Patients with Wounds and UlcersRegistry
USWR23Non Invasive Arterial Assessment of patients with lower extremity wounds or ulcers for determination of healing potentialRegistry
USWR24Patient Reported Experience of Care: Wound OutcomeRegistry
USWR25Pressure Ulcer* (PU) Healing or Closure for ulcers on the torso (body)Registry
USWR26Patient Reported Outcome of late effects of radiation symptoms following treatment with Hyperbaric Oxygen Therapy (HBOT)Registry
USWR27Assessment of Nutritionally At-Risk Patients for Malnutrition and Development of Nutrition Recommendations/Interventions by a Registered Dietitian NutritionistRegistry
USWR28Obtaining Preoperative Nutritional Recommendations from a Registered Dietitian Nutritionist (RDN) in Nutritionally At-Risk Surgical PatientsRegistry
WCHQ10Diabetes Care All or None Outcome Measure: Optimal ControlRegistry
WCHQ9Diabetes Care All or None Process Measure: Optimal TestingRegistry