Allergy Immunology (14)

Includes the following individual measures:

#	Measure Title	Submission Methods
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims, Electronic Health Record, Cms Web Interface, Registry
238	Use of High-Risk Medications in Older Adults	Electronic Health Record, Registry
317	Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	Claims, Electronic Health Record, Registry
331	Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)	Registry
332	Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)	Registry
338	HIV Viral Suppression	Electronic Health Record, Registry
340	HIV Medical Visit Frequency	Registry
374	Closing the Referral Loop: Receipt of Specialist Report	Electronic Health Record, Registry
398	Optimal Asthma Control	Registry
487	Screening for Social Drivers of Health	Registry
493	Adult Immunization Status	Registry
498	Connection to Community Service Provider	Registry
503	Gains in Patient Activation Measure (PAM) Scores at 12 Months	Registry

Anesthesiology (5)

Includes the following individual measures:

#	Measure Title	Submission Methods
404	Anesthesiology Smoking Abstinence	Registry
424	Perioperative Temperature Management	Registry
430	Prevention of Post-Operative Nausea and Vomiting (PONV) - Combination Therapy	Registry
463	Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics)	Registry
477	Multimodal Pain Management	Registry

Audiology (13)

Includes the following individual measures:

#	Measure Title	Submission Methods
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
134	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Claims, Electronic Health Record, Cms Web Interface, Registry
155	Falls: Plan of Care	Claims, Registry
181	Elder Maltreatment Screen and Follow-Up Plan	Claims, Registry
182	Functional Outcome Assessment	Registry
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims, Electronic Health Record, Cms Web Interface, Registry
261	Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness	Claims, Registry
317	Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	Claims, Electronic Health Record, Registry
318	Falls: Screening for Future Fall Risk	Electronic Health Record, Cms Web Interface
431	Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling	Registry
487	Screening for Social Drivers of Health	Registry
498	Connection to Community Service Provider	Registry
134SSP	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Registry

Cardiology (25)

Includes the following individual measures:

#	Measure Title	Submission Methods
005	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)	Electronic Health Record, Registry
006	Coronary Artery Disease (CAD): Antiplatelet Therapy	Registry
007	Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%)	Electronic Health Record, Registry
008	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)	Electronic Health Record, Registry
047	Advance Care Plan	Claims, Registry
118	Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%)	Registry
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
187	Stroke and Stroke Rehabilitation: Thrombolytic Therapy	Registry
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims, Electronic Health Record, Cms Web Interface, Registry
236	Controlling High Blood Pressure	Claims, Electronic Health Record, Cms Web Interface, Registry
238	Use of High-Risk Medications in Older Adults	Electronic Health Record, Registry
243	Cardiac Rehabilitation Patient Referral from an Outpatient Setting	Registry
317	Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	Claims, Electronic Health Record, Registry
322	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients	Registry
326	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Registry
344	Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)	Registry
374	Closing the Referral Loop: Receipt of Specialist Report	Electronic Health Record, Registry
431	Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling	Registry
438	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Electronic Health Record, Cms Web Interface, Registry
441	Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)	Registry
487	Screening for Social Drivers of Health	Registry
493	Adult Immunization Status	Registry
498	Connection to Community Service Provider	Registry
503	Gains in Patient Activation Measure (PAM) Scores at 12 Months	Registry
236SSP	Controlling High Blood Pressure	Registry

Certified Nurse Midwife (13)

Includes the following individual measures:

#	Measure Title	Submission Methods
047	Advance Care Plan	Claims, Registry
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims, Electronic Health Record, Cms Web Interface, Registry
335	Maternity Care: Elective Delivery (Without Medical Indication) at < 39 Weeks (Overuse)	Registry
336	Maternity Care: Postpartum Follow-up and Care Coordination	Registry
431	Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling	Registry
475	HIV Screening	Electronic Health Record
487	Screening for Social Drivers of Health	Registry
496	Cardiovascular Disease (CVD) Risk Assessment Measure - Proportion of Pregnant/Postpartum Patients that Receive CVD Risk Assessment with a Standardized Instrument	Registry
498	Connection to Community Service Provider	Registry
503	Gains in Patient Activation Measure (PAM) Scores at 12 Months	Registry
504	Initiation, Review, And/Or Update To Suicide Safety Plan For Individuals With Suicidal Thoughts, Behavior, Or Suicide Risk	Registry
505	Reduction in Suicidal Ideation or Behavior Symptoms	Registry

Chiropractic Medicine (10)

Includes the following individual measures:

#	Measure Title	Submission Methods
182	Functional Outcome Assessment	Registry
217	Functional Status Change for Patients with Knee Impairments	Registry
218	Functional Status Change for Patients with Hip Impairments	Registry
219	Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments	Registry
220	Functional Status Change for Patients with Low Back Impairments	Registry
221	Functional Status Change for Patients with Shoulder Impairments	Registry
222	Functional Status Change for Patients with Elbow, Wrist or Hand Impairments	Registry
478	Functional Status Change for Patients with Neck Impairments	Registry
487	Screening for Social Drivers of Health	Registry
498	Connection to Community Service Provider	Registry

Clinical Social Work (20)

Includes the following individual measures:

#	Measure Title	Submission Methods
047	Advance Care Plan	Claims, Registry
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
134	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Claims, Electronic Health Record, Cms Web Interface, Registry
181	Elder Maltreatment Screen and Follow-Up Plan	Claims, Registry
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims, Electronic Health Record, Cms Web Interface, Registry
281	Dementia: Cognitive Assessment	Electronic Health Record
282	Dementia: Functional Status Assessment	Registry
286	Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia	Registry
288	Dementia: Education and Support of Caregivers for Patients with Dementia	Registry
305	Initiation and Engagement of Substance Use Disorder Treatment	Electronic Health Record
370	Depression Remission at Twelve Months	Electronic Health Record, Cms Web Interface, Registry
382	Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment	Electronic Health Record
383	Adherence to Antipsychotic Medications For Individuals with Schizophrenia	Registry
431	Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling	Registry
487	Screening for Social Drivers of Health	Registry
498	Connection to Community Service Provider	Registry
502	Improvement or Maintenance of Functioning for Individuals with a Mental and/or Substance Use Disorder	Registry
504	Initiation, Review, And/Or Update To Suicide Safety Plan For Individuals With Suicidal Thoughts, Behavior, Or Suicide Risk	Registry
505	Reduction in Suicidal Ideation or Behavior Symptoms	Registry
134SSP	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Registry

Dentistry (2)

Includes the following individual measures:

#	Measure Title	Submission Methods
378	Children Who Have Dental Decay or Cavities	Electronic Health Record
379	Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists	Electronic Health Record

Dermatology (13)

Includes the following individual measures:

#	Measure Title	Submission Methods
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
137	Melanoma: Continuity of Care - Recall System	Registry
176	Tuberculosis Screening Prior to First Course of Biologic and/or Immune Response Modifier Therapy	Registry
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims, Electronic Health Record, Cms Web Interface, Registry
317	Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	Claims, Electronic Health Record, Registry
374	Closing the Referral Loop: Receipt of Specialist Report	Electronic Health Record, Registry
410	Psoriasis: Clinical Response to Systemic Medications	Registry
440	Skin Cancer: Biopsy Reporting Time - Pathologist to Clinician	Registry
485	Psoriasis- Improvement in Patient-Reported Itch Severity	Registry
486	Dermatitis – Improvement in Patient-Reported Itch Severity	Registry
487	Screening for Social Drivers of Health	Registry
498	Connection to Community Service Provider	Registry
503	Gains in Patient Activation Measure (PAM) Scores at 12 Months	Registry

Diagnostic Radiology (6)

Includes the following individual measures:

#	Measure Title	Submission Methods
145	Radiology: Exposure Dose Indices Reported for Procedures Using Fluoroscopy	Claims, Registry
360	Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies	Registry
364	Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines	Registry
405	Appropriate Follow-up Imaging for Incidental Abdominal Lesions	Claims, Registry
406	Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients	Claims, Registry
436	Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques	Claims, Registry

Electrophysiology Cardiac Specialist (2)

Includes the following individual measures:

#	Measure Title	Submission Methods
392	Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation	Registry
393	Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision	Registry

Emergency Medicine (14)

Includes the following individual measures:

#	Measure Title	Submission Methods
065	Appropriate Treatment for Upper Respiratory Infection (URI)	Electronic Health Record, Registry
066	Appropriate Testing for Pharyngitis	Electronic Health Record, Registry
116	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis	Registry
134	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Claims, Electronic Health Record, Cms Web Interface, Registry
187	Stroke and Stroke Rehabilitation: Thrombolytic Therapy	Registry
254	Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain	Registry
317	Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	Claims, Electronic Health Record, Registry
331	Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)	Registry
332	Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)	Registry
415	Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older	Registry
416	Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years	Registry
487	Screening for Social Drivers of Health	Registry
498	Connection to Community Service Provider	Registry
134SSP	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Registry

Endocrinology (21)

Includes the following individual measures:

#	Measure Title	Submission Methods
001	Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)	Claims, Electronic Health Record, Cms Web Interface, Registry
039	Screening for Osteoporosis for Women Aged 65-85 Years of Age	Claims, Registry
117	Diabetes: Eye Exam	Registry, Electronic Health Record
118	Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%)	Registry
126	Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy - Neurological Evaluation	Registry
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
134	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Claims, Electronic Health Record, Cms Web Interface, Registry
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims, Electronic Health Record, Cms Web Interface, Registry
236	Controlling High Blood Pressure	Claims, Electronic Health Record, Cms Web Interface, Registry
374	Closing the Referral Loop: Receipt of Specialist Report	Electronic Health Record, Registry
418	Osteoporosis Management in Women Who Had a Fracture	Claims, Registry
438	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Electronic Health Record, Cms Web Interface, Registry
462	Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy	Electronic Health Record
487	Screening for Social Drivers of Health	Registry
488	Kidney Health Evaluation	Registry, Electronic Health Record
493	Adult Immunization Status	Registry
498	Connection to Community Service Provider	Registry
503	Gains in Patient Activation Measure (PAM) Scores at 12 Months	Registry
001SSP	Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)	Registry
134SSP	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Registry
236SSP	Controlling High Blood Pressure	Registry

Family Medicine (66)

Includes the following individual measures:

#	Measure Title	Submission Methods
001	Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)	Claims, Electronic Health Record, Cms Web Interface, Registry
005	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)	Electronic Health Record, Registry
006	Coronary Artery Disease (CAD): Antiplatelet Therapy	Registry
007	Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%)	Electronic Health Record, Registry
008	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)	Electronic Health Record, Registry
009	Anti-Depressant Medication Management	Electronic Health Record
024	Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older	Claims, Registry
039	Screening for Osteoporosis for Women Aged 65-85 Years of Age	Claims, Registry
047	Advance Care Plan	Claims, Registry
048	Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older	Registry
050	Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older	Registry
065	Appropriate Treatment for Upper Respiratory Infection (URI)	Electronic Health Record, Registry
066	Appropriate Testing for Pharyngitis	Electronic Health Record, Registry
116	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis	Registry
117	Diabetes: Eye Exam	Registry, Electronic Health Record
126	Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy - Neurological Evaluation	Registry
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
134	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Claims, Electronic Health Record, Cms Web Interface, Registry
155	Falls: Plan of Care	Claims, Registry
176	Tuberculosis Screening Prior to First Course of Biologic and/or Immune Response Modifier Therapy	Registry
181	Elder Maltreatment Screen and Follow-Up Plan	Claims, Registry
182	Functional Outcome Assessment	Registry
236	Controlling High Blood Pressure	Claims, Electronic Health Record, Cms Web Interface, Registry
238	Use of High-Risk Medications in Older Adults	Electronic Health Record, Registry
243	Cardiac Rehabilitation Patient Referral from an Outpatient Setting	Registry
305	Initiation and Engagement of Substance Use Disorder Treatment	Electronic Health Record
309	Cervical Cancer Screening	Electronic Health Record
318	Falls: Screening for Future Fall Risk	Electronic Health Record, Cms Web Interface
321	CAHPS for MIPS Clinician/Group Survey	Certified Survey Vendor
326	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Registry
331	Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)	Registry
332	Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)	Registry
338	HIV Viral Suppression	Electronic Health Record, Registry
370	Depression Remission at Twelve Months	Electronic Health Record, Cms Web Interface, Registry
374	Closing the Referral Loop: Receipt of Specialist Report	Electronic Health Record, Registry
377	Functional Status Assessments for Heart Failure	Electronic Health Record
383	Adherence to Antipsychotic Medications For Individuals with Schizophrenia	Registry
387	Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users	Registry
394	Immunizations for Adolescents	Registry
398	Optimal Asthma Control	Registry
400	One-Time Screening for Hepatitis C Virus (HCV) and Treatment Initiation	Registry
401	Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis	Registry
418	Osteoporosis Management in Women Who Had a Fracture	Claims, Registry
431	Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling	Registry
438	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Electronic Health Record, Cms Web Interface, Registry
441	Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)	Registry
443	Non-Recommended Cervical Cancer Screening in Adolescent Females	Registry
464	Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use	Registry
468	Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)	Registry
472	Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture	Electronic Health Record
475	HIV Screening	Electronic Health Record
476	Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia	Electronic Health Record
483	Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM)	Registry
487	Screening for Social Drivers of Health	Registry
488	Kidney Health Evaluation	Registry, Electronic Health Record
493	Adult Immunization Status	Registry
495	Ambulatory Palliative Care Patients’ Experience of Feeling Heard and Understood	Registry
497	Preventive Care and Wellness (composite)	Registry
498	Connection to Community Service Provider	Registry
502	Improvement or Maintenance of Functioning for Individuals with a Mental and/or Substance Use Disorder	Registry
503	Gains in Patient Activation Measure (PAM) Scores at 12 Months	Registry
504	Initiation, Review, And/Or Update To Suicide Safety Plan For Individuals With Suicidal Thoughts, Behavior, Or Suicide Risk	Registry
505	Reduction in Suicidal Ideation or Behavior Symptoms	Registry
001SSP	Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)	Registry
134SSP	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Registry
236SSP	Controlling High Blood Pressure	Registry

Gastroenterology (14)

Includes the following individual measures:

#	Measure Title	Submission Methods
047	Advance Care Plan	Claims, Registry
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
185	Colonoscopy Interval for Patients with a History of Adenomatous Polyps - Avoidance of Inappropriate Use	Registry
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims, Electronic Health Record, Cms Web Interface, Registry
275	Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy	Registry
317	Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	Claims, Electronic Health Record, Registry
320	Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients	Claims, Registry
374	Closing the Referral Loop: Receipt of Specialist Report	Electronic Health Record, Registry
401	Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis	Registry
431	Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling	Registry
439	Age Appropriate Screening Colonoscopy	Registry
487	Screening for Social Drivers of Health	Registry
498	Connection to Community Service Provider	Registry
503	Gains in Patient Activation Measure (PAM) Scores at 12 Months	Registry

General Practice Family Medicine (10)

Includes the following individual measures:

#	Measure Title	Submission Methods
CAHPS_1	CAHPS for MIPS SSM: Getting Timely Care, Appointments, and Information	Certified Survey Vendor
CAHPS_2	CAHPS for MIPS SSM: How Well Providers Communicate	Certified Survey Vendor
CAHPS_3	CAHPS for MIPS SSM: Patient’s Rating of Provider	Certified Survey Vendor
CAHPS_4	CAHPS for MIPS SSM: Access to Specialists	Certified Survey Vendor
CAHPS_5	CAHPS for MIPS SSM: Health Promotion and Education	Certified Survey Vendor
CAHPS_6	CAHPS for MIPS SSM: Shared Decision Making	Certified Survey Vendor
CAHPS_7	CAHPS for MIPS SSM: Health Status and Functional Status	Certified Survey Vendor
CAHPS_8	CAHPS for MIPS SSM: Care Coordination	Certified Survey Vendor
CAHPS_9	CAHPS for MIPS SSM: Courteous and Helpful Office Staff	Certified Survey Vendor
CAHPS_11	CAHPS for MIPS SSM: Stewardship of Patient Resources	Certified Survey Vendor

General Surgery (13)

Includes the following individual measures:

#	Measure Title	Submission Methods
047	Advance Care Plan	Claims, Registry
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims, Electronic Health Record, Cms Web Interface, Registry
264	Sentinel Lymph Node Biopsy for Invasive Breast Cancer	Registry
317	Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	Claims, Electronic Health Record, Registry
354	Anastomotic Leak Intervention	Registry
355	Unplanned Reoperation within the 30 Day Postoperative Period	Registry
356	Unplanned Hospital Readmission within 30 Days of Principal Procedure	Registry
357	Surgical Site Infection (SSI)	Registry
358	Patient-Centered Surgical Risk Assessment and Communication	Registry
374	Closing the Referral Loop: Receipt of Specialist Report	Electronic Health Record, Registry
487	Screening for Social Drivers of Health	Registry
498	Connection to Community Service Provider	Registry

Geriatrics (23)

Includes the following individual measures:

#	Measure Title	Submission Methods
039	Screening for Osteoporosis for Women Aged 65-85 Years of Age	Claims, Registry
047	Advance Care Plan	Claims, Registry
048	Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older	Registry
050	Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older	Registry
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
134	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Claims, Electronic Health Record, Cms Web Interface, Registry
155	Falls: Plan of Care	Claims, Registry
181	Elder Maltreatment Screen and Follow-Up Plan	Claims, Registry
238	Use of High-Risk Medications in Older Adults	Electronic Health Record, Registry
281	Dementia: Cognitive Assessment	Electronic Health Record
282	Dementia: Functional Status Assessment	Registry
286	Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia	Registry
288	Dementia: Education and Support of Caregivers for Patients with Dementia	Registry
318	Falls: Screening for Future Fall Risk	Electronic Health Record, Cms Web Interface
370	Depression Remission at Twelve Months	Electronic Health Record, Cms Web Interface, Registry
476	Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia	Electronic Health Record
487	Screening for Social Drivers of Health	Registry
488	Kidney Health Evaluation	Registry, Electronic Health Record
489	Adult Kidney Disease: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy	Registry
493	Adult Immunization Status	Registry
497	Preventive Care and Wellness (composite)	Registry
498	Connection to Community Service Provider	Registry
134SSP	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Registry

Hospitalists (4)

Includes the following individual measures:

#	Measure Title	Submission Methods
005	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)	Electronic Health Record, Registry
008	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)	Electronic Health Record, Registry
047	Advance Care Plan	Claims, Registry
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record

Infectious Disease (15)

Includes the following individual measures:

#	Measure Title	Submission Methods
065	Appropriate Treatment for Upper Respiratory Infection (URI)	Electronic Health Record, Registry
066	Appropriate Testing for Pharyngitis	Electronic Health Record, Registry
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
176	Tuberculosis Screening Prior to First Course of Biologic and/or Immune Response Modifier Therapy	Registry
205	Sexually Transmitted Infection (STI) Testing for People with HIV	Electronic Health Record, Registry
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims, Electronic Health Record, Cms Web Interface, Registry
240	Childhood Immunization Status	Electronic Health Record
338	HIV Viral Suppression	Electronic Health Record, Registry
340	HIV Medical Visit Frequency	Registry
387	Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users	Registry
394	Immunizations for Adolescents	Registry
475	HIV Screening	Electronic Health Record
487	Screening for Social Drivers of Health	Registry
493	Adult Immunization Status	Registry
498	Connection to Community Service Provider	Registry

Internal Medicine (62)

Includes the following individual measures:

#	Measure Title	Submission Methods
001	Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)	Claims, Electronic Health Record, Cms Web Interface, Registry
005	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)	Electronic Health Record, Registry
006	Coronary Artery Disease (CAD): Antiplatelet Therapy	Registry
007	Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%)	Electronic Health Record, Registry
008	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)	Electronic Health Record, Registry
009	Anti-Depressant Medication Management	Electronic Health Record
024	Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older	Claims, Registry
039	Screening for Osteoporosis for Women Aged 65-85 Years of Age	Claims, Registry
047	Advance Care Plan	Claims, Registry
048	Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older	Registry
050	Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older	Registry
116	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis	Registry
117	Diabetes: Eye Exam	Registry, Electronic Health Record
126	Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy - Neurological Evaluation	Registry
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
134	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Claims, Electronic Health Record, Cms Web Interface, Registry
155	Falls: Plan of Care	Claims, Registry
176	Tuberculosis Screening Prior to First Course of Biologic and/or Immune Response Modifier Therapy	Registry
181	Elder Maltreatment Screen and Follow-Up Plan	Claims, Registry
236	Controlling High Blood Pressure	Claims, Electronic Health Record, Cms Web Interface, Registry
238	Use of High-Risk Medications in Older Adults	Electronic Health Record, Registry
243	Cardiac Rehabilitation Patient Referral from an Outpatient Setting	Registry
277	Sleep Apnea: Severity Assessment at Initial Diagnosis	Registry
279	Sleep Apnea: Assessment of Adherence to Obstructive Sleep Apnea (OSA) Therapy.	Registry
305	Initiation and Engagement of Substance Use Disorder Treatment	Electronic Health Record
309	Cervical Cancer Screening	Electronic Health Record
318	Falls: Screening for Future Fall Risk	Electronic Health Record, Cms Web Interface
321	CAHPS for MIPS Clinician/Group Survey	Certified Survey Vendor
326	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Registry
331	Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)	Registry
332	Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)	Registry
338	HIV Viral Suppression	Electronic Health Record, Registry
370	Depression Remission at Twelve Months	Electronic Health Record, Cms Web Interface, Registry
374	Closing the Referral Loop: Receipt of Specialist Report	Electronic Health Record, Registry
377	Functional Status Assessments for Heart Failure	Electronic Health Record
383	Adherence to Antipsychotic Medications For Individuals with Schizophrenia	Registry
387	Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users	Registry
398	Optimal Asthma Control	Registry
400	One-Time Screening for Hepatitis C Virus (HCV) and Treatment Initiation	Registry
401	Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis	Registry
418	Osteoporosis Management in Women Who Had a Fracture	Claims, Registry
431	Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling	Registry
438	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Electronic Health Record, Cms Web Interface, Registry
441	Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)	Registry
443	Non-Recommended Cervical Cancer Screening in Adolescent Females	Registry
468	Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)	Registry
472	Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture	Electronic Health Record
475	HIV Screening	Electronic Health Record
476	Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia	Electronic Health Record
483	Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM)	Registry
487	Screening for Social Drivers of Health	Registry
488	Kidney Health Evaluation	Registry, Electronic Health Record
493	Adult Immunization Status	Registry
495	Ambulatory Palliative Care Patients’ Experience of Feeling Heard and Understood	Registry
497	Preventive Care and Wellness (composite)	Registry
498	Connection to Community Service Provider	Registry
502	Improvement or Maintenance of Functioning for Individuals with a Mental and/or Substance Use Disorder	Registry
503	Gains in Patient Activation Measure (PAM) Scores at 12 Months	Registry
504	Initiation, Review, And/Or Update To Suicide Safety Plan For Individuals With Suicidal Thoughts, Behavior, Or Suicide Risk	Registry
001SSP	Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)	Registry
134SSP	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Registry
236SSP	Controlling High Blood Pressure	Registry

Interventional Radiology (9)

Includes the following individual measures:

#	Measure Title	Submission Methods
145	Radiology: Exposure Dose Indices Reported for Procedures Using Fluoroscopy	Claims, Registry
374	Closing the Referral Loop: Receipt of Specialist Report	Electronic Health Record, Registry
409	Clinical Outcome Post Endovascular Stroke Treatment	Registry
413	Door to Puncture Time for Endovascular Stroke Treatment	Registry
420	Varicose Vein Treatment with Saphenous Ablation: Outcome Survey	Registry
421	Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal	Registry
465	Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian Arteries	Registry
487	Screening for Social Drivers of Health	Registry
498	Connection to Community Service Provider	Registry

Mental Behavioral Health (23)

Includes the following individual measures:

#	Measure Title	Submission Methods
009	Anti-Depressant Medication Management	Electronic Health Record
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
134	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Claims, Electronic Health Record, Cms Web Interface, Registry
181	Elder Maltreatment Screen and Follow-Up Plan	Claims, Registry
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims, Electronic Health Record, Cms Web Interface, Registry
281	Dementia: Cognitive Assessment	Electronic Health Record
282	Dementia: Functional Status Assessment	Registry
286	Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia	Registry
288	Dementia: Education and Support of Caregivers for Patients with Dementia	Registry
305	Initiation and Engagement of Substance Use Disorder Treatment	Electronic Health Record
317	Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	Claims, Electronic Health Record, Registry
366	Follow-Up Care for Children Prescribed ADHD Medication (ADD)	Electronic Health Record
370	Depression Remission at Twelve Months	Electronic Health Record, Cms Web Interface, Registry
382	Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment	Electronic Health Record
383	Adherence to Antipsychotic Medications For Individuals with Schizophrenia	Registry
431	Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling	Registry
468	Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)	Registry
487	Screening for Social Drivers of Health	Registry
498	Connection to Community Service Provider	Registry
502	Improvement or Maintenance of Functioning for Individuals with a Mental and/or Substance Use Disorder	Registry
504	Initiation, Review, And/Or Update To Suicide Safety Plan For Individuals With Suicidal Thoughts, Behavior, Or Suicide Risk	Registry
505	Reduction in Suicidal Ideation or Behavior Symptoms	Registry
134SSP	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Registry

Nephrology (16)

Includes the following individual measures:

#	Measure Title	Submission Methods
001	Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)	Claims, Electronic Health Record, Cms Web Interface, Registry
047	Advance Care Plan	Claims, Registry
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
182	Functional Outcome Assessment	Registry
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims, Electronic Health Record, Cms Web Interface, Registry
317	Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	Claims, Electronic Health Record, Registry
318	Falls: Screening for Future Fall Risk	Electronic Health Record, Cms Web Interface
400	One-Time Screening for Hepatitis C Virus (HCV) and Treatment Initiation	Registry
482	Hemodialysis Vascular Access: Practitioner Level Long-term Catheter Rate	Registry
487	Screening for Social Drivers of Health	Registry
488	Kidney Health Evaluation	Registry, Electronic Health Record
489	Adult Kidney Disease: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy	Registry
493	Adult Immunization Status	Registry
498	Connection to Community Service Provider	Registry
503	Gains in Patient Activation Measure (PAM) Scores at 12 Months	Registry
001SSP	Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)	Registry

Neurology (25)

Includes the following individual measures:

#	Measure Title	Submission Methods
047	Advance Care Plan	Claims, Registry
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
134	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Claims, Electronic Health Record, Cms Web Interface, Registry
155	Falls: Plan of Care	Claims, Registry
181	Elder Maltreatment Screen and Follow-Up Plan	Claims, Registry
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims, Electronic Health Record, Cms Web Interface, Registry
268	Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy	Registry
277	Sleep Apnea: Severity Assessment at Initial Diagnosis	Registry
279	Sleep Apnea: Assessment of Adherence to Obstructive Sleep Apnea (OSA) Therapy.	Registry
281	Dementia: Cognitive Assessment	Electronic Health Record
282	Dementia: Functional Status Assessment	Registry
286	Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia	Registry
288	Dementia: Education and Support of Caregivers for Patients with Dementia	Registry
290	Assessment of Mood Disorders and Psychosis for Patients with Parkinson's Disease	Registry
291	Assessment of Cognitive Impairment or Dysfunction for Patients with Parkinson's Disease	Registry
293	Rehabilitative Therapy Referral for Patients with Parkinson's Disease	Registry
317	Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	Claims, Electronic Health Record, Registry
374	Closing the Referral Loop: Receipt of Specialist Report	Electronic Health Record, Registry
386	Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences	Registry
419	Overuse of Imaging for the Evaluation of Primary Headache	Registry
431	Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling	Registry
487	Screening for Social Drivers of Health	Registry
498	Connection to Community Service Provider	Registry
503	Gains in Patient Activation Measure (PAM) Scores at 12 Months	Registry
134SSP	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Registry

Neurosurgical (12)

Includes the following individual measures:

#	Measure Title	Submission Methods
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
187	Stroke and Stroke Rehabilitation: Thrombolytic Therapy	Registry
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims, Electronic Health Record, Cms Web Interface, Registry
260	Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2)	Registry
344	Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)	Registry
409	Clinical Outcome Post Endovascular Stroke Treatment	Registry
413	Door to Puncture Time for Endovascular Stroke Treatment	Registry
459	Back Pain After Lumbar Surgery	Registry
461	Leg Pain After Lumbar Surgery	Registry
471	Functional Status After Lumbar Surgery	Registry
487	Screening for Social Drivers of Health	Registry
498	Connection to Community Service Provider	Registry

Nutrition Dietician (11)

Includes the following individual measures:

#	Measure Title	Submission Methods
001	Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)	Claims, Electronic Health Record, Cms Web Interface, Registry
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
134	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Claims, Electronic Health Record, Cms Web Interface, Registry
181	Elder Maltreatment Screen and Follow-Up Plan	Claims, Registry
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims, Electronic Health Record, Cms Web Interface, Registry
239	Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents	Electronic Health Record
431	Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling	Registry
487	Screening for Social Drivers of Health	Registry
498	Connection to Community Service Provider	Registry
001SSP	Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)	Registry
134SSP	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Registry

Obstetrics Gynecology (29)

Includes the following individual measures:

#	Measure Title	Submission Methods
039	Screening for Osteoporosis for Women Aged 65-85 Years of Age	Claims, Registry
047	Advance Care Plan	Claims, Registry
048	Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older	Registry
050	Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older	Registry
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
236	Controlling High Blood Pressure	Claims, Electronic Health Record, Cms Web Interface, Registry
309	Cervical Cancer Screening	Electronic Health Record
310	Chlamydia Screening for Women	Electronic Health Record
335	Maternity Care: Elective Delivery (Without Medical Indication) at < 39 Weeks (Overuse)	Registry
336	Maternity Care: Postpartum Follow-up and Care Coordination	Registry
374	Closing the Referral Loop: Receipt of Specialist Report	Electronic Health Record, Registry
418	Osteoporosis Management in Women Who Had a Fracture	Claims, Registry
422	Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury	Claims, Registry
431	Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling	Registry
432	Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair	Registry
433	Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair	Registry
443	Non-Recommended Cervical Cancer Screening in Adolescent Females	Registry
448	Appropriate Workup Prior to Endometrial Ablation	Registry
472	Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture	Electronic Health Record
475	HIV Screening	Electronic Health Record
487	Screening for Social Drivers of Health	Registry
493	Adult Immunization Status	Registry
496	Cardiovascular Disease (CVD) Risk Assessment Measure - Proportion of Pregnant/Postpartum Patients that Receive CVD Risk Assessment with a Standardized Instrument	Registry
497	Preventive Care and Wellness (composite)	Registry
498	Connection to Community Service Provider	Registry
503	Gains in Patient Activation Measure (PAM) Scores at 12 Months	Registry
504	Initiation, Review, And/Or Update To Suicide Safety Plan For Individuals With Suicidal Thoughts, Behavior, Or Suicide Risk	Registry
505	Reduction in Suicidal Ideation or Behavior Symptoms	Registry
236SSP	Controlling High Blood Pressure	Registry

Oncology (26)

Includes the following individual measures:

#	Measure Title	Submission Methods
047	Advance Care Plan	Claims, Registry
102	Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients	Electronic Health Record, Registry
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
134	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Claims, Electronic Health Record, Cms Web Interface, Registry
143	Oncology: Medical and Radiation - Pain Intensity Quantified	Electronic Health Record, Registry
144	Oncology: Medical and Radiation - Plan of Care for Pain	Registry
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims, Electronic Health Record, Cms Web Interface, Registry
238	Use of High-Risk Medications in Older Adults	Electronic Health Record, Registry
250	Radical Prostatectomy Pathology Reporting	Claims, Registry
317	Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	Claims, Electronic Health Record, Registry
321	CAHPS for MIPS Clinician/Group Survey	Certified Survey Vendor
374	Closing the Referral Loop: Receipt of Specialist Report	Electronic Health Record, Registry
431	Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling	Registry
450	Appropriate Treatment for Patients with Stage I (T1c) - III HER2 Positive Breast Cancer	Registry
451	RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy	Registry
452	Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies	Registry
453	Percentage of Patients Who Died from Cancer Receiving Systemic Cancer-Directed Therapy in the Last 14 Days of Life (lower score – better)	Registry
457	Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score - better)	Registry
462	Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy	Electronic Health Record
487	Screening for Social Drivers of Health	Registry
490	Appropriate Intervention of Immune-Related Diarrhea and/or Colitis in Patients Treated with Immune Checkpoint Inhibitors	Registry
493	Adult Immunization Status	Registry
495	Ambulatory Palliative Care Patients’ Experience of Feeling Heard and Understood	Registry
498	Connection to Community Service Provider	Registry
503	Gains in Patient Activation Measure (PAM) Scores at 12 Months	Registry
134SSP	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Registry

Ophthalmology (19)

Includes the following individual measures:

#	Measure Title	Submission Methods
012	Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation	Electronic Health Record
019	Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care	Electronic Health Record, Registry
117	Diabetes: Eye Exam	Registry, Electronic Health Record
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
141	Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 20% OR Documentation of a Plan of Care.	Claims, Registry
191	Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery	Electronic Health Record, Registry
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims, Electronic Health Record, Cms Web Interface, Registry
238	Use of High-Risk Medications in Older Adults	Electronic Health Record, Registry
303	Cataracts: Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery	Registry
304	Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery	Registry
374	Closing the Referral Loop: Receipt of Specialist Report	Electronic Health Record, Registry
384	Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery	Registry
385	Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery	Registry
389	Cataract Surgery: Difference Between Planned and Final Refraction	Registry
487	Screening for Social Drivers of Health	Registry
498	Connection to Community Service Provider	Registry
499	Appropriate screening and plan of care for elevated intraocular pressure following intravitreal or periocular steroid therapy	Registry
500	Acute posterior vitreous detachment appropriate examination and follow-up	Registry
501	Acute posterior vitreous detachment and acute vitreous hemorrhage appropriate examination and follow-up	Registry

Orthopedic Surgery (32)

Includes the following individual measures:

#	Measure Title	Submission Methods
024	Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older	Claims, Registry
047	Advance Care Plan	Claims, Registry
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
134	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Claims, Electronic Health Record, Cms Web Interface, Registry
155	Falls: Plan of Care	Claims, Registry
178	Rheumatoid Arthritis (RA): Functional Status Assessment	Registry
180	Rheumatoid Arthritis (RA): Glucocorticoid Management	Registry
182	Functional Outcome Assessment	Registry
217	Functional Status Change for Patients with Knee Impairments	Registry
218	Functional Status Change for Patients with Hip Impairments	Registry
219	Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments	Registry
220	Functional Status Change for Patients with Low Back Impairments	Registry
221	Functional Status Change for Patients with Shoulder Impairments	Registry
222	Functional Status Change for Patients with Elbow, Wrist or Hand Impairments	Registry
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims, Electronic Health Record, Cms Web Interface, Registry
317	Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	Claims, Electronic Health Record, Registry
318	Falls: Screening for Future Fall Risk	Electronic Health Record, Cms Web Interface
350	Total Knee or Hip Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy	Registry
351	Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation	Registry
358	Patient-Centered Surgical Risk Assessment and Communication	Registry
374	Closing the Referral Loop: Receipt of Specialist Report	Electronic Health Record, Registry
376	Functional Status Assessment for Total Hip Replacement	Electronic Health Record
418	Osteoporosis Management in Women Who Had a Fracture	Claims, Registry
459	Back Pain After Lumbar Surgery	Registry
461	Leg Pain After Lumbar Surgery	Registry
470	Functional Status After Primary Total Knee Replacement	Registry
471	Functional Status After Lumbar Surgery	Registry
478	Functional Status Change for Patients with Neck Impairments	Registry
480	Risk-standardized complication rate (RSCR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) for Merit-based Incentive Payment System (MIPS)	Administrative Claims
487	Screening for Social Drivers of Health	Registry
498	Connection to Community Service Provider	Registry
134SSP	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Registry

Otolaryngology (22)

Includes the following individual measures:

#	Measure Title	Submission Methods
047	Advance Care Plan	Claims, Registry
066	Appropriate Testing for Pharyngitis	Electronic Health Record, Registry
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
155	Falls: Plan of Care	Claims, Registry
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims, Electronic Health Record, Cms Web Interface, Registry
238	Use of High-Risk Medications in Older Adults	Electronic Health Record, Registry
277	Sleep Apnea: Severity Assessment at Initial Diagnosis	Registry
279	Sleep Apnea: Assessment of Adherence to Obstructive Sleep Apnea (OSA) Therapy.	Registry
317	Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	Claims, Electronic Health Record, Registry
318	Falls: Screening for Future Fall Risk	Electronic Health Record, Cms Web Interface
331	Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)	Registry
332	Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)	Registry
355	Unplanned Reoperation within the 30 Day Postoperative Period	Registry
357	Surgical Site Infection (SSI)	Registry
358	Patient-Centered Surgical Risk Assessment and Communication	Registry
374	Closing the Referral Loop: Receipt of Specialist Report	Electronic Health Record, Registry
398	Optimal Asthma Control	Registry
431	Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling	Registry
464	Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use	Registry
487	Screening for Social Drivers of Health	Registry
493	Adult Immunization Status	Registry
498	Connection to Community Service Provider	Registry

Pathology (7)

Includes the following individual measures:

#	Measure Title	Submission Methods
249	Barrett's Esophagus	Claims, Registry
250	Radical Prostatectomy Pathology Reporting	Claims, Registry
395	Lung Cancer Reporting (Biopsy/Cytology Specimens)	Claims, Registry
396	Lung Cancer Reporting (Resection Specimens)	Claims, Registry
397	Melanoma Reporting	Claims, Registry
440	Skin Cancer: Biopsy Reporting Time - Pathologist to Clinician	Registry
491	Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status in Colorectal Carcinoma, Endometrial, Gastroesophageal, or Small Bowel Carcinoma	Registry

Pediatrics (19)

Includes the following individual measures:

#	Measure Title	Submission Methods
065	Appropriate Treatment for Upper Respiratory Infection (URI)	Electronic Health Record, Registry
066	Appropriate Testing for Pharyngitis	Electronic Health Record, Registry
116	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis	Registry
134	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Claims, Electronic Health Record, Cms Web Interface, Registry
205	Sexually Transmitted Infection (STI) Testing for People with HIV	Electronic Health Record, Registry
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims, Electronic Health Record, Cms Web Interface, Registry
239	Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents	Electronic Health Record
240	Childhood Immunization Status	Electronic Health Record
305	Initiation and Engagement of Substance Use Disorder Treatment	Electronic Health Record
310	Chlamydia Screening for Women	Electronic Health Record
366	Follow-Up Care for Children Prescribed ADHD Medication (ADD)	Electronic Health Record
370	Depression Remission at Twelve Months	Electronic Health Record, Cms Web Interface, Registry
382	Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment	Electronic Health Record
394	Immunizations for Adolescents	Registry
398	Optimal Asthma Control	Registry
464	Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use	Registry
487	Screening for Social Drivers of Health	Registry
498	Connection to Community Service Provider	Registry
134SSP	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Registry

Physical Medicine (11)

Includes the following individual measures:

#	Measure Title	Submission Methods
047	Advance Care Plan	Claims, Registry
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
155	Falls: Plan of Care	Claims, Registry
182	Functional Outcome Assessment	Registry
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims, Electronic Health Record, Cms Web Interface, Registry
317	Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	Claims, Electronic Health Record, Registry
374	Closing the Referral Loop: Receipt of Specialist Report	Electronic Health Record, Registry
431	Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling	Registry
468	Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)	Registry
487	Screening for Social Drivers of Health	Registry
498	Connection to Community Service Provider	Registry

Physical Therapy Occupational Therapy (27)

Includes the following individual measures:

#	Measure Title	Submission Methods
048	Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older	Registry
050	Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older	Registry
126	Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy - Neurological Evaluation	Registry
127	Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention - Evaluation of Footwear	Registry
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
134	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Claims, Electronic Health Record, Cms Web Interface, Registry
155	Falls: Plan of Care	Claims, Registry
181	Elder Maltreatment Screen and Follow-Up Plan	Claims, Registry
182	Functional Outcome Assessment	Registry
217	Functional Status Change for Patients with Knee Impairments	Registry
218	Functional Status Change for Patients with Hip Impairments	Registry
219	Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments	Registry
220	Functional Status Change for Patients with Low Back Impairments	Registry
221	Functional Status Change for Patients with Shoulder Impairments	Registry
222	Functional Status Change for Patients with Elbow, Wrist or Hand Impairments	Registry
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims, Electronic Health Record, Cms Web Interface, Registry
281	Dementia: Cognitive Assessment	Electronic Health Record
286	Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia	Registry
288	Dementia: Education and Support of Caregivers for Patients with Dementia	Registry
291	Assessment of Cognitive Impairment or Dysfunction for Patients with Parkinson's Disease	Registry
318	Falls: Screening for Future Fall Risk	Electronic Health Record, Cms Web Interface
478	Functional Status Change for Patients with Neck Impairments	Registry
487	Screening for Social Drivers of Health	Registry
498	Connection to Community Service Provider	Registry
502	Improvement or Maintenance of Functioning for Individuals with a Mental and/or Substance Use Disorder	Registry
503	Gains in Patient Activation Measure (PAM) Scores at 12 Months	Registry
134SSP	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Registry

Plastic Surgery (9)

Includes the following individual measures:

#	Measure Title	Submission Methods
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims, Electronic Health Record, Cms Web Interface, Registry
317	Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	Claims, Electronic Health Record, Registry
355	Unplanned Reoperation within the 30 Day Postoperative Period	Registry
356	Unplanned Hospital Readmission within 30 Days of Principal Procedure	Registry
357	Surgical Site Infection (SSI)	Registry
358	Patient-Centered Surgical Risk Assessment and Communication	Registry
487	Screening for Social Drivers of Health	Registry
498	Connection to Community Service Provider	Registry

Podiatry (11)

Includes the following individual measures:

#	Measure Title	Submission Methods
126	Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy - Neurological Evaluation	Registry
127	Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention - Evaluation of Footwear	Registry
155	Falls: Plan of Care	Claims, Registry
219	Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments	Registry
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims, Electronic Health Record, Cms Web Interface, Registry
317	Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	Claims, Electronic Health Record, Registry
318	Falls: Screening for Future Fall Risk	Electronic Health Record, Cms Web Interface
358	Patient-Centered Surgical Risk Assessment and Communication	Registry
487	Screening for Social Drivers of Health	Registry
498	Connection to Community Service Provider	Registry
503	Gains in Patient Activation Measure (PAM) Scores at 12 Months	Registry

Preventive Medicine (24)

Includes the following individual measures:

#	Measure Title	Submission Methods
001	Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)	Claims, Electronic Health Record, Cms Web Interface, Registry
024	Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older	Claims, Registry
039	Screening for Osteoporosis for Women Aged 65-85 Years of Age	Claims, Registry
047	Advance Care Plan	Claims, Registry
048	Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older	Registry
116	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis	Registry
126	Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy - Neurological Evaluation	Registry
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
134	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Claims, Electronic Health Record, Cms Web Interface, Registry
155	Falls: Plan of Care	Claims, Registry
182	Functional Outcome Assessment	Registry
243	Cardiac Rehabilitation Patient Referral from an Outpatient Setting	Registry
374	Closing the Referral Loop: Receipt of Specialist Report	Electronic Health Record, Registry
431	Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling	Registry
438	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Electronic Health Record, Cms Web Interface, Registry
475	HIV Screening	Electronic Health Record
487	Screening for Social Drivers of Health	Registry
488	Kidney Health Evaluation	Registry, Electronic Health Record
493	Adult Immunization Status	Registry
497	Preventive Care and Wellness (composite)	Registry
498	Connection to Community Service Provider	Registry
503	Gains in Patient Activation Measure (PAM) Scores at 12 Months	Registry
001SSP	Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)	Registry
134SSP	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Registry

Pulmonology (16)

Includes the following individual measures:

#	Measure Title	Submission Methods
047	Advance Care Plan	Claims, Registry
052	Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation for Long-Acting Inhaled Bronchodilator Therapy	Registry
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims, Electronic Health Record, Cms Web Interface, Registry
236	Controlling High Blood Pressure	Claims, Electronic Health Record, Cms Web Interface, Registry
238	Use of High-Risk Medications in Older Adults	Electronic Health Record, Registry
277	Sleep Apnea: Severity Assessment at Initial Diagnosis	Registry
279	Sleep Apnea: Assessment of Adherence to Obstructive Sleep Apnea (OSA) Therapy.	Registry
374	Closing the Referral Loop: Receipt of Specialist Report	Electronic Health Record, Registry
398	Optimal Asthma Control	Registry
431	Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling	Registry
487	Screening for Social Drivers of Health	Registry
493	Adult Immunization Status	Registry
498	Connection to Community Service Provider	Registry
503	Gains in Patient Activation Measure (PAM) Scores at 12 Months	Registry
236SSP	Controlling High Blood Pressure	Registry

Radiation Oncology (4)

Includes the following individual measures:

#	Measure Title	Submission Methods
102	Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients	Electronic Health Record, Registry
143	Oncology: Medical and Radiation - Pain Intensity Quantified	Electronic Health Record, Registry
144	Oncology: Medical and Radiation - Plan of Care for Pain	Registry
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims, Electronic Health Record, Cms Web Interface, Registry

Rheumatology (18)

Includes the following individual measures:

#	Measure Title	Submission Methods
024	Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older	Claims, Registry
039	Screening for Osteoporosis for Women Aged 65-85 Years of Age	Claims, Registry
047	Advance Care Plan	Claims, Registry
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
176	Tuberculosis Screening Prior to First Course of Biologic and/or Immune Response Modifier Therapy	Registry
177	Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity	Registry
178	Rheumatoid Arthritis (RA): Functional Status Assessment	Registry
180	Rheumatoid Arthritis (RA): Glucocorticoid Management	Registry
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims, Electronic Health Record, Cms Web Interface, Registry
236	Controlling High Blood Pressure	Claims, Electronic Health Record, Cms Web Interface, Registry
238	Use of High-Risk Medications in Older Adults	Electronic Health Record, Registry
317	Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	Claims, Electronic Health Record, Registry
374	Closing the Referral Loop: Receipt of Specialist Report	Electronic Health Record, Registry
487	Screening for Social Drivers of Health	Registry
493	Adult Immunization Status	Registry
498	Connection to Community Service Provider	Registry
503	Gains in Patient Activation Measure (PAM) Scores at 12 Months	Registry
236SSP	Controlling High Blood Pressure	Registry

Skilled Nursing Facility (13)

Includes the following individual measures:

#	Measure Title	Submission Methods
006	Coronary Artery Disease (CAD): Antiplatelet Therapy	Registry
007	Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%)	Electronic Health Record, Registry
008	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)	Electronic Health Record, Registry
047	Advance Care Plan	Claims, Registry
118	Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%)	Registry
155	Falls: Plan of Care	Claims, Registry
181	Elder Maltreatment Screen and Follow-Up Plan	Claims, Registry
238	Use of High-Risk Medications in Older Adults	Electronic Health Record, Registry
317	Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	Claims, Electronic Health Record, Registry
326	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Registry
487	Screening for Social Drivers of Health	Registry
493	Adult Immunization Status	Registry
498	Connection to Community Service Provider	Registry

Speech Language Pathology (9)

Includes the following individual measures:

#	Measure Title	Submission Methods
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
134	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Claims, Electronic Health Record, Cms Web Interface, Registry
181	Elder Maltreatment Screen and Follow-Up Plan	Claims, Registry
182	Functional Outcome Assessment	Registry
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims, Electronic Health Record, Cms Web Interface, Registry
291	Assessment of Cognitive Impairment or Dysfunction for Patients with Parkinson's Disease	Registry
487	Screening for Social Drivers of Health	Registry
498	Connection to Community Service Provider	Registry
134SSP	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Registry

Thoracic Surgery (12)

Includes the following individual measures:

#	Measure Title	Submission Methods
047	Advance Care Plan	Claims, Registry
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
164	Coronary Artery Bypass Graft (CABG): Prolonged Intubation	Registry
167	Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure	Registry
168	Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration	Registry
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims, Electronic Health Record, Cms Web Interface, Registry
356	Unplanned Hospital Readmission within 30 Days of Principal Procedure	Registry
358	Patient-Centered Surgical Risk Assessment and Communication	Registry
374	Closing the Referral Loop: Receipt of Specialist Report	Electronic Health Record, Registry
445	Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)	Registry
487	Screening for Social Drivers of Health	Registry
498	Connection to Community Service Provider	Registry

Urgent Care (12)

Includes the following individual measures:

#	Measure Title	Submission Methods
065	Appropriate Treatment for Upper Respiratory Infection (URI)	Electronic Health Record, Registry
066	Appropriate Testing for Pharyngitis	Electronic Health Record, Registry
116	Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis	Registry
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims, Electronic Health Record, Cms Web Interface, Registry
317	Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	Claims, Electronic Health Record, Registry
331	Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)	Registry
332	Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)	Registry
431	Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling	Registry
464	Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use	Registry
487	Screening for Social Drivers of Health	Registry
498	Connection to Community Service Provider	Registry

Urology (26)

Includes the following individual measures:

#	Measure Title	Submission Methods
047	Advance Care Plan	Claims, Registry
048	Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older	Registry
050	Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older	Registry
102	Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients	Electronic Health Record, Registry
104	Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate Cancer	Registry
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
134	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Claims, Electronic Health Record, Cms Web Interface, Registry
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims, Electronic Health Record, Cms Web Interface, Registry
238	Use of High-Risk Medications in Older Adults	Electronic Health Record, Registry
317	Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	Claims, Electronic Health Record, Registry
321	CAHPS for MIPS Clinician/Group Survey	Certified Survey Vendor
358	Patient-Centered Surgical Risk Assessment and Communication	Registry
374	Closing the Referral Loop: Receipt of Specialist Report	Electronic Health Record, Registry
431	Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling	Registry
432	Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair	Registry
433	Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair	Registry
453	Percentage of Patients Who Died from Cancer Receiving Systemic Cancer-Directed Therapy in the Last 14 Days of Life (lower score – better)	Registry
457	Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score - better)	Registry
462	Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy	Electronic Health Record
476	Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia	Electronic Health Record
481	Intravesical Bacillus-Calmette Guerin for Non-muscle Invasive Bladder Cancer	Electronic Health Record
487	Screening for Social Drivers of Health	Registry
488	Kidney Health Evaluation	Registry, Electronic Health Record
498	Connection to Community Service Provider	Registry
503	Gains in Patient Activation Measure (PAM) Scores at 12 Months	Registry
134SSP	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Registry

Vascular Surgery (16)

Includes the following individual measures:

#	Measure Title	Submission Methods
047	Advance Care Plan	Claims, Registry
130	Documentation of Current Medications in the Medical Record	Registry, Electronic Health Record
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims, Electronic Health Record, Cms Web Interface, Registry
236	Controlling High Blood Pressure	Claims, Electronic Health Record, Cms Web Interface, Registry
259	Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #2)	Registry
260	Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2)	Registry
317	Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	Claims, Electronic Health Record, Registry
344	Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)	Registry
357	Surgical Site Infection (SSI)	Registry
358	Patient-Centered Surgical Risk Assessment and Communication	Registry
374	Closing the Referral Loop: Receipt of Specialist Report	Electronic Health Record, Registry
420	Varicose Vein Treatment with Saphenous Ablation: Outcome Survey	Registry
441	Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)	Registry
487	Screening for Social Drivers of Health	Registry
498	Connection to Community Service Provider	Registry
236SSP	Controlling High Blood Pressure	Registry