H - 2012_PhysQualRptg_MAV_ProcessforClaimsBasedReporting_111011

2012 PH
QU
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Y S I C I A N Q U A L I T Y R E P O R T I N G S Y S T E M ( P H Y S I C I A N
A L I T Y R E P O R T I N G ) M E A S U R E - A P P L I C A B I L I T Y
VALIDATION(MAV)PROCESS FOR
L A I M S - B A S E D R E P O R T I N G O F I N D I V I D U A L M E A S U R E S

The 2012 Physician Quality Reporting System (Physician Quality Reporting) will include validation
processes. Under the claims-based reporting method of individual measure(s), the determination of
satisfactory reporting will itself serve as a general validation because the analysis will assess whether
quality-data codes (QDCs) are appropriately submitted in a sufficient proportion of the instances when a
reporting opportunity exists. In addition, for those eligible professionals who satisfactorily submit QDCs
for fewer than three Physician Quality Reporting measures, a measure-applicability validation process
will determine whether they should have submitted QDCs for additional measures.
CMS will apply a two-step process to operationalize measure-applicability validation: (1) a “clinical
relation” test, and (2) a “minimum threshold” test. Those who fail the validation process will not earn the
Physician Quality Reporting incentive payment for 2012.
CMS may determine that it is necessary to modify the measure-applicability validation process after the
start of the 2012 reporting period. However, any changes will result in the process being applied more
leniently, thereby (1) allowing a greater number of eligible professionals to pass validation and (2)
causing no eligible professional who would otherwise have passed to fail.
Prerequisites for Measure-Applicability Validation
Eligible professionals who submit QDCs for only one or only two Physician Quality Reporting measures
for at least 50 percent of their patients or encounters eligible for each measure and who do not submit any
QDCs for any other measure will be subject to the measure-applicability validation process. Selection of
eligible professionals for measure-applicability validation may be accomplished through a sampling
mechanism.
Step 1: Clinical Relation Test
The clinical relation test is the first step in the two-step measure-applicability validation that will be
applied to those who are subject to the validation process. This test is based on: (1) an extension of the
statutory presumption that if an eligible professional submits data for a measure, then that measure applies
to her/his practice and (2) the concept that if one measure in a cluster of measures related to a particular
clinical topic or eligible professional service is applicable to an eligible professional’s practice, then other
closely-related measures (measures in that same cluster) may also be applicable.
The following is an example of how the clinical relation test will be applied: An eligible professional who
is subject to measure-applicability validation submitted QDCs for one of the Physician Quality Reporting
measures related to pneumonia. The eligible professional’s claims will then be analyzed using the
minimum threshold test described below in Step 2 to determine whether another pneumonia measure (or
two more pneumonia measures) could also have been submitted.
The list of clusters of related measures and the Physician Quality Reporting measures that are included
within each cluster are presented below. CMS may determine this list should be modified to apply the
measure-applicability validation process more leniently. Any such modifications will be published on the
CMS Physician Quality Reporting website as soon as possible after a determination has been made.

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A L I T Y R E P O R T I N G ) M E A S U R E - A P P L I C A B I L I T Y
VALIDATION(MAV)PROCESS FOR
L A I M S - B A S E D R E P O R T I N G O F I N D I V I D U A L M E A S U R E S

Clusters of Clinically Related Measures Used in Step 1 of the 2012 Physician Quality Reporting
Measure-Applicability Validation for Claims-Based Reporting of Individual Measures
Cluster
Number

Cluster Title

Measure
Number

Measure Title

1

Preventive

39

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

48

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

110

Preventive Care and Screening: Influenza Immunization

111

Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years
and Older

112

Preventive Care and Screening: Screening Mammography

113

Preventive Care and Screening: Colorectal Cancer Screening

2

3

4

5

6

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Chronic Diabetic
Care

COPD Care

Asthma Care

Pneumonia Care

1

Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus

2

Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes
Mellitus

3

Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus

163

Diabetes Mellitus: Foot Exam

51

Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation

52

Chronic Obstructive Pulmonary Disease (COPD): Bronchodilator Therapy

53

Asthma: Pharmacologic Therapy for Persistent Asthma

64

Asthma: Assessment of Asthma Control

231

Asthma: Tobacco Use: Screening - Ambulatory Care Setting

232

Asthma: Tobacco Use: Intervention - Ambulatory Care Setting

56

Emergency Medicine: Community-Acquired Pneumonia (CAP): Vital Signs

57

Emergency Medicine: Community-Acquired Pneumonia (CAP): Assessment
of Oxygen Saturation

58

Emergency Medicine: Community-Acquired Pneumonia (CAP): Assessment
of Mental Status

59

Emergency Medicine: Community-Acquired Pneumonia (CAP): Empiric
Antibiotic

67

Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias:
Baseline Cytogenetic Testing Performed on Bone Marrow

68

Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron
Stores in Patients Receiving Erythropoietin Therapy

Cancer Care 1

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A L I T Y R E P O R T I N G ) M E A S U R E - A P P L I C A B I L I T Y
VALIDATION(MAV)PROCESS FOR
L A I M S - B A S E D R E P O R T I N G O F I N D I V I D U A L M E A S U R E S

Cluster
Number

Cluster Title

7

Cancer Care 2

8

Cancer Care 3:
Radiation Oncology

9

10

Breast Cancer Care

Urinary Incontinence
Care

11

12

13

14

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Fracture Follow-Up
Care

Ear, Nose, Throat
Care

Pediatric ENT

Emergency Care

Measure
Number

Measure Title

69

Hematology: Multiple Myeloma: Treatment with Bisphosphonates

70

Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow
Cytometry

72

Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients

194

Oncology: Cancer Stage Documented

104

Prostate Cancer: Adjuvant Hormonal Therapy for High-Risk Prostate Cancer
Patients

105

Prostate Cancer: Three-Dimensional (3D) Radiotherapy

71

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

262

Image Confirmation of Successful Excision of Image-Localized Breast
Lesion

263

Preoperative Diagnosis of Breast Cancer

49

Urinary Incontinence: Characterization of Urinary Incontinence in Women
Aged 65 Years and Older

50

Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged
65 Years and Older

24

Osteoporosis: Communication with the Physician Managing On-Going Care
Post-Fracture of Hip, Spine, or Distal Radius for Men and Women Aged 50
Years and Older

40

Osteoporosis: Management Following Fracture of Hip, Spine, or Distal
Radius for Men and Women Aged 50 Years and Older

91

Acute Otitis Externa (AOE): Topical Therapy

92

Acute Otitis Externa (AOE): Pain Assessment

93

Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of
Inappropriate Use

65

Treatment for Children with Upper Respiratory Infection (URI): Avoidance
of Inappropriate Use

66

Appropriate Testing for Children with Pharyngitis

28

Aspirin at Arrival for Acute Myocardial Infarction (AMI)

54

Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for NonTraumatic Chest Pain

55

Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for
Syncope

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A L I T Y R E P O R T I N G ) M E A S U R E - A P P L I C A B I L I T Y
VALIDATION(MAV)PROCESS FOR
L A I M S - B A S E D R E P O R T I N G O F I N D I V I D U A L M E A S U R E S

Cluster
Number

15

16

17

18

19

20

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Cluster Title

Pathology

Diagnostic Imaging

Depression

Eye Care 1

Eye Care 2

Eye Care 3

Measure
Number

Measure Title

252

Anticoagulation for Acute Pulmonary Embolus Patients

253

Pregnancy Test for Female Abdominal Pain Patients

254

Ultrasound Determination of Pregnancy Location for Pregnant Patients with
Abdominal Pain

255

Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of
Fetal Blood Exposure

99

Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor)
and pN Category (Regional Lymph Nodes) with Histologic Grade

100

Colorectal Cancer Resection Pathology Reporting: pT Category (Primary
Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade

249

Barrett’s Esophagus

250

Radical Prostatectomy Pathology Reporting

251

Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor
Receptor 2 Testing (HER2) for Breast Cancer Patients

10

Stroke and Stroke Rehabilitation: Computed Tomography (CT) or Magnetic
Resonance Imaging (MRI) Reports

145

Radiology: Exposure Time Reported for Procedures Using Fluoroscopy

146

Radiology: Inappropriate Use of “Probably Benign” Assessment Category in
Mammography Screening

147

Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients
Undergoing Bone Scintigraphy

225

Radiology: Reminder System for Mammograms

9

Major Depressive Disorder (MDD): Antidepressant Medication During Acute
Phase for Patients with MDD

106

Major Depressive Disorder (MDD): Diagnostic Evaluation

107

Major Depressive Disorder (MDD): Suicide Risk Assessment

12

Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation

141

Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure
(IOP) by 15% OR Documentation of a Plan of Care

18

Diabetic Retinopathy: Documentation of Presence or Absence of Macular
Edema and Level of Severity of Retinopathy

19

Diabetic Retinopathy: Communication with the Physician Managing OnGoing Diabetes Care

14

Age-Related Macular Degeneration (AMD): Dilated Macular Examination

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A L I T Y R E P O R T I N G ) M E A S U R E - A P P L I C A B I L I T Y
VALIDATION(MAV)PROCESS FOR
L A I M S - B A S E D R E P O R T I N G O F I N D I V I D U A L M E A S U R E S

Cluster
Number

Cluster Title

Hepatitis Care

21

22

23

Renal Disease Care

Stroke Management

24

25

26

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Stroke Discharge

Surgical Care

Cardiac Surgical
Care

Measure
Number

Measure Title

140

Age-Related Macular Degeneration (AMD): Counseling on Antioxidant
Supplement

84

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

85

Hepatitis C: HCV Genotype Testing Prior to Treatment

86

Hepatitis C: Antiviral Treatment Prescribed

87

Hepatitis C: HCV Ribonucleic Acid (RNA) Testing at Week 12 of Treatment

89

Hepatitis C: Counseling Regarding Risk of Alcohol Consumption

90

Hepatitis C: Counseling Regarding Use of Contraception Prior to Antiviral
Treatment

183

Hepatitis C: Hepatitis A Vaccination in Patients with HCV

184

Hepatitis C: Hepatitis B Vaccination in Patients with HCV

121

Adult Kidney Disease: Laboratory Testing Lipid Profile

122

Adult Kidney Disease: Blood Pressure Management

123

Adult Kidney Disease: Patients on Erythropoiesis-Stimulating Agents (ESA)
Hemoglobin Level >12.0 g/dL

31

Stroke and Stroke Rehabilitation: Deep Vein Thrombosis (DVT) Prophylaxis
for Ischemic Stroke or Intracranial Hemorrhage

35

Stroke and Stroke Rehabilitation: Screening for Dysphagia

32

Stroke and Stroke Rehabilitation: Discharged on Antithrombotic Therapy

36

Stroke and Stroke Rehabilitation: Rehabilitation Services Ordered

20

Perioperative Care: Timing of Antibiotic Prophylaxis – Ordering Physician

21

Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second
Generation Cephalosporin

22

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

23

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

43

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

44

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

45

Perioperative Care: Discontinuation of Prophylactic Antibiotics (Cardiac
Procedures)
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A L I T Y R E P O R T I N G ) M E A S U R E - A P P L I C A B I L I T Y
VALIDATION(MAV)PROCESS FOR
L A I M S - B A S E D R E P O R T I N G O F I N D I V I D U A L M E A S U R E S

Cluster
Number

Cluster Title

27

Diabetic Foot Care

28

29

Osteoarthritis Care

Rheumatoid Arthritis
Care

30

31

Falls

Anesthesia Care 1

Measure
Number

Measure Title

126

Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy –
Neurological Evaluation

127

Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention –
Evaluation of Footwear

109

Osteoarthritis (OA): Function and Pain Assessment

142

Osteoarthritis (OA): Assessment for Use of Anti-Inflammatory or Analgesic
Over-the-Counter (OTC) Medications

108

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

176

Rheumatoid Arthritis (RA): Tuberculosis Screening

177

Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity

178

Rheumatoid Arthritis (RA): Functional Status Assessment

179

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

180

Rheumatoid Arthritis (RA): Glucocorticoid Management

154

Falls: Risk Assessment

155

Falls: Plan of Care

30

Perioperative Care: Timely Administration of Prophylactic Parenteral
Antibiotics

76

Prevention of Catheter-Related Bloodstream Infections (CRBSI): Central
Venous Catheter (CVC) Insertion Protocol
When reporting #76 alone, it is not subject to MAV

32

Anesthesia Care 2

76

Prevention of Catheter-Related Bloodstream Infections (CRBSI): Central
Venous Catheter (CVC) Insertion Protocol

193

Perioperative Temperature Management
When reporting #76 alone, it is not subject to MAV

33

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Ear Care

188

Referral for Otologic Evaluation for Patients with Congenital or Traumatic
Deformity of the Ear

189

Referral for Otologic Evaluation for Patients with a History of Active
Drainage from the Ear Within the Previous 90 Days

190

Referral for Otolgic Evaluation for Patients with a History of Sudden or
Rapidly Progressive Hearing Loss

261

Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness

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A L I T Y R E P O R T I N G ) M E A S U R E - A P P L I C A B I L I T Y
VALIDATION(MAV)PROCESS FOR
L A I M S - B A S E D R E P O R T I N G O F I N D I V I D U A L M E A S U R E S

Cluster
Number

Cluster Title

Measure
Number

34

Ischemic Vascular
Disease

201

Ischemic Vascular Disease (IVD): Blood Pressure Management Control

241

Ischemic Vascular Disease (IVD): Complete Lipid Profile and Low Density
Lipoprotein (LDL-C) Control

204
35

Chronic Wound Care

36

37

Epilepsy Care

Substance Use
Disorders

Measure Title

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

245

Chronic Wound Care: Use of Wound Surface Culture Technique in Patients
with Chronic Skin Ulcers

246

Chronic Wound Care: Use of Wet to Dry Dressings in Patients with Chronic
Skin Ulcers

186

Wound Care: Use of Compression System in Patients with Venous Ulcers

266

Epilepsy: Seizure Types(s) and Current Seizure Frequency(ies)

267

Epilepsy: Documentation of Etiology of Epilespy or Epilespy Syndrome

268

Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy

247

Substance Use Disorders: Counseling Regarding Psychosocial and
Pharmacologic Treatment Options for Alcohol Dependence

248

Substance Use Disorders: Screening for Depression Among Patients with
Substance Abuse or Dependence.

Measures Not Included Within a Cluster in 2012 Physician Quality Reporting
For 2012 measure-applicability validation, CMS will not include measures that are deemed to be
generally or broadly applicable to all or many Medicare patients and, therefore, potentially unreasonable
to attribute to individual eligible professionals using claims-based data. Other measures are not included
in a cluster of closely clinically related measures for other clinical or technical reasons, such as: (1) the
measure may not fit any cluster; or (2) the measure may fit reasonably with more than one cluster.
Measures excluded from 2012 measure-applicability validation for claims-based participation may or may
not be included in groupings of measures used in validation protocols for other mechanisms of data
submission, such as those based on extracts from medical registries or electronic health records, or for
other purposes or programs.
Based on such developments as refinements to a particular measure’s specifications or enhancements of
the Physician Quality Reporting list of available claims-based measures, any measure excluded from
measure-applicability validation for 2012 may also, in subsequent program years, be included in a
measure-applicability validation for claims-based participation in Physician Quality Reporting.

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A L I T Y R E P O R T I N G ) M E A S U R E - A P P L I C A B I L I T Y
VALIDATION(MAV)PROCESS FOR
L A I M S - B A S E D R E P O R T I N G O F I N D I V I D U A L M E A S U R E S

At a minimum, the following claim-based measures will be excluded from measure-applicability
validation for 2012:
Measure 6
Measure 41
Measure 46
Measure 47
Measure 102
Measure 116
Measure 117
Measure 119
Measure 124
Measure 128
Measure 130
Measure 131
Measure 134
Measure 156
Measure 157
Measure 158
Measure 172
Measure 173
Measure 181
Measure 182
Measure 185
Measure 195
Measure 226
Measure 235

Coronary Artery Disease (CAD): Antiplatelet Therapy
Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years and Older
Medication Reconciliation: Reconciliation After Discharge from an Inpatient Facility
Advance Care Plan
Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low-Risk Prostate Cancer
Patients
Antibiotic Treatment for Adults with Acute Bronchitis: Avoidance of Inappropriate Use
Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient
Diabetes Mellitus: Urine Screening for Microalbumin or Medical Attention for Nephropathy in
Diabetic Patients
Health Information Technology (HIT): Adoption/Use of Electronic Health Records (EHR)
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up
Documentation of Current Medications in the Medical Record
Pain Assessment and Follow-Up
Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan
Oncology: Radiation Dose Limits to Normal Tissues
Thoracic Surgery: Recording of Clinical Stage Prior to Lung Cancer or Esophageal Cancer
Resection
Carotid Endarterectomy: Use of Patch During Conventional Carotid Endarterectomy
Hemodialysis Vascular Access Decision-Making by Surgeon to Maximize Placement of
Autogenous Arterial Venous (AV) Fistula
Preventive Care and Screening: Unhealthy Alcohol Use – Screening
Elder Maltreatment Screen and Follow-Up Plan
Functional Outcome Assessment
Endoscopy & Polyp Surveillance: Colonoscopy Interval for Patients with a History of
Adenomatous Polyps – Avoidance of Inappropriate Use
Radiology: Stenosis Measurement in Carotid Imaging Studies
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Hypertension (HTN): Plan of Care

Prior to performing the analysis to determine satisfactory reporting, CMS may determine that additional
Physician Quality Reporting measures should be excluded from measure-applicability validation. Any
additions to this list will be published on the CMS Physician Quality Reporting website as soon as
possible after a determination has been made.
Step 2: Minimum Threshold Test
This second step will be applied to those who are subject to measure-applicability validation and who
have potential additional measures that could have been submitted identified during the clinical relation
test.
The minimum threshold test is based on the concept that during the 2012 reporting period January 1, 2012
through December 31, 2012, if an eligible professional treated more than a certain number of Medicare
patients with a condition to which a certain measure applied (that is, the eligible professional treated more
than a “threshold” number of patients or encounters), then that eligible professional should be accountable
for submitting the QDC(s) for that measure. The common minimum threshold, based on statistical and
clinical frequency considerations, will not be less than 15 patients (or encounters) for the 12-month
reporting period for each 2012 Physician Quality Reporting measure.
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A L I T Y R E P O R T I N G ) M E A S U R E - A P P L I C A B I L I T Y
VALIDATION(MAV)PROCESS FOR
L A I M S - B A S E D R E P O R T I N G O F I N D I V I D U A L M E A S U R E S

The following are examples of how the minimum threshold test will be applied: An emergency
department physician treated 20 Medicare patients with pneumonia during the 12-month reporting period
for 2012. If that emergency department physician is subject to validation and was found to have submitted
a QDC for at least one of the pneumonia measures under the clinical relation test, then the physician
would be deemed responsible for submitting QDCs for at least one other Physician Quality Reporting
pneumonia measure and will not earn the 2012 incentive payment. Alternatively, if an internist was
subject to validation and was found to have submitted a QDC for at least one of the pneumonia measures
under the clinical relation test, but treated only two Medicare patients with pneumonia during the same
period, then the internist would not be responsible for submitting the additional pneumonia measures and
would not be precluded from receiving an incentive payment.
During the reporting period, CMS will determine a minimum threshold for each individual Physician
Quality Reporting measure based on analysis of Part B claims data. However, no threshold will fall below
the common threshold of 15 patients (or encounters) described above.
Other Program Integrity Considerations
QDCs submitted on claims must be supported in medical record documentation. Other laws and
regulations relating to Medicare program integrity may also apply to Physician Quality Reporting.
Measures Reported via Registry or Measures Group Only - Not Applicable to MAV
The following list of measures will be reported through qualified registries or by measure group reporting
only, therefore, are not subject to measure-applicability validation.
Measure

5

Measure

7

Measure 8
Measure 33
Measure 81
Measure 82
Measure 83
Measure 118

Measure 137
Measure 138
Measure 143
Measure 144
Measure 148
Measure 149
Measure 150
Measure 151
Measure 159
Measure 160
Measure 161
Measure 162
Measure 164
Measure 165
Measure 166
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Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor
Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Coronary Artery Disease (CAD): Beta-Blocker Therapy - Prior Myocardial Infarction (MI) or Left
Ventricular Systolic Dysfunction (LVEF < 40%)
Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Stroke and Stroke Rehabilitation: Anticoagulant Therapy Prescribed for Atrial Fibrillation (AF) at
Discharge
Adult Kidney Disease: Hemodialysis Adequacy: Solute
Adult Kidney Disease: Peritoneal Dialysis Adequacy: Solute
Hepatitis C: Testing for Chronic Hepatitis C – Confirmation of Hepatitis C Viremia
Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin
Receptor Blocker (ARB) Therapy for Patients with CAD and Diabetes and/or Left Ventricular Systolic
Dysfunction (LVSD)
Melanoma: Continuity of Care-Recall System
Melanoma: Coordination of Care
Oncology: Medical and Radiation – Pain Intensity Quantified
Oncology: Medical and Radiation – Plan of Care for Pain
Back Pain: Initial Visit
Back Pain: Physical Exam
Back Pain: Advice for Normal Activities
Back Pain: Advice Against Bed Rest
HIV/AIDS: CD4+ Cell Count or CD4+ Percentage
HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis
HIV/AIDS: Adolescent and Adult Patients with HIV/AIDS Who Are Prescribed Potent Antiretroviral
Therapy
HIV/AIDS: HIV RNA Control After Six Months of Potent Antiretroviral Therapy
Coronary Artery Bypass Graft (CABG): Prolonged Intubation
Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate
Coronary Artery Bypass Graft (CABG): Stroke
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A L I T Y R E P O R T I N G ) M E A S U R E - A P P L I C A B I L I T Y
VALIDATION(MAV)PROCESS FOR
L A I M S - B A S E D R E P O R T I N G O F I N D I V I D U A L M E A S U R E S

Measure 167
Measure 168
Measure 169
Measure 170
Measure 171
Measure 187
Measure 191
Measure 192
Measure 196
Measure 197
Measure 198
Measure 205
Measure 206
Measure 207
Measure 208
Measure 209
Measure 210
Measure 211
Measure 212
Measure 213
Measure 214
Measure 215
Measure 216
Measure 217
Measure 218
Measure 219
Measure 220
Measure 221
Measure 222
Measure 223
Measure 224
Measure 228
Measure 233
Measure 234
Measure 236
Measure 242
Measure 243
Measure 244
Measure 256
Measure 257
Measure 258
Measure 259
Measure 260
Measure 264
Measure 265
Measure 269
Measure 270
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Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure
Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration
Coronary Artery Bypass Graft (CABG): Antiplatelet Medications at Discharge
Coronary Artery Bypass Graft (CABG): Beta-Blockers Administered at Discharge
Coronary Artery Bypass Graft (CABG): Anti-Lipid Treatment at Discharge
Stroke and Stroke Rehabilitation: Thrombolytic Therapy
Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery
Cataracts: Complication within 30 Days Following Cataract Surgery Requiring Additional
Surgical Procedures
Coronary Artery Disease (CAD): Symptom and Activity Assessment
Coronary Artery Disease (CAD): Lipid Control
Heart Failure: Left Ventricular Ejection Fraction (LVEF) Assessment
HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia and Gonorrhea
HIV/AIDS: Screening for High Risk Sexual Behaviors
HIV/AIDS: Screening for Injection Drug Use
HIV/AIDS: Sexually Transmitted Disease Screening for Syphilis
Functional Communication Measure - Spoken Language Comprehension
Functional Communication Measure – Attention
Functional Communication Measure – Memory
Functional Communication Measure - Motor Speech
Functional Communication Measure – Reading
Functional Communication Measure – Spoken Language Expression
Functional Communication Measure – Writing
Functional Communication Measure – Swallowing
Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Knee Impairments
Functional Deficit: Change in Risk- Adjusted Functional Status for Patients with Hip Impairments
Functional Deficit: Change in Risk- Adjusted Functional Status for Patients with Lower Leg, Foot or
Ankle Impairments
Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Lumbar Spine
Impairments
Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Shoulder Impairments
Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Elbow, Wrist or Hand
Impairments
Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Neck, Cranium, Mandible,
Thoracic Spine, Ribs, or Other General Orthopedic Impairments
Melanoma: Overutilization of Imaging Studies in Melanoma
Heart Failure (HF): Left Ventricular Function (LVF) Testing
Thoracic Surgery: Recording of Performance Status Prior to Lung or Esophageal Cancer Resection
Thoracic Surgery: Pulmonary Function Tests Before Major Anatomic Lung Resection (Pneumonectomy,
Lobectomy, or Formal Segmentectomy)
Hypertension (HTN) Controlling High Blood Pressure
Coronary Artery Disease (CAD): Symptom Management
Cardiac Rehabilitation Patient Referral from an Outpatient Setting
Hypertension: Blood Pressure Management
Surveillance after Endovascular Abdominal Aortic Aneurysm Repair (EVAR)
Statin Therapy at Discharge after Lower Extremity Bypass (LEB)
Rate of Open Elective Repair of Small or Moderate Abdominal Aortic Aneurysms (AAA) without Major
Complications (Discharged to Home by Post-Operative Day #7)
Rate of Elective Endovascular Aortic Repair (EVAR) of Small or Moderate Abdominal Aortic Aneurysms
(AAA) without Major Complications (Discharged to Home Post-Operative Day #2)
Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications
(Discharged to Home Post-Operative #2)
Sentinel Lymph Node Biopsy for Invasive Breast Cancer
Biopsy Follow-Up
Inflammatory Bowel Disease (IBD): Type, Anatomic Location and Activity All Documented
Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Sparing Therapy
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Y S I C I A N Q U A L I T Y R E P O R T I N G S Y S T E M ( P H Y S I C I A N
A L I T Y R E P O R T I N G ) M E A S U R E - A P P L I C A B I L I T Y
VALIDATION(MAV)PROCESS FOR
L A I M S - B A S E D R E P O R T I N G O F I N D I V I D U A L M E A S U R E S

Measure 271
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Version 6.0

Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury – Bone
Loss Assessment
Inflammatory Bowel Disease (IBD): Preventive Care: Influenza Immunization
Inflammatory Bowel Disease (IBD): Preventive Care: Pneumococcal Immunization
Inflammatory Bowel Disease (IBD): Testing for Latent TB Before Initating Anti-TNF (Tumor Necrosis
Factor) Therapy
Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating AntiTNF (Tumor Necrosis Factor) Therapy
Sleep Apnea: Assessment of Sleep Symptoms
Sleep Apnea: Severity Assessment at Initial Diagnosis
Sleep Apnea: Positive Airway Pressure Therapy Prescribed
Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy
Dementia: Staging of Dementia
Dementia: Cognitive Assessment
Dementia: Functional Status Assessment
Dementia: Neuropsychiatric Symptom Assessment
Dementia: Management of Neuropsychiatric Symptoms
Dementia: Screening for Depressive Symptoms
Dementia: Counseling Regarding Safety Concerns
Dementia: Counseling Regarding Risks of Driving
Dementia: Caregiver Education and Support
Parkinson’s Disease: Annual Parkinson’s Disease Diagnosis Review
Parkinson’s Disease: Psychiatric Disorders or Disturbances Assessment
Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment
Parkinson’s Disease: Querying about Sleep Disturbances
Parkinson’s Disease: Rehabilitative Therapy Options
Parkinson’s Disease: Parkinson’s Disease Medical and Surgical Treatment Options Reviewed
Hypertension: Appropriate Use of Aspirin or Other Antiplatelet or Anticoagulant Therapy
Hypertension: Complete Lipid Profile
Hypertension: Urine Protein Test
Hypertension: Annual Serum Creatinine Test
Hypertension: Diabetes Mellitus Screening Test
Hypertension: Blood Pressure Control
Hypertension: Low Density Lipoprotein (LDL-C) Control
Hypertension: Dietary and Physical Activity Modifications Appropriately Prescribed
Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery
Cataracts: Patient Satisfaction within 90 Days following Cataract Surgery
Preventive Care and Screening: Screening for High Blood Pressure

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