CMS-5517-P 04/19/2016 RR
TABLE A: Finalized Individual Quality Measures Available for MIPS Reporting in 2017 (Existing Measures Finalized in CMS-1631-FC).
The 2016 PQRS Measures Specifications Supporting Documents can be found at the following link: https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/pqrs/measurescodes.html.
Note: Existing measures with finalized substantive changes are noted with an asterisk (*), new finalized measures are noted with a plus symbol (+), core measures as agreed upon by Core Quality Measure Collaborative (CQMC) are noted with the symbol (§), high priority measures are noted with an exclamation point (!), and high priority measures that are appropriate use measures are noted with a double exclamation point (!!), in the column.
[Please note that the proposals contained in Tables D and G of the Appendix of the proposed rule have been incorporated into and are addressed in Table A below.]
Indicator |
NQF/ Quality # |
CMS E-Measure ID |
National Quality Strategy Domain |
Data submission Method |
Measure Type |
Measure Title and Description¥ |
Primary Measure Steward |
|
* § !
|
0059/001 |
122 V5 |
Effective Clinical Care
|
Claims, Web Interface, Registry, EHR |
Intermediate Outcome |
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%): Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.
Comments: One commenter did not support the inclusion of this measure because they did not believe it would result in better patient care. Commenters also asked that CMS modify the measure.
Response: CMS believes this to be a significant measure because it monitors hemoglobin levels and identifies poor control. CMS believes that monitoring of hemoglobin levels will lead to better treatment and outcomes for patients. Additionally, this measure is not owned by CMS and, therefore, cannot be modified without coordinating with the measure owner. CMS will share measure modification requests with the measure owner prior to any modifications being made and, as necessary, proposed in future rulemaking
Final Decision: CMS is finalizing this measure for the CY 2017 performance period and its proposal in Table G of the Appendix of the proposed rule (81 FR 28531) to change the measure description that clarifies the definition of Hemoglobin A1c required for poor control. This change does not constitute a change in measure intent or logic coding. Hemoglobin A1c >9.0% is consistent with clinical guidelines and practice. Additionally, in response to the finalized MIPS policy that no longer includes Measures Group as a data submission mechanism, Measures Group is being removed from this measure as a data submission mechanism.
|
National Committee for Quality Assurance |
|
§ |
0081/005 |
135v5 |
Effective Clinical Care
|
Registry, EHR |
Process |
Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD): Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge.
Comment: CMS did not receive specific comments regarding this measure other than its relationship with a specialty measure set.
Response: CMS will address all specialty measure set comments in Table E.
Final Decision: CMS is finalizing Q #005 for 2017 Performance Period.
|
Physician Consortium for Performance Improvement (PCPI®) Foundation |
|
* § |
0067/006 |
N/A |
Effective Clinical Care
|
Registry |
Process |
Chronic Stable Coronary Artery Disease (CAD): Antiplatelet Therapy: Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12 month period who were prescribed aspirin or clopidogrel.
Comments: Commenters recommended additional substantive changes to the measure. Another commenter asked for revisions related to the specialty measure set.
Response: This measure is not owned by CMS and, therefore, cannot be modified without coordinating with the measure owner. CMS will share measure modification requests with the measure owner prior to any modifications being made and, as necessary, proposed in future rulemaking. Although CMS thanks the commenter for their recommendations, CMS will finalize the measure in 2017 without the recommended changes and may consider these changes for future rulemaking. Additionally, CMS will address all specialty measure set comments in Table E.
Final Decision: CMS is finalizing this measure for the CY 2017 performance period and its proposal in Table G of the Appendix of the proposed rule (81 FR 28531) to change the measure title to align with the NQF endorsed version of this measure and to clarify the intent of the measure. This change does not constitute a change in the measure intent. The measure description remains the same where patients diagnosed with CAD are prescribed an antiplatelet within 12 months. Additionally, in response to the finalized MIPS policy that no longer includes Measures Group as a data submission mechanism, Measures Group is being removed from this measure as a data submission method.
|
American Heart Association |
|
§ |
007 0/007 |
145v5 |
Effective Clinical Care |
Registry, EHR |
Process |
Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%): Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have prior MI OR a current or prior LVEF < 40% who were prescribed beta-blocker therapy.
Comments: CMS received a comment that this measure cannot be reported for three years. The commenter did not provide justification behind the comment.
Response: CMS does not agree with the comment. This measure has been implemented in PQRS since 2007, so CMS believes this measure has been well tested for implementation.
Final Decision: CMS is finalizing Q #007 for 2017 Performance Period.
|
Physician Consortium for Performance Improvement Foundation (PCPI®) |
|
* § |
0083/008 |
144v5 |
Effective Clinical Care |
Registry, EHR |
Process |
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD): Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge.
Comments: One commenter requested that CMS make substantive changes to this measure. Several commenters made various requests to include this measure in specialty measure sets.
Response: This measure is not owned by CMS and, therefore, cannot be modified without coordinating with the measure owner. CMS will share measure modification requests with the measure owner prior to any modifications being made and, as necessary, proposed in future rulemaking. CMS will finalize the measure in 2017 without the recommended changes and may consider these changes for future rulemaking. Additionally, CMS will address all specialty measure set comments in Table E.
Final Decision: CMS is finalizing this measure for the CY 2017 performance period and its proposal in Table G of the Appendix of the proposed rule (81 FR 28532) to change the reporting mechanism for this measure by removing it from the Web Interface. The Web Interface measure set contains measures for primary care and also includes relevant measures from the PCMH Core Measure Set established by the Core Quality Measure Collaborative (CQMC). This measure is not a measure in the core set and is being finalized for removal from the Web Interface to align the Web Interface measure set with the PCMH Core Measure Set. Additionally, in response to the finalized MIPS policy that no longer includes Measures Group as a data submission mechanism, Measures Group is being removed from this measure as a data submission mechanism. |
Physician Consortium for Performance Improvement Foundation(PCPI®) |
|
|
0105/ 009 |
128v5 |
Effective Clinical Care |
EHR |
Process |
Anti-Depressant Medication Management: Percentage of patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on antidepressant medication treatment. Two rates are reported a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks). b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months).
Comment: Commenter supports CMS’s decision to include this measure in the MIPS Quality measure set.
Response: CMS thanks the commenter for their support.
Final Decision: CMS is finalizing Q#009 for 2017 Performance Period.
|
National Committee for Quality Assurance |
|
|
0086/012 |
143v5 |
Effective Clinical Care |
Claims, Registry, EHR |
Process |
Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation: Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more office visits within 12 months.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #012 for 2017 Performance Period.
|
Physician Consortium for Performance Improvement (PCPI®) Foundation |
|
|
0087/014 |
N/A |
Effective Clinical Care |
Claims, Registry |
Process |
Age-Related Macular Degeneration (AMD): Dilated Macular Examination: Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or hemorrhage AND the level of macular degeneration severity during one or more office visits within 12 months.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q#014 for 2017 Performance Period.
|
American Academy of Ophthalmology |
|
|
0088/018 |
167v5 |
Effective Clinical Care |
EHR |
Process |
Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy: Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy and the presence or absence of macular edema during one or more office visits within 12 months.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #018 for 2017 Performance Period.
|
Physician Consortium for Performance Improvement (PCPI®) Foundation |
|
! |
0089/019 |
142v5 |
Communication and Care Coordination |
Claims, Registry, EHR |
Process |
Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care: Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #019 for 2017 Performance Period.
|
Physician Consortium for Performance Improvement (PCPI®) Foundation |
|
!! |
0268/021 |
N/A |
Patient Safety |
Claims, Registry |
Process |
Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin: Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic who had an order for a first OR second generation cephalosporin for antimicrobial prophylaxis.
Comment: Commenters support CMS’s decision to include this measure in the MIPS Quality measure set.
Response: CMS thanks the commenter for their support.
Final Decision: CMS is finalizing Q #021 for 2017 Performance Period.
|
American Society of Plastic Surgeons |
|
! |
0239/023 |
N/A |
Patient Safety |
Claims, Registry |
Process |
Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients): Percentage of surgical patients aged 18 years and older undergoing procedures for which venous thromboembolism (VTE) prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time.
Comment: Commenters support CMS’s decision to include this measure in the MIPS Quality measure set.
Response: CMS thanks the commenter for their support
Final Decision: CMS is finalizing Q #023 for 2017 Performance Period.
|
American Society of Plastic Surgeons |
|
! |
0045/024 |
N/A |
Communication and Care Coordination |
Claims, Registry |
Process |
Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older: Percentage of patients aged 50 years and older treated for a fracture with documentation of communication, between the physician treating the fracture and the physician or other clinician managing the patient’s on-going care, that a fracture occurred and that the patient was or should be considered for osteoporosis treatment or testing. This measure is reported by the physician who treats the fracture and who therefore is held accountable for the communication.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #024 for 2017 Performance Period.
|
National Committee for Quality Assurance |
|
|
0325/032 |
N/A |
Effective Clinical Care |
Claims, Registry |
Process |
Stroke and Stroke Rehabilitation: Discharged on Antithrombotic Therapy: Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or transient ischemic attack (TIA) who were prescribed an antithrombotic therapy at discharge.
Comment: Commenters made various requests to include this measure in specialty measure sets.
Response: CMS will address all specialty measure set comments in Table E.
Final Decision: CMS is finalizing Q #032 for 2017 Performance Period. This measure remains a process measure.
|
American Academy of Neurology |
|
|
0046/039 |
N/A |
Effective Clinical Care |
Claims, Registry |
Process |
Screening for Osteoporosis for Women Aged 65-85 Years of Age: Percentage of female patients aged 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) to check for osteoporosis.
Comment: One commenter supports CMS’s decision to include this measure in the MIPS Quality measure set.
Response: CMS thanks the commenter for their support.
Final Decision: CMS is finalizing Q #039 for 2017 Performance Period.
|
National Committee for Quality Assurance / American Medical Association-Physician Consortium for Performance Improvement |
|
|
0134/043 |
N/A |
Effective Clinical Care |
Registry |
Process |
Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery: Percentage of patients aged 18 years and older undergoing isolated CABG surgery who received an IMA graft.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #043 for 2017 Performance Period.
|
Society of Thoracic Surgeons |
|
|
0236/044 |
N/A |
Effective Clinical Care |
Registry |
Process |
Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery: Percentage of isolated Coronary Artery Bypass Graft (CABG) surgeries for patients aged 18 years and older who received a beta-blocker within 24 hours prior to surgical incision.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #044 for 2017 Performance Period.
|
Centers for Medicare & Medicaid Services |
|
* § ! |
0097/046 |
N/A |
Communication and Care Coordination |
Claims, Web Interface, Registry |
Process |
Medication Reconciliation Post-Discharge: The percentage of discharges from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years and older of age seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record. This measure is reported as three rates stratified by age group:
• Reporting Criteria 1: 18-64 years of age • Reporting Criteria 2: 65 years and older • Total Rate: All patients 18 years of age and older.
Comments: One commenter supports CMS’s decision to include this measure in the MIPS Quality measure set. Another commenter requested that CMS include this measure in a specialty measure set.
Response: CMS thanks the commenter for their support. Additionally, CMS will address all specialty measure set comments in Table E of the appendix of the final rule with comments.
Final Decision: CMS is finalizing Q #046 for 2017 Performance Period. CMS is also finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28532) to change the data submission method for this measure by adding it to the Web Interface. The Web Interface measure set contains measures for primary care and also includes relevant measures from the PCMH Core Measure Set established by the CQMC. This measure is a core measure and is being finalized for the Web Interface to align the Web Interface measure set with the PCMH Core Measure Set. Furthermore, this measure is replacing PQRS #130: Documentation of Current Medications in the Medical Record in the Web Interface.
|
National Committee for Quality Assurance |
|
! |
0326/047 |
N/A |
Communication and Care Coordination |
Claims, Registry |
Process |
Care Plan: Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
Comments: Some commenters were concerned that documenting care plan on annual basis is burdensome, while others believed that an annual update of current care was not overly burdensome and would be considered appropriate care for patient preference.
Response: CMS believes that an annual update of a current care plan is not burdensome and would be considered appropriate care for patient preference. If a patient has an existing care plan, an annual update in subsequent years is not considered burdensome.
Final Decision: CMS is finalizing Q #047 for 2017 Performance Period. This measure remains a process measure.
|
National Committee for Quality Assurance |
|
|
N/A/048 |
N/A |
Effective Clinical Care |
Claims, Registry |
Process |
Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older: Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months.
Comments: One commenter supports CMS’s decision to include this measure in the MIPS Quality measure set. Another commenter requested that CMS include this measure in a specialty measure set.
Response: CMS thanks the commenter for their support. Additionally, CMS will address all specialty measure set comments in Table E.
Final Decision: CMS is finalizing Q #048 for 2017 Performance Period.
|
National Committee for Quality Assurance |
|
! |
N/A/050 |
N/A |
Person and Caregiver-Centered Experience and Outcomes |
Claims, Registry |
Process |
Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older: Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months.
Comment: One commenter did not support CMS’s decision to include this measure in MIPS. The commenter also stated, without going into detail, that the measure discourages development of patient-specific care plans. Another commenter recommends CMS modify the measure. Finally, a third commenter requested that CMS include this measure in a specialty measure set.
Response: While CMS appreciates commenter’s opinion regarding the clinical appropriateness of the measure as it relates to personalized care plans, CMS does not agree with commenter’s opinion. CMS believes that eligible clinicians are not prohibited in acting in the best interest of the patient and further developing a care plan. Furthermore, regarding the request for measure modifications, this measure is not owned by CMS and, therefore, cannot be modified without coordinating with the measure owner. CMS will share measure modification requests with the measure owner prior to any modifications being made and, as necessary, proposed in future rulemaking. CMS will finalize the measure in 2017 without the recommended changes and may consider these changes for future rulemaking. Finally, CMS will address all specialty measure set comments in Table E.
Final Decision: CMS is finalizing Q #050 for 2017 Performance Period.
|
National Committee for Quality Assurance |
|
|
0091/051 |
N/A |
Effective Clinical Care |
Claims, Registry |
Process |
Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation: Percentage of patients aged 18 years and older with a diagnosis of COPD who had spirometry results documented.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #051 for 2017 Performance Period.
|
American Thoracic Society |
|
|
0102/052 |
N/A |
Effective Clinical Care |
Claims, Registry |
Process |
Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy: Percentage of patients aged 18 years and older with a diagnosis of COPD (FEV1/FVC < 70%) and who have an FEV1 less than 60% predicted and have symptoms who were prescribed a long-acting inhaled bronchodilator.
Comment: One commenter requested that CMS include this measure in a specialty measure set.
Response: CMS will address all specialty measure set comments in Table E.
Final Decision: CMS is finalizing Q #052 for 2017 Performance Period.
|
American Thoracic Society |
|
!! |
0069/065 |
154v5 |
Efficiency and Cost Reduction |
Registry, EHR |
Process |
Appropriate Treatment for Children with Upper Respiratory Infection (URI): Percentage of children 3 months through 18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode.
Comments: We received a comment from a commenter who did not agree with the classification of this measure in the efficiency and cost reduction domain. Instead, the commenter indicated that the measure should be classified as resource use.
Response: Resource use is not an NQS domain and does not adequately reflect all aspects of the measure. We believe this measure should remain classified in the efficiency and cost reduction domain.
Final Decision: CMS is finalizing Q #065 for 2017 Performance Period. This measure remains within the Efficiency and Cost Reduction domain.
|
National Committee for Quality Assurance |
|
* !! |
N/A/066 |
146v5 |
Efficiency and Cost Reduction |
Registry, EHR |
Process |
Appropriate Testing for Children with Pharyngitis: Percentage of children 3-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode.
Comments: We received a comment from a commenter who did not agree with the classification of this measure in the efficiency and cost reduction domain. Instead, the commenter indicated that the measure should be classified as resource use.
Response: Resource use is not an NQS domain and does not adequately reflect all aspects of the measure. We believe this measure should remain classified in the efficiency and cost reduction domain.
Final Decision: CMS is finalizing Q #066 for 2017 Performance Period. CMS is also finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28533) to change the measure description due to guideline changes in 2013 where the age range changed to 3-18. Furthermore, this measure is no longer endorsed by the National Quality Forum (NQF); therefore, CMS is finalizing the removal of the NQF number as a reference for this measure.
|
National Committee for Quality Assurance |
|
|
0377/067 |
N/A |
Effective Clinical Care |
Registry |
Process |
Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemia: Baseline Cytogenetic Testing Performed on Bone Marrow: Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) or an acute leukemia who had baseline cytogenetic testing performed on bone marrow.
Comment: A commenter requested that CMS modify the measure.
Response: This measure is not owned by CMS and, therefore, cannot be modified without coordinating with the measure owner. CMS will share measure modification requests with the measure owner prior to any modifications being made and, as necessary, proposed in future rulemaking. CMS will finalize the measure in 2017 without the recommended changes and may consider these changes for future rulemaking.
Final Decision: CMS is finalizing Q #067 for 2017 Performance Period.
|
American Society of Hematology |
|
|
0378/068 |
N/A |
Effective Clinical Care |
Registry |
Process |
Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow: Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) who are receiving erythropoietin therapy with documentation of iron stores within 60 days prior to initiating erythropoietin therapy.
Comment: A commenter requested that CMS modify the measure. Additionally, one commenter requested that CMS include this measure in a specialty measure set.
Response: This measure is not owned by CMS and, therefore, cannot be modified without coordinating with the measure owner. CMS will share measure modification requests with the measure owner prior to any modifications being made and, as necessary, proposed in future rulemaking. CMS will finalize the measure in 2017 without the recommended changes and may consider these changes for future rulemaking. Furthermore, CMS will address all specialty measure set comments in the Table E.
Final Decision: CMS is finalizing Q #068 for 2017 Performance Period.
|
American Society of Hematology |
|
|
0380/069 |
N/A |
Effective Clinical Care |
Registry |
Process |
Hematology: Multiple Myeloma: Treatment with Bisphosphonates: Percentage of patients aged 18 years and older with a diagnosis of multiple myeloma, not in remission, who were prescribed or received intravenous bisphosphonate therapy within the 12-month reporting period.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #069 for 2017 Performance Period.
|
American Society of Hematology |
|
|
0379/070 |
N/A |
Effective Clinical Care |
Registry |
Process |
Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry: Percentage of patients aged 18 years and older seen within a 12 month reporting period with a diagnosis of chronic lymphocytic leukemia (CLL) made at any time during or prior to the reporting period who had baseline flow cytometry studies performed and documented in the chart.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #070 for 2017 Performance Period.
|
American Society of Hematology |
|
! |
N/A/076 |
N/A |
Patient Safety |
Claims, Registry |
Process |
Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections: Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed.
Comment: CMS received a comment in support of the measure proposed as a registry data submission method. A commenter also requested a modification to the measure. One commenter requested that CMS include this measure in a specialty measure set.
Response: This measure is not owned by CMS and, therefore, cannot be modified without coordinating with the measure owner. CMS will share measure modification requests with the measure owner prior to any modifications being made and, as necessary, proposed in future rulemaking. CMS will finalize the measure in 2017 without the recommended changes and may consider these changes for future rulemaking. Furthermore, CMS will address all specialty measure set comments in the Table E.
Final Decision: CMS is finalizing Q #076 for 2017 Performance Period.
|
American Society of Anesthesiologists |
|
!! |
0653/091 |
N/A |
Effective Clinical Care |
Claims, Registry |
Process |
Acute Otitis Externa (AOE): Topical Therapy: Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #091 for 2017 Performance Period.
|
American Academy of Otolaryngology-Head and Neck Surgery |
|
!! |
0654/093 |
N/A |
Efficiency and Cost Reduction |
Claims, Registry |
Process |
Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use: Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy.
Comments: One commenter did not agree with the classification of this measure in the efficiency and cost reduction domain, but believed that it should be classified as resource use instead.
Response: Resource use is not an NQS domain. We believe this measure should remain classified in the efficiency and cost reduction domain.
Final Decision: CMS is finalizing Q #093 for 2017 Performance Period.
|
American Academy of Otolaryngology-Head and Neck Surgery |
|
|
0391/099 |
N/A |
Effective Clinical Care |
Claims, Registry |
Process |
Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade: Percentage of breast cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes), and the histologic grade.
Comment: One commenter supported the inclusion of this measure in the MIPS Quality measure set but did not agree with the classification of this measure as a process measure. The commenter believed that it should be classified as an outcome measure instead.
Response: CMS does not agree with commenter but instead believes this measure should continue to be a process measure. The pathologist is reading and interpreting the presence of tumor as well as the type/grade of the tumor. They go through a process (reading the slide) to make the diagnosis and assign a pT, pN and grade. Reading/interpreting the slide is not an outcome as the pathologist cannot alter what is or is not contained in the specimen.
Final Decision: CMS is finalizing Q #099 for 2017 Performance Period. This measure remains a process measure.
|
College of American Pathologists |
|
|
0392/100 |
N/A |
Effective Clinical Care |
Claims, Registry |
Process |
Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade: Percentage of colon and rectum cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes) and the histologic grade.
Comment: One commenter supported the inclusion of this measure in the MIPS Quality measure set but did not agree with the classification of this measure as a process measure. The commenter believed that it should be classified as an outcome measure instead.
Response: CMS does not agree with commenter but instead believes this measure should continue to be a process measure. The pathologist is reading and interpreting the presence of tumor as well as the type/grade of the tumor. They go through a process (reading the slide) to make the diagnosis and assign a pT, pN and grade. Reading/interpreting the slide is not an outcome as the pathologist cannot alter what is or is not contained in the specimen.
Final Decision: CMS is finalizing Q #100 for 2017 Performance Period. This measure remains a process measure.
|
College of American Pathologists |
|
* § !! |
0389/102 |
129v6 |
Efficiency and Cost Reduction |
Registry, EHR |
Process |
Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients: Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer.
Comments: CMS received a comment that supported this change in the measure description. CMS also received a request to include this measure in a specialty measure set.
Response: We thank the commenters for their support. Additionally, CMS will address all specialty measure set comments in Table E.
Final Decision: CMS is finalizing Q #102 for 2017 Performance Period. CMS is also finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28534) to change the measure description due to a change in clinical guidelines that includes very low and low risk of prostate cancer recurrence. CMS believes that this change does not change the intent of the measure but merely ensures the measure remains up-to-date according to clinical guidelines and practice.
|
Physician Consortium for Performance Improvement Foundation (PCPI®) |
|
|
0390/104 |
N/A |
Effective Clinical Care |
Registry |
Process |
Prostate Cancer: Adjuvant Hormonal Therapy for High Risk or Very High Risk Prostate Cancer: Percentage of patients, regardless of age, with a diagnosis of prostate cancer at high or very high risk of recurrence receiving external beam radiotherapy to the prostate who were prescribed adjuvant hormonal therapy (GnRH [gonadotropin-releasing hormone] agonist or antagonist)
Comment: CMS received a comment requesting a modification to the measure. Another commenter stated that the measure did not reflect appropriate standard of care.
Response: While we thank the commenter for their comment, CMS disagrees with the commenter and believes this measure appropriately reflects healthcare standards. Additionally, this measure is not owned by CMS and, therefore, cannot be modified without coordinating with the measure owner. CMS will share measure modification requests with the measure owner prior to any modifications being made and, as necessary, proposed in future rulemaking. CMS will finalize the measure in 2017 without the recommended changes and may consider these changes for future rulemaking.
Final Decision: CMS is finalizing Q #104 for 2017 Performance Period.
|
American Urological Association Education and Research |
|
|
0104/ 107 |
161v5 |
Effective Clinical Care |
EHR |
Process |
Adult Major Depressive Disorder (MDD): Suicide Risk Assessment: Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #107 for 2017 Performance Period.
|
Physician Consortium for Performance Improvement Foundation (PCPI®) |
|
! |
N/A/109 |
N/A |
Person and Caregiver-Centered Experience and Outcomes |
Claims, Registry |
Process |
Osteoarthritis (OA): Function and Pain Assessment: Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain.
Comment: CMS received a comment that did not support the inclusion of this measure in the MIPS quality measure set. The commenter cited that it was clinically inappropriate for physicians to assess pain and function in all patients 21 years of age and older.
Response: CMS thanks the commenter for their comment. However, we disagree with the commenter’s belief. We believe that pain assessment is important for every patient with a diagnosis of Osteoarthritis.
Final Decision: CMS is finalizing Q #109 for 2017 Performance Period.
|
American Academy of Orthopedic Surgeons |
|
|
0041/110 |
147v6 |
Community/Population Health |
Claims, Web Interface, Registry, EHR |
Process |
Preventive Care and Screening: Influenza Immunization: Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization.
Comment: A Commenter supported the inclusion of this measure in the MIPS quality measure set. CMS received several comments requesting this measure be included in various specialty measure sets. One commenter also requested that this measure be added to the cross-cutting measures list.
Response: CMS thanks the commenters for their support of including this measure in the MIPS quality measure set. We will address all specialty set comments in Table E. Finally, CMS will not finalize the cross-cutting measure requirement but appreciates the commenter’s request to include the measure in the list. CMS may consider this request for future rulemaking.
Final Decision: CMS is finalizing Q #110 for 2017 Performance Period. There will not be a cross-cutting measure requirement, therefore, this measure will not be included on the list of cross-cutting measures for the 2017 performance period.
|
Physician Consortium for Performance Improvement Foundation (PCPI®) |
|
|
0043/111 |
127v5 |
Community/Population Health |
Claims, Web Interface, Registry, EHR |
Process |
Pneumonia Vaccination Status for Older Adults: Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine.
Comment: A commenter supported the inclusion of this measure in the MIPS quality measure set. CMS also received a comment requesting this measure be included in a specialty measure set. A commenter also requested that this measure be added to the cross-cutting measures list.
Response: CMS thanks the commenter for their support of including this measure in the MIPS quality measure set. We will address all specialty set comments in Table E. Additionally, CMS will not finalize the cross-cutting measure requirement but appreciates the commenters request to include the measure in the list. CMS may consider this request for future rulemaking.
Final Decision: CMS is finalizing Q #111 for 2017 Performance Period. There will not be a cross-cutting measure requirement, therefore, this measure will not be included on the list of cross-cutting measures for the 2017 performance period.
|
National Committee for Quality Assurance |
|
* § |
2372/112 |
125v5 |
Effective Clinical Care |
Claims, Web Interface, Registry, EHR |
Process |
Breast Cancer Screening: Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #112 for 2017 Performance Period. CMS is also finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28534) to change the measure description due to clinical guideline changes that occurred in 2013 which changed the age requirement for mammograms from 40-69 years to 50-74 years. CMS believes that this change does not change the intent of the measure but merely ensures the measure remains up-to-date according to clinical guidelines and practice. Additionally, in response to the finalized MIPS policy that no longer includes Measures Group as a data submission mechanism, Measures Group is being removed from this measure as a data submission mechanism. Furthermore, this measure has been recently endorsed by NQF with the updated age range. Therefore, CMS is finalizing the addition of the NQF #2372 to the measure.
|
National Committee for Quality Assurance |
|
§ |
0034/113 |
130v5 |
Effective Clinical Care |
Claims, Web Interface, Registry, EHR |
Process |
Colorectal Cancer Screening: Percentage of patients 50 - 75 years of age who had appropriate screening for colorectal cancer.
Comment: A commenter requested this measure be removed from a specialty measure set. Additionally, a commenter requested a modification to the measure.
Response: We will address all specialty set comments in Table E. This measure is not owned by CMS and, therefore, cannot be modified without coordinating with the measure owner. CMS will share measure modification requests with the measure owner prior to any modifications being made and, as necessary, proposed in future rulemaking. CMS will finalize the measure in 2017 without the recommended changes and may consider these changes for future rulemaking.
Final Decision: CMS is finalizing Q #113 for 2017 Performance Period.
|
National Committee for Quality Assurance |
|
§ !! |
0058/116 |
N/A |
Efficiency and Cost Reduction |
Registry |
Process |
Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis: Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
Comments: Commenters supported inclusion of this measure. One commenter also supported the “appropriate use” designation for this measure.
Response: We thank the commenters for their support.
Final Decision: CMS is finalizing Q #116 for 2017 Performance Period. This measure remains an appropriate use measure.
|
National Committee for Quality Assurance |
|
§ |
0055/117 |
131v5 |
Effective Clinical Care |
Claims, Web Interface, Registry, EHR |
Process |
Diabetes: Eye Exam: Percentage of patients 18 - 75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal exam (no evidence of retinopathy) in the 12 months prior to the measurement period.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #117 for 2017 Performance Period.
|
National Committee for Quality Assurance |
|
* § |
0066/118 |
N/A |
Effective Clinical Care |
Registry |
Process |
Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy -- Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%): Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy.
Comments: CMS received a comment stating the measure steward will no longer steward the measure. CMS also received a comment requesting modifications to the measure in addition to the proposed substantive changes in Table G.
Response: CMS would like to note that this measure has a steward as indicated in Table A of the Appendix of the rule. This measure is not owned by CMS and, therefore, cannot be modified without coordinating with the measure owner. CMS will share measure modification requests with the measure owner prior to any modifications being made and, as necessary, proposed in future rulemaking. CMS will finalize the measure in 2017 without the recommended changes and may consider these changes for future rulemaking.
Final Decision: CMS is finalizing Q #118 for 2017 Performance Period. CMS proposed in Table G of the Appendix of the proposed rule (81 FR 28535) to change the data submission method for this measure by removing the Web Interface as a submission method. The Web Interface measure set contains measures for primary care and also includes relevant measures from the core measure set. This measure is not a measure in the CQMC set and is being finalized for removal from the Web Interface to align the Web Interface measure set with the CQMC measure set for ACOs/PCMHs.
|
American Heart Association |
|
* § |
0062/119 |
134v5 |
Effective Clinical Care |
Registry, EHR |
Process |
Diabetes: Medical Attention for Nephropathy: The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period
Comments: CMS received a comment to include this measure in a specialty measure set.
Response: CMS will address all comments on specialty measure sets in Table E.
Final Decision: CMS is finalizing Q #119 for 2017 Performance Period. CMS is also finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28535) to revise the title of this measure to align with the measure’s intent to increase reporting clarity and to match the NQF endorsed measure’s title. Additionally, in response to the finalized MIPS policy that no longer includes Measures Group as a data submission mechanism, Measures Group is being removed from this measure as a data submission mechanism. |
National Committee for Quality Assurance |
|
! |
N/A/122 |
N/A |
Effective Clinical Care |
Registry |
Intermediate Outcome |
Adult Kidney Disease: Blood Pressure Management: Percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (stage 3, 4, or 5, not receiving Renal Replacement Therapy [RRT]) with a blood pressure < 140/90 mmHg OR ≥ 140/90 mmHg with a documented plan of care
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #122 for 2017 Performance Period.
|
Renal Physicians Association |
|
|
0417/126 |
N/A |
Effective Clinical Care |
Registry |
Process |
Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy –Neurological Evaluation: Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 months.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #126 for 2017 Performance Period. This measure remains a process measure.
|
American Podiatric Medical Association |
|
|
0416/127 |
N/A |
Effective Clinical Care |
Registry |
Process |
Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear: Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #127 for 2017 Performance Period. This measure remains a process measure.
|
American Podiatric Medical Association |
|
* § |
0421/128 |
69 v5 |
Community/Population Health |
Claims, Web Interface, Registry, EHR |
Process |
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan: Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter
Normal Parameters: Age 18 – 64 years BMI ≥ 18.5 and < 25 kg/m2.
Comments: We received a comment stating that according to the Binge Eating Disorder Association, this measure is not supported by current clinical evidence with respect to improved health outcomes for all patients. The commenter stated the measure could harm patients with Binge eating disorders.
Response: CMS recognizes that this measure may not be ideal for providers whose patients are suffering from this specific condition. However, CMS ascertains that this measure is meant for providers whose patients may have weight or BMI issues associated with being outside of normal weight parameters. CMS relies on the provider to provide the appropriate follow-up for patients, recognizing the various associated issues a patient may or may not face. Because, there are a number of chronic illnesses that are linked to being outside of normal weight parameters and research shows that proper screening and follow-up is an appropriate way to address weight related issues, CMS believes this is a valid measure and should remain in the program.
Final Decision: CMS is finalizing Q #128 for 2017 Performance Period. CMS is also finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28536) to remove the upper parameter from the measure description to align with the recommendations of technical expert panel and clinical expertise. Additionally, in response to the finalized MIPS policy that no longer includes Measures Group as a data submission mechanism, Measures Group is being removed from this measure as a data submission mechanism.
|
Centers for Medicare & Medicaid Services |
|
* ! |
0419/130 |
68v6 |
Patient Safety |
Claims, Registry, EHR |
Process |
Documentation of Current Medications in the Medical Record: Percentage of visits for patients aged 18 years and older for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration.
Comments: CMS received a comment supporting the inclusion of this measure in the MIPS Quality measure set for the 2017 performance period.
Response: CMS thanks the commenter for their support.
Final Decision: CMS is finalizing Q #130 for 2017 Performance Period. CMS is also finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28536) to revise the data submission method of this measure to remove it from use in the Web Interface. This measure is being replaced in the Web Interface with the core measure, PQRS #46: Medication Reconciliation Post-Discharge. Since these measures cover similar topic areas, CMS proposes to remove this measure from the Web Interface. Additionally, in response to the finalized MIPS policy that no longer includes Measures Group as a data submission mechanism, Measures Group is being removed from this measure as a data submission mechanism.
|
Centers for Medicare & Medicaid Services |
|
! |
0420/131 |
N/A |
Communication and Care Coordination |
Claims, Registry |
Process |
Pain Assessment and Follow-Up: Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present.
Comment: One commenter did not support CMS’s decision to include this measure in the MIPS quality measure set stating that it was not practical in every area of the country. Another commenter requested that CMS add this measure to the cross-cutting measures list.
Response: CMS has identified this measure as high priority because it addresses key issues that are valuable for quality healthcare. While we recognize there may be limited access to pain management specialists in certain areas, we fully support the inclusion of this measure in the program as it addresses the overarching need of appropriate referral for pain management. Additionally, CMS will not finalize the cross-cutting measure requirement but appreciates the commenters request to include the measure in the list. CMS may consider this request for future rulemaking
Final Decision: CMS is finalizing Q #131 for 2017 Performance Period. There will not be a cross-cutting measure requirement, therefore, this measure will not be included on the list of cross-cutting measures for the 2017 performance period.
|
Centers for Medicare & Medicaid Services |
|
* |
0418/134 |
2v6 |
Community/Population Health |
Claims, Web Interface, Registry, EHR |
Process |
Preventive Care and Screening: Screening for Depression and Follow-Up Plan: Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen.
Comments: CMS received several comments supporting our decision to include this measure in the MIPS quality measure set. One commenter applauds CMS for taking action on depression screening. Another commenter recommends CMS revise the measure to be more appropriate.
Response: CMS thanks the commenters for their support of the measure. We would also note that suggestions for the revision of the measure have been shared with our technical expert panel for further review. If our technical expert panel recommends the revision, CMS will test the revised measure and make it available for public comment according the Measure Management System Blueprint. CMS will finalize the measure in 2017 without the recommended changes and may consider these changes for future rulemaking once this process is complete.
Final Decision: CMS is finalizing Q #134 for 2017 Performance Period. CMS is also finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28537) to revise the title and measure description to align with the recommendations of the technical expert panel and clinical expertise in the field. CMS believes the revision provides clarity to providers when reporting depression screening and follow-up. Additionally, in response to the finalized MIPS policy that no longer includes Measures Group as a data submission mechanism, Measures Group is being removed from this measure as a data submission mechanism.
|
Centers for Medicare & Medicaid Services |
|
! |
0650/137 |
N/A |
Communication and Care Coordination |
Registry |
Structure |
Melanoma: Continuity of Care – Recall System: Percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered, at least once within a 12 month period, into a recall system that includes: • A target date for the next complete physical skin exam, AND • A process to follow up with patients who either did not make an appointment within the specified timeframe or who missed a scheduled appointment.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #137 for the 2017 Performance Period.
|
American Academy of Dermatology |
|
! |
N/A/138 |
N/A |
Communication and Care Coordination |
Registry |
Process |
Melanoma: Coordination of Care: Percentage of patient visits, regardless of age, with a new occurrence of melanoma who have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #138 for the 2017 Performance Period. |
American Academy of Dermatology |
|
|
0566/140
|
N/A |
Effective Clinical Care |
Claims, Registry |
Process |
Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement: Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) or their caregiver(s) who were counseled within 12 months on the benefits and/or risks of the Age-Related Eye Disease Study (AREDS) formulation for preventing progression of AMD.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #140 for the 2017 Performance Period.
|
American Academy of Ophthalmology |
|
! |
0563/141 |
N/A |
Communication and Care Coordination |
Claims, Registry |
Outcome |
Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care: Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 15% from the pre- intervention level) OR if the most recent IOP was not reduced by at least 15% from the pre- intervention level, a plan of care was documented within 12 months.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #141 for the 2017 Performance Period.
|
American Academy of Ophthalmology |
|
§ ! |
0384/143 |
157v5 |
Person and Caregiver-Centered Experience and Outcomes |
Registry, EHR |
Process |
Oncology: Medical and Radiation – Pain Intensity Quantified: Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #143 for the 2017 Performance Period.
|
Physician Consortium for Performance Improvement Foundation (PCPI® |
|
! |
0383/144 |
N/A |
Person and Caregiver-Centered Experience and Outcomes |
Registry |
Process |
Oncology: Medical and Radiation – Plan of Care for Pain: Percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain.
Comments: CMS received a comment requesting modifications to the measure.
Response: This measure is not owned by CMS and, therefore, cannot be modified without coordinating with the measure owner. CMS will share measure modification requests with the measure owner prior to any modifications being made and, as necessary, proposed in future rulemaking. CMS will finalize the measure in 2017 without the recommended changes and may consider these changes for future rulemaking.
Final Decision: CMS is finalizing Q #144 for the 2017 Performance Period.
|
American Society of Clinical Oncology |
|
!! |
N/A/145 |
N/A |
Patient Safety |
Claims, Registry |
Process |
Radiology: Exposure Dose or Time Reported for Procedures Using Fluoroscopy: Final reports for procedures using fluoroscopy that document radiation exposure indices, or exposure time and number of fluorographic images (if radiation exposure indices are not available).
Comment: One commenter identified a discrepancy regarding the proposed data submission methods for this measure in the proposed rule.
Response: CMS has corrected this discrepancy throughout the appendix of the final rule with comments and appreciates the commenter for their thorough review.
Final Decision: CMS is finalizing Q #145 for the 2017 Performance Period. This measure is reportable via claims and registry data submission methods. |
American College of Radiology |
|
! |
0508/146 |
N/A |
Efficiency and Cost Reduction |
Claims, Registry |
Process |
Radiology: Inappropriate Use of “Probably Benign” Assessment Category in Mammography Screening: Percentage of final reports for screening mammograms that are classified as “probably benign”.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #146 for the 2017 Performance Period. |
American College of Radiology |
|
! |
N/A/147 |
N/A |
Communication and Care Coordination |
Claims, Registry |
Process |
Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy: Percentage of final reports for all patients, regardless of age, undergoing bone scintigraphy that include physician documentation of correlation with existing relevant imaging studies (e.g., x-ray, MRI, CT, etc.) that were performed.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #147 for the 2017 Performance Period. |
Society of Nuclear Medicine and Molecular Imaging |
|
! |
0101/154 |
N/A |
Patient Safety |
Claims, Registry |
Process |
Falls: Risk Assessment: Percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls completed within 12 months.
Comment: One commenter supported our decision to include this measure in the MIPS quality measure set stating that is was based on current evidence and that a performance gap exists. A commenter also requested that this measure be added to the cross-cutting measures list.
Response: CMs thanks the commenter for their support and note that we agree with the commenter that this is an important issue that has a clear performance gap. We will not finalize the cross-cutting measure requirement but appreciates the commenter’s request to include the measure in the list. CMS may consider this request for future rulemaking.
Final Decision: CMS is finalizing Q #154 for the 2017 Performance Period. There will not be a cross-cutting measure requirement, therefore, this measure will not be included on the list of cross-cutting measures for the 2017 performance period.
|
National Committee for Quality Assurance |
|
! |
0101/155 |
N/A |
Communication and Care Coordination |
Claims, Registry |
Process |
Falls: Plan of Care: Percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months.
Comment: A commenter requested that this measure be added to the cross-cutting measures list.
Response: CMS will not finalize the cross-cutting measure requirement but appreciates the commenter’s request to include the measure in the list. CMS may consider this request for future rulemaking.
Final Decision: CMS is finalizing Q #155 for the 2017 Performance Period. There will not be a cross-cutting measures list for 2017. |
National Committee for Quality Assurance |
|
!! |
0382/156 |
N/A |
Patient Safety |
Claims, Registry |
Process |
Oncology: Radiation Dose Limits to Normal Tissues: Percentage of patients, regardless of age, with a diagnosis of breast, rectal, pancreatic or lung cancer receiving 3D conformal radiation therapy who had documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues.
Comment: CMS received a comment supporting our decision to include this measure in the MIPS quality measure set.
Response: CMS thanks the commenters for their support of the measure
Final Decision: CMS is finalizing Q #156 for the 2017 Performance Period. |
American Society for Radiation Oncology |
|
* § |
0405/160 |
52v5 |
Effective Clinical Care |
EHR |
Process |
HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis: Percentage of patients aged 6 weeks and older with a diagnosis of HIV/AIDS who were prescribed Pneumocystis Jiroveci Pneumonia (PCP) prophylaxis.
Comment: CMS received a comment supporting our decision to include this measure in the MIPS quality measure set.
Response: CMS thanks the commenters for their support of the measure
Final Decision: CMS is finalizing Q #160 for the 2017 Performance Period. CMS is also finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28538) to change the data submission method for this measure from Measures Group to EHR only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the finalized MIPS policy that no longer includes Measures Group as a data submission mechanism, Measures Group is being removed from this measure as a data submission mechanism. |
National Committee for Quality Assurance |
|
* § |
0056/163 |
123v5 |
Effective Clinical Care |
EHR |
Process |
Diabetes: Foot Exam: Percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a foot exam (visual inspection and sensory exam with mono filament and a pulse exam) during the measurement year.
Comments: CMS received a comment that the measure description as proposed was not consistent with other measure descriptions with “the” preceding the word “percentage”.
Response: CMS is correcting the description by removing the word “the” from the beginning of the measure description.
Final Decision: CMS is finalizing Q #163 for the 2017 Performance Period. CMS is also finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28538) to change the measure description as written above to improve clarity for providers about what constitutes a foot exam. CMS believes this change does not change the intent of the measure, but merely provides clarity in response to providers’ feedback. |
National Committee for Quality Assurance |
|
! |
0129/164 |
N/A |
Effective Clinical Care |
Registry |
Outcome |
Coronary Artery Bypass Graft (CABG): Prolonged Intubation: Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation > 24 hours.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q#164 for the 2017 Performance Period.
|
Society of Thoracic Surgeons |
|
* ! |
0130/165 |
N/A |
Effective Clinical Care |
Registry |
Outcome |
Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate: Percentage of patients aged 18 years and older undergoing isolated CABG surgery who, within 30 days postoperatively, develop deep sternal wound infection involving muscle, bone, and/or mediastinum requiring operative intervention.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #165 for the 2017 Performance Period. CMS is also finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28538) to change the reporting mechanism for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
Society of Thoracic Surgeons |
|
* ! |
0131/166
|
N/A |
Effective Clinical Care |
Registry |
Outcome |
Coronary Artery Bypass Graft (CABG): Stroke: Percentage of patients aged 18 years and older undergoing isolated CABG surgery who have a postoperative stroke (i.e., any confirmed neurological deficit of abrupt onset caused by a disturbance in blood supply to the brain) that did not resolve within 24 hours.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q#166 for the 2017 Performance Period. CMS is also finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28539) to change the reporting mechanism for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
|
Society of Thoracic Surgeons |
|
* ! |
0114/167 |
N/A |
Effective Clinical Care |
Registry |
Outcome |
Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure: Percentage of patients aged 18 years and older undergoing isolated CABG surgery (without pre-existing renal failure) who develop postoperative renal failure or require dialysis.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #167 for the 2017 Performance Period. CMS is also finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28539) to change the reporting mechanism for this measure from Measures Group only to registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
Society of Thoracic Surgeons |
|
* ! |
0115/168 |
N/A |
Effective Clinical Care |
Registry |
Outcome |
Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration: Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require a return to the operating room (OR) during the current hospitalization for mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction, or other cardiac reason.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #168 for the 2017 Performance Period. CMS is also finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28540) to change the reporting mechanism for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
Society of Thoracic Surgeons |
|
* |
N/A/176 |
N/A |
Effective Clinical Care |
Registry |
Process |
Rheumatoid Arthritis (RA): Tuberculosis Screening: Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have documentation of a tuberculosis (TB) screening performed and results interpreted within 6 months prior to receiving a first course of therapy using a biologic disease-modifying anti-rheumatic drug (DMARD).
Comment: A commenter requested this measure be removed from a specialty measure set and added to another.
Response: We will address all specialty set comments in Table E of the appendix.
Final Decision: CMS is finalizing Q #176 for the 2017 Performance Period. CMS is also finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28540) to change the reporting mechanism for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
|
American College of Rheumatology |
|
* |
N/A/ 177 |
N/A |
Effective Clinical Care |
Registry |
Process |
Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity: Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease activity within 12 months.
Comment: A commenter requested this measure be removed from a specialty measure set and added to another. CMS also received a comment requesting modifications to the measure.
Response: We will address all specialty set comments in Table E of the appendix. This measure is not owned by CMS and, therefore, cannot be modified without coordinating with the measure owner. CMS will share measure modification requests with the measure owner prior to any modifications being made and, as necessary, proposed in future rulemaking. CMS will finalize the measure in 2017 without the recommended changes and may consider these changes for future rulemaking.
Final Decision: CMS is finalizing Q #177 for the 2017 Performance Period. CMS is also finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28541) to change the reporting mechanism for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
American College of Rheumatology |
|
|
N/A/178 |
N/A |
Effective Clinical Care |
Registry |
Process |
Rheumatoid Arthritis (RA): Functional Status Assessment: Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) for whom a functional status assessment was performed at least once within 12 months.
Comment: A commenter requested this measure be removed from a specialty measure set and added to another.
Response: We will address all specialty set comments in Table E of the appendix.
Final Decision: CMS is finalizing Q #178 for the 2017 Performance Period.
|
American College of Rheumatology |
|
* |
N/A/179 |
N/A |
Effective Clinical Care |
Registry |
Process |
Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis: Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease prognosis at least once within 12 months.
Comment: A commenter requested this measure be removed from a specialty measure set and added to another. CMS also received a comment requesting modifications to the measure.
Response: We will address all specialty set comments in Table E of the appendix. This measure is not owned by CMS and, therefore, cannot be modified without coordinating with the measure owner. CMS will share measure modification requests with the measure owner prior to any modifications being made and, as necessary, proposed in future rulemaking. CMS will finalize the measure in 2017 without the recommended changes and may consider these changes for future rulemaking.
Final Decision: CMS is finalizing Q #179 for the 2017 Performance Period. CMS is also finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28541) to change the reporting mechanism for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
American College of Rheumatology |
|
*
|
N/A/180 |
N/A |
Effective Clinical Care |
Registry |
Process |
Rheumatoid Arthritis (RA): Glucocorticoid Management: Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone ≥ 10 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months.
Comment: A commenter requested this measure be removed from a specialty measure set and added to another.
Response: We will address all specialty set comments in Table E of the appendix
Final Decision: CMS is finalizing Q #180 for the 2017 Performance Period. CMS is finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28542) to change the reporting mechanism for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
American College of Rheumatology |
|
! |
N/A/181 |
N/A |
Patient Safety |
Claims, Registry |
Process |
Elder Maltreatment Screen and Follow-Up Plan: Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening Tool on the date of encounter AND a documented follow-up plan on the date of the positive screen.
Comment: A commenter did not support our proposal to include this measure in the MIPS quality measure set for 2017 stating that it is not appropriate for physicians to document elder maltreatment. Another commenter requested that this measure be modified.
Response: While CMS appreciates the comment, we believe this is an important priority that requires further study. We would also note that there is a significant gap in data and performance regarding the assessment of maltreatment in older adults. We would also note that suggestions for the revision of the measure have been shared with our technical expert panel for further review. If our technical expert panel recommends the revision, CMS will test the revised measure and make it available for public comment according the Measure Management System Blueprint. CMS will finalize the measure in 2017 without the recommended changes and may consider these changes for future rulemaking once this process is complete.
Final Decision: CMS is finalizing Q #181 for the 2017 Performance Period.
|
Centers for Medicare & Medicaid Services |
|
! |
2624/182
|
N/A |
Communication and Care Coordination |
Claims, Registry |
Process |
Functional Outcome Assessment: Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies.
Comment: CMS received various comments on this measure ranging from supporting the inclusion of the measure in the cross-cutting measures list to not supporting the measure in MIPS. We also received a request to modify the measure to expand the denominator for primary care providers.
Response: CMS will not finalize the cross-cutting measure requirement but appreciates the commenter’s request to include the measure in the list. CMS may consider this request for future rulemaking. We would also note that suggestions for the revision of the measure have been shared with our technical expert panel for further review. If our technical expert panel recommends the revision, CMS will test the revised measure and make it available for public comment according the Measure Management System Blueprint. CMS will finalize the measure for the 2017 performance period without the recommended changes and may consider these changes for future rulemaking once this process is complete.
Final Decision: CMS is finalizing Q #182 for the 2017 Performance Period. There will not be a cross-cutting measure requirement, therefore, this measure will not be included on the list of cross-cutting measures for the 2017 performance period.
|
Centers for Medicare & Medicaid Services
|
|
§ !! |
0659/185 |
N/A |
Communication and Care Coordination |
Claims, Registry |
Process |
Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use: Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior adenomatous polyp(s) in previous colonoscopy findings, who had an interval of 3 or more years since their last colonoscopy.
Comments: CMS received a comment supporting our decision to include this measure in the MIPS quality measure set.
Response: CMS thanks the commenters for their support of the measure.
Final Decision: CMS is finalizing Q #185 for the 2017 Performance Period. |
American Gastroenterological Association/ American Society for Gastrointestinal Endoscopy/ American College of Gastroenterology |
|
* |
N/A/187 |
N/A |
Effective Clinical Care |
Registry |
Process |
Stroke and Stroke Rehabilitation: Thrombolytic Therapy: Percentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who arrive at the hospital within two hours of time last known well and for whom IV t-PA was initiated within three hours of time last known well.
Comments: A commenter requested this measure be added to a specialty measure set.
Response: We will address all specialty set comments in Table E of the appendix.
Final Decision: CMS is finalizing Q #187 for the 2017 Performance Period. CMS is also finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28542) to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis, CMS believes the classification of this measure is process measure. |
American Heart Association |
|
! |
0565/191 |
133v5 |
Effective Clinical Care |
Registry, EHR |
Outcome |
Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery: Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following the cataract surgery.
Comments: CMS received a comment requesting that we not remove this measure from the MIPS quality measure set for 2017. Response: CMS notes that we did not propose removal of this measure and appreciates the commenters support for inclusion in MIPS.
Final Decision: CMS is finalizing Q #191 for the 2017 Performance Period. |
Physician Consortium for Performance Improvement Foundation (PCPI® |
|
! |
0564/192 |
132v5 |
Patient Safety |
Registry, EHR |
Outcome |
Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures: Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and had any of a specified list of surgical procedures in the 30 days following cataract surgery which would indicate the occurrence of any of the following major complications: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence.
Comments: CMS received a comment requesting that we not remove this measure from the MIPS quality measure set for 2017.
Response: CMS notes that we did not propose removal of this measure and appreciates the commenter’s support for inclusion in MIPS.
Final Decision: CMS is finalizing Q #192 for the 2017 Performance Period.
|
Physician Consortium for Performance Improvement Foundation (PCPI® |
|
|
0507/195 |
N/A |
Effective Clinical Care |
Claims, Registry |
Process |
Radiology: Stenosis Measurement in Carotid Imaging Reports: Percentage of final reports for carotid imaging studies (neck magnetic resonance angiography [MRA], neck computed tomography angiography [CTA], neck duplex ultrasound, carotid angiogram) performed that include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #195 for the 2017 Performance Period. |
American College of Radiology |
|
* § |
0068/204
|
164v5 |
Effective Clinical Care |
Claims, Web Interface, Registry, EHR |
Process |
Ischemic (IVD): Use of Aspirin or Another Antiplatelet: Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period and who had documentation of use of aspirin or another antiplatelet during the measurement period.
Comments: A commenter requested this measure be added to a specialty measure set. CMS also received a comment requesting modifications to the measure.
Response: We will address all specialty set comments in Table E of the appendix. This measure is not owned by CMS and, therefore, cannot be modified without coordinating with the measure owner. CMS will share measure modification requests with the measure owner prior to any modifications being made and, as necessary, proposed in future rulemaking. CMS will finalize the measure in 2017 without the recommended changes and may consider these changes for future rulemaking.
Final Decision: CMS is finalizing Q #204 for the 2017 Performance Period. CMS is also finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28543) to revise the measure title and description to align with the measure’s intent and to provide clarity for providers. Additionally, in response to the finalized MIPS policy that no longer includes Measures Group as a data submission mechanism, Measures Group is being removed from this measure as a data submission mechanism. |
National Committee for Quality Assurance |
|
§ |
0409/205 |
N/A
|
Effective Clinical Care |
Registry |
Process |
HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis: Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia, gonorrhea and syphilis screenings were performed at least once since the diagnosis of HIV infection.
Comments: CMS received a comment supporting our decision to include this measure in the MIPS quality measure set. Response: CMS thanks the commenters for their support of the measure.
Final Decision: CMS is finalizing Q #205 for the 2017 Performance Period. |
National Committee for Quality Assurance |
|
* ! |
0422/217
|
N/A |
Communication and Care Coordination |
Registry |
Outcome |
Functional Status Change for Patients with Knee Impairments: A self-report measure of change in functional status for patients 14 year+ with knee impairments. The change in functional status assessed using FOTO’s (knee) PROM is adjusted to patient characteristics known to be associated with functional status outcomes (risk-adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality.
Comments: One commenter identified a discrepancy regarding this measure in the proposed rule noting that the measure type was identified as process in several areas of the appendix.
Response: CMS has corrected this discrepancy throughout the appendix of this final rule with comment and appreciates the commenter for their thorough review. This measure will be identified as outcome throughout the appendix to align with Table A.
Final Decision: CMS is finalizing Q #217 for the 2017 Performance Period. CMS is also finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28543) to revise the measure title and description to align with the NQF-endorsed version of the measure. The measure owner revised the title and description of the measure to be consistent with the change in numerator details that now calculate the change in functional status score and denominator details that include patients that completed the FOTO knee FS PROM at admission and discharge. Additionally, this change in numerator and denominator details entails that the measure type changes from process to outcome. |
Focus on Therapeutic Outcomes, Inc. |
|
* ! |
0423/218 |
N/A |
Communication and Care Coordination |
Registry |
Outcome |
Functional Status Change for Patients with Hip Impairments: A self-report measure of change in functional status for patients 14 years+ with hip impairments. The change in functional status assessed using FOTO’s (hip) PROM is adjusted to patient characteristics known to be associated with functional status outcomes (risk-adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality.
Comments: One commenter identified a discrepancy regarding this measure in the proposed rule noting that the measure type was identified as process in several areas of the appendix and outcome in others.
Response: CMS has corrected this discrepancy throughout the appendix of the final rule with comments and appreciates the commenter for their thorough review. This measure will be identified as outcome throughout the appendix to align with Table A.
Final Decision: CMS is finalizing Q #218 for the 2017 Performance Period. CMS is also finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28544) to revise the measure title and description to align with the NQF-endorsed version of the measure. The measure owner revised the title and description of the measure to be consistent with the change in numerator details that now calculate the average change in functional status scores in patients who were treated in a 12 month period and denominator details that include patients that completed the FOTO hip FS PROM at admission and discharge.
|
Focus on Therapeutic Outcomes, Inc. |
|
* ! |
0424/219 |
N/A |
Communication and Care Coordination |
Registry |
Outcome |
Functional Status Change for Patients with Foot and Ankle Impairments: A self-report measure of change in functional status for patients 14 years+ with foot and ankle impairments. The change in functional status assessed using FOTO’s (foot and ankle) PROM is adjusted to patient characteristics known to be associated with functional status outcomes (risk-adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality.
Comments: One commenter identified a discrepancy regarding this measure in the proposed rule noting that the measure type was identified as process in several areas of the appendix and outcome in others.
Response: CMS has corrected this discrepancy throughout the appendix of this final rule with commentand appreciates the commenter for their thorough review. This measure will be identified as outcome throughout the appendix to align with Table A.
Final Decision: CMS is finalizing Q #219 for the 2017 Performance Period. CMS is also finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28545) to revise the measure title and description to align with the NQF-endorsed version of the measure. The measure owner revised the title and description of the measure to be consistent with the change in numerator details that now calculate the average change in functional status scores in patients who were treated in a 12 month period and denominator details that include patients that completed the FOTO hip FS PROM at admission and discharge. |
Focus on Therapeutic Outcomes, Inc. |
|
* ! |
0425/220 |
N/A |
Communication and Care Coordination |
Registry |
Outcome |
Functional Status Change for Patients with Lumbar Impairments: A self-report outcome measure of functional status for patients 14 years+ with lumbar impairments. The change in functional status assessed using FOTO’s (lumbar) PROM is adjusted to patient characteristics known to be associated with functional status outcomes (risk-adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality.
Comments: One commenter identified a discrepancy regarding this measure in the proposed rule noting that the measure type was identified as process in several areas of the appendix and outcome in others.
Response: CMS has corrected this discrepancy throughout the appendix of this final rule with comment and appreciates the commenter for their thorough review. This measure will be identified as outcome throughout the appendix to align with Table A.
Final Decision: CMS is finalizing Q #220 for the 2017 Performance Period. CMS is finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28545) to revise the measure title and description to align with the NQF-endorsed version of the measure. The measure owner revised the title and description of the measure to be consistent with the change in numerator details that now calculate the average functional status score for patients treated in a 12-month period compared to a standard threshold and denominator details that include patients that completed the FOTO (lumbar) PROM.
|
Focus on Therapeutic Outcomes, Inc. |
|
* ! |
0426/221 |
N/A |
Communication and Care Coordination |
Registry |
Outcome |
Functional Status Change for Patients with Shoulder Impairments: A self-report outcome measure of change in functional status for patients 14 years+ with shoulder impairments. The change in functional status assessed using FOTO’s (shoulder) PROM is adjusted to patient characteristics known to be associated with functional status outcomes (risk-adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality.
Comments: One commenter identified a discrepancy regarding this measure in the proposed rule noting that the measure type was identified as process in several areas of the appendix and outcome in others.
Response: CMS has corrected this discrepancy throughout the appendix of this final rule with comment and appreciates the commenter for their thorough review. This measure will be identified as outcome throughout the appendix to align with Table A.
Final Decision: CMS is finalizing Q #221 for the 2017 Performance Period. CMS is finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28546) to revise the measure title and description to align with the NQF-endorsed version of the measure. The measure owner revised the title and description of the measure to be consistent with the change in numerator details that now calculate the average functional status score in patients treated in a 12-month period and denominator details that include patients that completed the FOTO shoulder FS outcome instrument at admission and discharge.
|
Focus on Therapeutic Outcomes, Inc. |
|
* ! |
0427/222 |
N/A |
Communication and Care Coordination |
Registry |
Outcome |
Functional Status Change for Patients with Elbow, Wrist and Hand Impairments: A self-report outcome measure of functional status for patients 14 years+ with elbow, wrist and hand impairments. The change in functional status assessed using FOTO’s (elbow, wrist and hand) PROM is adjusted to patient characteristics known to be associated with functional status outcomes (risk-adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality.
Comments: One commenter identified a discrepancy regarding this measure in the proposed rule noting that the measure type was identified as process in several areas of the appendix and outcome in others.
Response: CMS has corrected this discrepancy throughout the appendix of this final rule with comment and appreciates the commenter for their thorough review. This measure will be identified as outcome throughout the appendix to align with Table A.
Final Decision: CMS is finalizing Q #222 for the 2017 Performance Period. CMS is finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28547) to revise the measure title and description to align with the NQF-endorsed version of the measure. The measure owner revised the title and description of the measure to be consistent with the change in numerator details that now calculate the average functional status scores for patients treated over a 12 month period and denominator details that include patients that completed the FOTO (elbow, wrist, and hand) PROM.
|
Focus on Therapeutic Outcomes, Inc. |
|
* ! |
0428/223 |
N/A |
Communication and Care Coordination |
Registry |
Outcome |
Functional Status Change for Patients with General Orthopedic Impairments: A self-report outcome measure of functional status for patients 14 years+ with general orthopedic impairments. The change in functional status assessed using FOTO (general orthopedic) PROM is adjusted to patient characteristics known to be associated with functional status outcomes (risk-adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality.
Comments: One commenter identified a discrepancy regarding this measure in the proposed rule noting that the measure type was identified as process in several areas of the appendix and outcome in others.
Response: CMS has corrected this discrepancy throughout the appendix of the final rule with comments and appreciates the commenter for their thorough review. This measure will be identified as outcome throughout the appendix to align with Table A.
Final Decision: CMS is finalizing Q #223 for the 2017 Performance Period. CMS is finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28547) to revise the measure title and description to align with the NQF-endorsed version of the measure. The measure owner revised the title and description of the measure to be consistent with the change in numerator details that now calculate the change in functional status scores for patients over a 12 month period and denominator details that include patients that completed the FOTO (general orthopedic) PROM. |
Focus on Therapeutic Outcomes, Inc. |
|
!! |
0562/224 |
N/A |
Efficiency and Cost Reduction |
Registry |
Process |
Melanoma: Overutilization of Imaging Studies in Melanoma: Percentage of patients, regardless of age, with a current diagnosis of stage 0 through IIC melanoma or a history of melanoma of any stage, without signs or symptoms suggesting systemic spread, seen for an office visit during the one-year measurement period, for whom no diagnostic imaging studies were ordered.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #224 for the 2017 Performance Period. |
American Academy of Dermatology |
|
! |
0509/225 |
N/A |
Communication and Care Coordination |
Claims, Registry |
Structure |
Radiology: Reminder System for Screening Mammograms: Percentage of patients undergoing a screening mammogram whose information is entered into a reminder system with a target due date for the next mammogram.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #225 for the 2017 Performance Period. |
American College of Radiology |
|
§ |
0028/226 |
138v5 |
Community/Population Health |
Claims, Web Interface, Registry, EHR |
Process |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.
Comments: CMS received several comments supporting our decision to include this measure in the MIPS quality measure set. A commenter also requested this measure be added to a specialty measure set.
Response: CMS thanks the commenters for their support of the measure. We will address all specialty set comments in Table E of the appendix.
Final Decision: CMS is finalizing Q #226 for the 2017 Performance Period.
|
Physician Consortium for Performance Improvement Foundation (PCPI®) |
|
§ ! |
0018/236 |
165v5 |
Effective Clinical Care |
Claims, Web Interface, Registry, EHR |
Intermediate Outcome |
Controlling High Blood Pressure: Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90 mmHg) during the measurement period.
Comments: CMS received a comment supporting our decision to include this measure in the MIPS quality measure set. CMS also received a comment requesting modifications to the measure. A third commenter requested this measure be added to a specialty measure set.
Response: CMS thanks the commenters for their support of the measure. We would also note that suggestions for the revision of the measure have been shared with our technical expert panel for further review. If our technical expert panel recommends the revision, CMS will test the revised measure and make it available for public comment according the Measure Management System Blueprint. CMS will finalize the measure in 2017 without the recommended changes and may consider these changes for future rulemaking once this process is complete. We will also note that we will address all specialty set comments in Table E of the appendix.
Final Decision: CMS is finalizing Q #236 for the 2017 Performance Period.
|
National Committee for Quality Assurance |
|
! |
0022/238 |
156v5 |
Patient Safety |
Registry, EHR |
Process |
Use of High-Risk Medications in the Elderly: Percentage of patients 66 years of age and older who were ordered high-risk medications. Two rates are reported. a. Percentage of patients who were ordered at least one high-risk medication. b. Percentage of patients who were ordered at least two different high-risk medications.
Comment: CMS received several comments supporting the inclusion of the measure in the MIPS quality measure set for 2017. However, we also received a comment requesting this measure be removed. One commenter noted that they support the inclusion of the measure with specific modifications for patient risk groups.
Response: While CMS appreciates all the comments we received regarding this measure, we could not identify justification from the commenter that supported removing the measure. Since this measure is not owned by CMS and, therefore, cannot be modified without coordinating with the measure owner. CMS will share measure modification requests with the measure owner prior to any modifications being made and, as necessary, proposed in future rulemaking. CMS will finalize the measure in 2017 without the recommended changes and may consider these changes for future rulemaking.
Final Decision: CMS is finalizing Q #238 for the 2017 Performance Period.
|
National Committee for Quality Assurance |
|
|
0024/239 |
155v5 |
Community/Population Health |
EHR |
Process |
Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents: Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported. - Percentage of patients with height, weight, and body mass index (BMI) percentile documentation - Percentage of patients with counseling for nutrition - Percentage of patients with counseling for physical activity
Comments: We received a comment stating that according to the Binge Eating Disorder Association, this measure is not supported by current clinical evidence with respect to improved health outcomes for all patients. The commenter stated the measure could harm patients with Binge eating disorders.
Response: CMS recognizes that this measure may not be ideal for providers whose patients are suffering from this specific condition. However, CMS ascertains that this measure is meant for providers whose patients may have weight or BMI issues associated with being outside of normal weight parameters. CMS relies on the provider to provide the appropriate clinical follow-up for patients, recognizing the various associated issues a patient may or may not face. Because, there are a number of chronic illnesses that are linked to being outside of normal weight parameters and research shows that proper screening and follow-up is an appropriate way to address weight related issues, CMS believes this is a valid measure and should remain in the program.
Final Decision: CMS is finalizing Q #239 for the 2017 Performance Period. |
National Committee for Quality Assurance |
|
|
0038/240 |
117v5 |
Community/Population Health |
EHR |
Process |
Childhood Immunization Status: Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday.
Comments: CMS received comments supporting our decision to include this measure in the MIPS quality measure set. CMS also received a comment requesting modifications to the measure. A commenter also requested that this measure be added to the cross-cutting measures list.
Response: This measure is not owned by CMS and, therefore, cannot be modified without coordinating with the measure owner. CMS will share measure modification requests with the measure owner prior to any modifications being made and, as necessary, proposed in future rulemaking. CMS will finalize the measure in 2017 without the recommended changes and may consider these changes for future rulemaking Additionally, CMS will not finalize the cross-cutting measure requirement but appreciates the commenters request to include the measure in the list. CMS may consider this request for future rulemaking.
Final Decision: CMS is finalizing Q #240 for the 2017 Performance Period. There will not be a cross-cutting measures list for 2017.
|
National Committee for Quality Assurance |
|
! |
0643/243 |
N/A |
Communication and Care Coordination |
Registry |
Process |
Cardiac Rehabilitation Patient Referral from an Outpatient Setting: Percentage of patients evaluated in an outpatient setting who within the previous 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the qualifying event/diagnosis who were referred to a CR program.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #243 for the 2017 Performance Period.
|
American College of Cardiology Foundation |
|
|
1854/249 |
N/A |
Effective Clinical Care |
Claims, Registry |
Process |
Barrett's Esophagus: Percentage of esophageal biopsy reports that document the presence of Barrett’s mucosa that also include a statement about dysplasia.
Comments: CMS received comments requesting that this measure be categorized as an outcome measure rather than a process measure.
Response: CMS reviewed details of the measure and consulted NQF regarding the appropriate designation. NQF identified this measure as a process measure, with which CMS agrees. Therefore, CMS is finalizing this measure as a process measure.
Final Decision: CMS is finalizing Q #249 with the process measure designation for the 2017 Performance Period.
|
College of American Pathologists |
|
§ |
1853/250 |
N/A |
Effective Clinical Care |
Claims, Registry |
Process |
Radical Prostatectomy Pathology Reporting: Percentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin status.
Comments: CMS received comments requesting that this measure be categorized as an outcome measure rather than a process measure.
Response: CMS reviewed details of the measure and consulted NQF regarding the appropriate designation. NQF identified this measure as a process measure, with which CMS agrees. Therefore, CMS is finalizing this measure as a process measure.
Final Decision: CMS is finalizing Q #250 with the process measure designation for the 2017 Performance Period. |
College of American Pathologists |
|
|
1855/251 |
N/A |
Effective Clinical Care |
Claims, Registry |
Structure |
Quantitative Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) for Breast Cancer Patients: This is a measure based on whether quantitative evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) by immunohistochemistry (IHC) uses the system recommended in the current ASCO/CAP Guidelines for Human Epidermal Growth Factor Receptor 2 Testing in breast cancer.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #251 for the 2017 Performance Period. This measure remains a structural measure.
|
College of American Pathologists |
|
|
0651/254 |
N/A |
Effective Clinical Care |
Claims, Registry |
Process |
Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain: Percentage of pregnant female patients aged 14 to 50 who present to the emergency department (ED) with a chief complaint of abdominal pain or vaginal bleeding who receive a trans-abdominal or trans-vaginal ultrasound to determine pregnancy location.
Comments: One commenter requested that we remove this measure from the Emergency specialty set, citing only the burden of reporting. Another commenter believed this measure is relevant and should remain in Emergency specialty set.
Response: CMS believes this measure is relevant to emergency medicine and will retain this measure in the Emergency specialty set.
Final Decision: CMS is finalizing Q #254 for the 2017 Performance Period.
|
American College of Emergency Physicians |
|
|
N/A/255 |
N/A |
Effective Clinical Care |
Claims, Registry |
Process |
Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure: Percentage of Rh-negative pregnant women aged 14-50 years at risk of fetal blood exposure who receive Rh-Immunoglobulin (Rhogam) in the emergency department (ED).
Comments: One commenter requested that we remove measure from Emergency specialty set, citing only the burden of reporting. Another commenter believed this measure is relevant and should remain in Emergency specialty set.
Response: We note that we will address all specialty set comments in Table E of the appendix.
Final Decision: CMS is finalizing Q #255 for the 2017 Performance Period.
|
American College of Emergency Physicians |
|
|
1519/257 |
N/A |
Effective Clinical Care |
Registry |
Process |
Statin Therapy at Discharge after Lower Extremity Bypass (LEB): Percentage of patients aged 18 years and older undergoing infra-inguinal lower extremity bypass who are prescribed a statin medication at discharge.
Comments: CMS received a comment supporting our decision to include this measure in the MIPS quality measure set. CMS also received a comment requesting modifications to the measure.
Response: CMS thanks the commenters for their support of the measure. This measure is not owned by CMS and, therefore, cannot be modified without coordinating with the measure owner. CMS will share measure modification requests with the measure owner prior to any modifications being made and, as necessary, proposed in future rulemaking. CMS will finalize the measure in 2017 without the recommended changes and may consider these changes for future rulemaking.
Final Decision: CMS is finalizing Q #257 for the 2017 Performance Period.
|
Society for Vascular Surgeons |
|
! |
N//A/258 |
N/A |
Patient Safety |
Registry |
Outcome |
Rate of Open Repair of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7): Percent of patients undergoing open repair of small or moderate sized non-ruptured infrarenal abdominal aortic aneurysms who do not experience a major complication (discharge to home no later than post-operative day #7).
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #258 for the 2017 Performance Period. This measure remains an outcome measure.
|
Society for Vascular Surgeons |
|
! |
N/A/259 |
N/A |
Patient Safety |
Registry |
Outcome |
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): Percent of patients undergoing endovascular repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) that do not experience a major complication (discharged to home no later than post-operative day #2).
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #259 for the 2017 Performance Period. This measure remains an outcome measure.
|
Society for Vascular Surgeons |
|
! |
N/A/260 |
N/A |
Patient Safety |
Registry |
Outcome |
Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2): Percent of asymptomatic patients undergoing CEA who are discharged to home no later than post-operative day #2.
Comment: Commenter did not support the inclusion of this measure in the MIPS quality measure set for 2017. Commenter noted that there could be significant potential to cause patient harm by incentivizing clinicians to discharge patients too early.
Response: CMS appreciates the commenter’s concern regarding patient safety when it comes to length of stay. However, CMS would advise that this measure should be used as a good barometer for eligible clinicians to meet appropriate stay criteria. We believe this measure provides an estimate of length of stay and should remain in the measure set.
Final Decision: CMS is finalizing Q #422 for the 2017 Performance Period. This measure remains an outcome measure.
|
Society for Vascular Surgeons |
|
! |
N/A/261 |
N/A |
Communication and Care Coordination |
Claims, Registry |
Process |
Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness: Percentage of patients aged birth and older referred to a physician (preferably a physician specially trained in disorders of the ear) for an otologic evaluation subsequent to an audiologic evaluation after presenting with acute or chronic dizziness.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #261 for the 2017 Performance Period.
|
Audiology Quality Consortium |
|
! |
N/A/262 |
N/A |
Patient Safety |
Registry |
Process |
Image Confirmation of Successful Excision of Image–Localized Breast Lesion: Image confirmation of lesion(s) targeted for image guided excisional biopsy or image guided partial mastectomy in patients with nonpalpable, image-detected breast lesion(s). Lesions may include: microcalcifications, mammographic or sonographic mass or architectural distortion, focal suspicious abnormalities on magnetic resonance imaging (MRI) or other breast imaging amenable to localization such as positron emission tomography (PET) mammography, or a biopsy marker demarcating site of confirmed pathology as established by previous core biopsy.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #262 for the 2017 Performance Period.
|
American Society of Breast Surgeons |
|
|
N/A/263 |
N/A |
Effective Clinical Care |
Registry |
Process |
Preoperative Diagnosis of Breast Cancer: The percent of patients undergoing breast cancer operations who obtained the diagnosis of breast cancer preoperatively by a minimally invasive biopsy method.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #263 for the 2017 Performance Period. |
American Society of Breast Surgeons |
|
|
N/A/264 |
N/A |
Effective Clinical Care |
Registry |
Process |
Sentinel Lymph Node Biopsy for Invasive Breast Cancer: The percentage of clinically node negative (clinical stage T1N0M0 or T2N0M0) breast cancer patients who undergo a sentinel lymph node (SLN) procedure.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #264 for the 2017 Performance Period.
|
American Society of Breast Surgeons |
|
! |
N/A/265 |
N/A |
Communication and Care Coordination |
Registry |
Process |
Biopsy Follow-Up: Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient by the performing physician.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #265 for the 2017 Performance Period.
|
American Academy of Dermatology |
|
* |
1814/268 |
N/A |
Effective Clinical Care |
Claims, Registry |
Process |
Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy: All female patients of childbearing potential (12 - 44 years old) diagnosed with epilepsy who were counseled or referred for counseling for how epilepsy and its treatment may affect contraception OR pregnancy at least once a year.
Comments: CMS received a comment that did not support including this measure in the MIPS quality measure set for 2017 because the commenter believes it is inappropriate for clinicians to spend time counseling patients annually on the effect of epilepsy on contraception and childbearing. A commenter also requested this measure be substantively modified. We also received a comment requesting this measure be added to a specialty measure set.
Response: Regarding the comment for inclusion, CMS does not agree that it is inappropriate to have annual counseling for women of childbearing potential with epilepsy. The severity of epilepsy treatment on contraception and an unborn fetus should have providers more cautious to work with women to ensure counseling is done and follow-up plans are covered if patient preferences change. This measure is not owned by CMS and, therefore, cannot be modified without coordinating with the measure owner. CMS will share measure modification requests with the measure owner prior to any modifications being made and, as necessary, proposed in future rulemaking. CMS will finalize the measure in 2017 without the recommended changes and may consider these changes for future rulemaking. We will address all specialty set comments in Table E of the appendix.
Final Decision: CMS is finalizing Q #268 for the 2017 Performance Period. CMS is finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28548) to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis of the measure specification, CMS believes the classification of this measure to be a process measure. This would be consistent with the clinical action required for the measure and would align the measure type with the NQF-endorsed version.
|
American Academy of Neurology |
|
§ |
N/A/271 |
N/A |
Effective Clinical Care |
Registry |
Process |
Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury – Bone Loss Assessment: Percentage of patients aged 18 years and older with an inflammatory bowel disease encounter who were prescribed prednisone equivalents greater than or equal to 10 mg/day for 60 or greater consecutive days or a single prescription equating to 600mg prednisone or greater for all fills and were documented for risk of bone loss once during the reporting year or the previous calendar year.
Comments: A commenter requested this measure be removed from a specialty measure set.
Response: We will address all specialty set comments in Table E of the appendix.
Final Decision: CMS is finalizing Q #271 for the 2017 Performance Period.
|
American Gastroenterological Association |
|
|
N/A/275 |
N/A |
Effective Clinical Care |
Registry |
Process |
Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy: Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status assessed and results interpreted within one year prior to receiving a first course of anti-TNF (tumor necrosis factor) therapy.
Comments: A commenter requested this measure be removed from a specialty measure set.
Response: We will address all specialty set comments in Table E of the appendix.
Final Decision: CMS is finalizing Q #275 for the 2017 Performance Period.
|
American Gastroenterological Association |
|
* |
N/A/276 |
N/A |
Effective Clinical Care |
Registry |
Process |
Sleep Apnea: Assessment of Sleep Symptoms: Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea that includes documentation of an assessment of sleep symptoms, including presence or absence of snoring and daytime sleepiness.
Comments: CMS received several comments supporting our decision to include this measure in the MIPS quality measure set.
Response: CMS thanks the commenters for their support of the measure
Final Decision: CMS is finalizing Q #276 for the 2017 Performance Period. CMS is also finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28549) to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
American Academy of Sleep Medicine |
|
* |
N/A/277 |
N/A |
Effective Clinical Care |
Registry |
Process |
Sleep Apnea: Severity Assessment at Initial Diagnosis: Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) measured at the time of initial diagnosis.
Comments: CMS received several comments supporting our decision to include this measure in the MIPS quality measure set.
Response: CMS thanks the commenters for their support of the measure
Final Decision: CMS is finalizing Q #277 for the 2017 Performance Period. CMS is finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28549) to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the finalized MIPS policy to no longer include Measure Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
American Academy of Sleep Medicine |
|
* |
N/A/278 |
N/A |
Effective Clinical Care |
Registry |
Process |
Sleep Apnea: Positive Airway Pressure Therapy Prescribed: Percentage of patients aged 18 years and older with a diagnosis of moderate or severe obstructive sleep apnea who were prescribed positive airway pressure therapy.
Comments: CMS received several comments supporting our decision to include this measure in the MIPS quality measure set.
Response: CMS thanks the commenters for their support of the measure
Final Decision: CMS is finalizing MIPS Q278 for the 2017 Performance Period. CMS proposed in Table G of the Appendix of the proposed rule (81 FR 28550) and is finalizing a change to the data submission method for this measure from Measures Group only to Registry only. As part of a Measures Group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, MIPS does not include Measures Groups, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
American Academy of Sleep Medicine |
|
* |
N/A/279 |
N/A |
Effective Clinical Care |
Registry |
Process |
Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy: Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea who were prescribed positive airway pressure therapy who had documentation that adherence to positive airway pressure therapy was objectively measured.
Comments: CMS received several comments supporting our decision to include this measure in the MIPS quality measure set.
Response: CMS thanks the commenters for their support of the measure
Final Decision: CMS is finalizing Q #279 for the 2017 Performance Period. CMS is finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28550) to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
|
American Academy of Sleep Medicine |
|
|
N/A/281 |
149v5 |
Effective Clinical Care |
EHR |
Process |
Dementia: Cognitive Assessment: Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12 month period.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #281 for the 2017 Performance Period.
|
Physician Consortium for Performance Improvement Foundation (PCPI®) |
|
*
|
N/A/282 |
N/A |
Effective Clinical Care |
Registry |
Process |
Dementia: Functional Status Assessment: Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of functional status is performed and the results reviewed at least once within a 12 month period.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #282 for the 2017 Performance Period. CMS proposed in Table G of the Appendix of the proposed rule (81 FR 28551) and is finalizing a change to the data submission method for this measure from Measures Group only to Registry only. As part of a Measures Group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, since MIPS does not include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
|
American Academy of Neurology
|
|
* |
N/A/283 |
N/A |
Effective Clinical Care |
Registry |
Process |
Dementia: Neuropsychiatric Symptom Assessment: Percentage of patients, regardless of age, with a diagnosis of dementia and for whom an assessment of neuropsychiatric symptoms is performed and results reviewed at least once in a 12 month period.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #283 for the 2017 Performance Period. CMS is finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28551) to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
American Academy of Neurology
|
|
* |
N/A/284 |
N/A |
Effective Clinical Care |
Registry |
Process |
Dementia: Management of Neuropsychiatric Symptoms: Percentage of patients, regardless of age, with a diagnosis of dementia who have one or more neuropsychiatric symptoms who received or were recommended to receive an intervention for neuropsychiatric symptoms within a 12 month period.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #284 for the 2017 Performance Period. CMS proposed in Table G of the Appendix of the proposed rule (81 FR 28552) and is finalizing a change to the data submission method for this measure from Measures Group only to Registry only. As part of a Measures Group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, since MIPS does not include Measures Groups, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
|
American Academy of Neurology
|
|
* ! |
N/A/286 |
N/A |
Patient Safety |
Registry |
Process |
Dementia: Counseling Regarding Safety Concerns: Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled or referred for counseling regarding safety concerns within a 12 month period.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #286 for the 2017 Performance Period. CMS is finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28552) to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
American Academy of Neurology
|
|
* ! |
N/A/288 |
N/A |
Communication and Care Coordination |
Registry |
Process |
Dementia: Caregiver Education and Support: Percentage of patients, regardless of age, with a diagnosis of dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND referred to additional sources for support within a 12 month period.
Comments: CMS received a comment supporting our decision to include this measure in the MIPS quality measure set.
Response: CMS thanks the commenters for their support of the measure.
Final Decision: CMS is finalizing Q #288 for the 2017 Performance Period. CMS is finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28553) to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
American Academy of Neurology
|
|
* |
N/A/290 |
N/A |
Effective Clinical Care |
Registry |
Process |
Parkinson’s Disease: Psychiatric Symptoms Assessment for Patients with Parkinson’s Disease: All patients with a diagnosis of Parkinson’s disease who were assessed for psychiatric symptoms (e.g., psychosis, depression, anxiety disorder, apathy, or impulse control disorder) in the last 12 months
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #290 for the 2017 Performance Period. CMS is finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28553) to change the data submission for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. Additionally, CMS proposes to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis of the measure specification, CMS proposes to revise the classification of this measure to process measure to match the clinical action of psychiatric disease assessment. |
American Academy of Neurology |
|
* |
N/A/291 |
N/A |
Effective Clinical Care |
Registry |
Process |
Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment: All patients with a diagnosis of Parkinson’s disease who were assessed for cognitive impairment or dysfunction in the last 12 months
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #291 for the 2017 Performance Period. CMS is finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28554) to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. Additionally, CMS proposes to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis, CMS proposes to revise the classification of this measure to process measure in order to match the clinical action of assessment of cognitive impairment. |
American Academy of Neurology |
|
* ! |
N/A/293 |
N/A |
Communication and Care Coordination |
Registry |
Process |
Parkinson’s Disease: Rehabilitative Therapy Options: All patients with a diagnosis of Parkinson’s disease (or caregiver(s), as appropriate) who had rehabilitative therapy options (e.g., physical, occupational, or speech therapy) discussed in the last 12 months
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #293 for the 2017 Performance Period. CMS is finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28554) to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. Additionally, CMS proposes to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis, CMS proposes to revise the classification of this measure to process measure in order to match the clinical action of communication about therapy options. |
American Academy of Neurology |
|
* ! |
N/A/294 |
N/A |
Communication and Care Coordination |
Registry |
Process |
Parkinson’s Disease: Parkinson’s Disease Medical and Surgical Treatment Options Reviewed: All patients with a diagnosis of Parkinson’s disease (or caregiver(s), as appropriate) who had the Parkinson’s disease treatment options (e.g., non-pharmacological treatment, pharmacological treatment, or surgical treatment) reviewed at least once annually.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #294 for the 2017 Performance Period. CMS is finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28555) to change the reporting mechanism for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. Additionally, CMS proposes to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis, CMS proposes to revise the classification of this measure to process measure in order to match the clinical action of communicating treatment options. |
American Academy of Neurology |
|
! |
1536/303 |
N/A |
Person and Caregiver-Centered Experience and Outcomes |
Registry |
Outcome |
Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery: Percentage of patients aged 18 years and older who had cataract surgery and had improvement in visual function achieved within 90 days following the cataract surgery, based on completing a pre-operative and post-operative visual function survey.
Comment: CMS received a comment requesting we not remove this measure adding that the denominator should be modified. We also received a comment suggesting the measure be removed from MIPS.
Response: CMS would like to clarify that we did not propose this measure for removal in the proposed rule. We do, however, agree that it should remain in the program. Regarding the modification to the denominator, this measure is not owned by CMS and, therefore, cannot be modified without coordinating with the measure owner. CMS will share measure modification requests with the measure owner prior to any modifications being made and, as necessary, proposed in future rulemaking. CMS will finalize the measure for the 2017 performance period without the recommended changes and may consider these changes for future rulemaking.
Final Decision: CMS is finalizing Q #303 for the 2017 Performance Period. |
American Academy of Ophthalmology |
|
! |
N/A/304 |
N/A |
Person and Caregiver-Centered Experience and Outcomes |
Registry |
Outcome |
Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery: Percentage of patients aged 18 years and older who had cataract surgery and were satisfied with their care within 90 days following the cataract surgery, based on completion of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey.
Comment: CMS received a comment requesting we not remove this measure adding that the denominator should be modified. We also received a comment suggesting the measure be removed from MIPS.
Response: CMS would like to clarify that we did not propose this measure for removal in the proposed rule. We do, however, agree that it should remain in the program. Regarding the modification to the denominator, this measure is not owned by CMS and, therefore, cannot be modified without coordinating with the measure owner. CMS will share measure modification requests with the measure owner prior to any modifications being made and, as necessary, proposed in future rulemaking. CMS will finalize the measure for the 2017 performance period without the recommended changes and may consider these changes for future rulemaking.
Final Decision: CMS is finalizing Q #304 for the 2017 Performance Period.
|
American Academy of Ophthalmology |
|
|
0004/305 |
137v5 |
Effective Clinical Care |
EHR |
Process |
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: Percentage of patients 13 years of age and older with a new episode of alcohol and other drug (AOD) dependence who received the following. Two rates are reported. a. Percentage of patients who initiated treatment within 14 days of the diagnosis. b. Percentage of patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #305 for the 2017 Performance Period. This measure remains a process measure.
|
National Committee for Quality Assurance |
|
* § |
0032/309 |
124v5 |
Effective Clinical Care |
EHR |
Process |
Cervical Cancer Screening: Percentage of women 21-64 years of age, who were screened for cervical cancer using either of the following criteria. • Women age 21–64 who had cervical cytology performed every 3 years • Women age 30–64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years
Comments: A commenter requested this measure be added to a specialty measure set.
Response: We will address all specialty set comments in Table E of the appendix
Final Decision: CMS is finalizing Q #309 for the 2017 Performance Period. CMS proposed in Table G of the Appendix of the proposed rule (81 FR 28555) and is finalizing a change to the measure description of this measure to align with measure intent and 2012 USPSTF recommendation: U.S. Preventive Services Task Force. 2012. "Screening for Cervical Cancer: U.S. Preventive Services Task Force Recommendation Statement." Ann Intern Med. 156(12):880-91.
|
National Committee for Quality Assurance |
|
|
0033/310 |
153v5 |
Community/Population Health |
EHR |
Process |
Chlamydia Screening for Women: Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period.
Comments: A commenter requested this measure be added to a specialty measure set. In particular, the commenter asked that the CMS pediatric core measure set align with the CHIPRA core set.
Response: We will address all specialty set comments in Table E of the appendix. However, regarding the specific request of the CHIPRA core measures, CMS has tried to align its pediatric core measure set with the CHIPRA core set where practicable.
Final Decision: CMS is finalizing Q #310 for the 2017 Performance Period.
|
National Committee for Quality Assurance |
|
§ !! |
0052/312 |
166v6 |
Efficiency and Cost Reduction |
EHR |
Process |
Use of Imaging Studies for Low Back Pain: Percentage of patients 18-50 years of age with a diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis.
Comment: CMS received a comment supporting the designation of this measure as an appropriate use measure.
Response: CMS thanks the commenter for their support of this measure being designated as an appropriate use measure.
Final Decision: CMS is finalizing Q #312 for the 2017 Performance Period and its proposal in Table G of the Appendix of the proposed rule (81 FR 28532) to change the reporting mechanism for this measure by removing it from the Web Interface. The Web Interface measure set contains measures for primary care and also includes relevant measures from the PCMH Core Measure Set established by the Core Quality Measure Collaborative (CQMC). This measure is not a measure in the core set and is being finalized for removal from the Web Interface to align the Web Interface measure set with the PCMH Core Measure Set. This measure remains a high priority, appropriate use and process measure.
|
National Committee for Quality Assurance |
|
* |
N/A/317 |
22v5 |
Community/Population Health |
Claims, Registry, EHR |
Process |
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented: Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.
Comments: CMS received a commenter that did not support inclusion of the measure in the MIPS quality measure set. CMS also received a further comment stating the measure does not align with USPSTF recommendations and monitoring blood pressure at home.
Response: CMS believes this measure, although not fully aligned with current USPSTF recommendations is appropriate for screening and follow-up. CMS continues to work with other stakeholders and experts in the field to determine the validity of the measure indices.
Final Decision: CMS is finalizing Q #317 for the 2017 Performance Period. CMS is finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28556) a change to the data submission method for this measure and remove it from the Web Interface. The Web Interface measure set contains measures for primary care and also includes relevant measures from the PCMH Core Measure Set established by the CQMC. This measure is not a core measure and is being removed to align the Web Interface measure set with the PCMH Core Measure Set. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, Measures Group is being removed from this measure as a data submission method. |
Centers for Medicare & Medicaid Services |
|
! |
0101/318 |
139v5 |
Patient Safety
|
Web Interface, EHR |
Process |
Falls: Screening for Fall Risk: Percentage of patients 65 years of age and older who were screened for future fall risk at least once during the measurement period.
Comment: A commenter requested that this measure be added to the cross-cutting measures list.
Response: CMS will not finalize the cross-cutting measure requirement but appreciates the commenter’s request to include the measure in the list. CMS may consider this request for future rulemaking.
Final Decision: CMS is finalizing Q #318 for the 2017 Performance Period. There will not be a cross-cutting measures list for the 2017 performance period.
|
National Committee for Quality Assurance |
|
§ !! |
0658/320
|
N/A |
Communication and Care Coordination |
Claims, Registry |
Process |
Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients: Percentage of patients aged 50 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report.
Comments: Commenter supports our decision to include this measure in the MIPS quality measure set.
Response: CMS thanks the commenters for their support of the measure.
Final Decision: CMS is finalizing Q #320 for the 2017 Performance Period. |
American Gastroenterological Association/ American Society for Gastrointestinal Endoscopy/ American College of Gastroenterology |
|
§ ! |
0005 & 0006/321 |
N/A |
Person and Caregiver-Centered Experience and Outcomes |
CMS-approved Survey Vendor |
Patient Engagement/Experience |
CAHPS for MIPS Clinician/Group Survey: Summary Survey Measures may include: • Getting Timely Care, Appointments, and Information; • How well Providers Communicate; • Patient’s Rating of Provider; • Access to Specialists; • Health Promotion and Education; • Shared Decision-Making; • Health Status and Functional Status; • Courteous and Helpful Office Staff; • Care Coordination; • Between Visit Communication; • Helping You to Take Medication as Directed; and • Stewardship of Patient Resources.
Comments: Although CMS did not receive specific comments regarding inclusion of this measure for 2017, we did receive numerous comments asking CMS to count this measure as more than one measure and to look at how certain modules count towards a clinician’s performance. CMS was also asked to explore the option of CAHPS being counted as an improvement activity.
Response: CMS will implement the measure for the 2017 performance period counting all modules towards the performance of one measure in the quality component of MIPS, as proposed. CMS agrees that this measure should be counted as an improvement activity. We are finalizing the following high-weighted improvement activity under the subcategory of Patient Safety and Practice Assessment: Participation in the Consumer Assessment of Healthcare Providers and Systems Survey or other supplemental questionnaire items (e.g., Cultural Competence or Health Information Technology supplemental item sets).
Final Decision: CMS is finalizing Q #321 for the 2017 Performance Period. |
Agency for Healthcare Research & Quality
|
|
!! |
N/A/322 |
N/A |
Efficiency and Cost Reduction |
Registry |
Efficiency |
Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients: Percentage of stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), or cardiac magnetic resonance (CMR) performed in low risk surgery patients 18 years or older for preoperative evaluation during the 12-month reporting period.
Comments: CMS received a comment supporting our decision to include this measure in the MIPS quality measure set but the commenter requested modifications to the measure. Another commenter supported the high priority designation for this measure.
Response: CMS thanks the commenters for their support of the measure and its designation as high priority. This measure is not owned by CMS and, therefore, cannot be modified without coordinating with the measure owner. CMS will share measure modification requests with the measure owner prior to any modifications being made and, as necessary, proposed in future rulemaking. CMS will finalize the measure in 2017 without the recommended changes and may consider these changes for future rulemaking.
Final Decision: CMS is finalizing Q #322 for the 2017 Performance Period. This measure remains a high priority and appropriate use measure.
|
American College of Cardiology |
|
!! |
N/A/323 |
N/A |
Efficiency and Cost Reduction |
Registry |
Efficiency |
Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI): Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in patients aged 18 years and older routinely after percutaneous coronary intervention (PCI), with reference to timing of test after PCI and symptom status.
Comments: CMS received a comment supporting our decision to include this measure in the MIPS quality measure set but the commenter requested modifications to the measure. Another commenter supported the high priority designation for this measure.
Response: CMS thanks the commenters for their support of the measure and its designation as high priority. This measure is not owned by CMS and, therefore, cannot be modified without coordinating with the measure owner. CMS will share measure modification requests with the measure owner prior to any modifications being made and, as necessary, proposed in future rulemaking. CMS will finalize the measure for the 2017 performance period without the recommended changes and may consider these changes for future rulemaking.
Final Decision: CMS is finalizing Q #323 for the 2017 Performance Period. This measure remains a high priority and appropriate use measure.
|
American College of Cardiology |
|
!! |
N/A/324 |
N/A |
Efficiency and Cost Reduction |
Registry |
Efficiency |
Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients: Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in asymptomatic, low coronary heart disease (CHD) risk patients 18 years and older for initial detection and risk assessment.
Comments: CMS received a comment supporting our decision to include this measure in the MIPS quality measure set because the commenter believes the measure may discourage clinicians from prescribing unnecessary stress imaging in asymptomatic patients.
Response: CMS thanks the commenters for their support of the measure and agrees that this measure in intended to decrease inappropriate and overuse of cardiac stress imaging in low-risk patients.
Final Decision: CMS is finalizing Q #324 for the 2017 Performance Period.
|
American College of Cardiology |
|
! |
N/A/325 |
N/A |
Communication and Care Coordination
|
Registry |
Process |
Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions: Percentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Renal Disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #325 for the 2017 Performance Period. This measure remains a high priority and process measure.
|
American Psychiatric Association |
|
§ |
1525/326 |
N/A |
Effective Clinical Care |
Claims, Registry |
Process |
Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy: Percentage of patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation (AF) or atrial flutter whose assessment of the specified thromboembolic risk factors indicate one or more high-risk factors or more than one moderate risk factor, as determined by CHADS2 risk stratification, who are prescribed warfarin OR another oral anticoagulant drug that is FDA approved for the prevention of thromboembolism.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #326 for the 2017 Performance Period. |
American College of Cardiology |
|
* ! |
N/A/327 |
N/A |
Effective Clinical Care |
Registry |
Process |
Pediatric Kidney Disease: Adequacy of Volume Management: Percentage of calendar months within a 12-month period during which patients aged 17 years and younger with a diagnosis of End Stage Renal Disease (ESRD) undergoing maintenance hemodialysis in an outpatient dialysis facility have an assessment of the adequacy of volume management from a nephrologist.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #327 for the 2017 Performance Period. CMS is also finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28556) to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis, CMS understands this measure to be a percentage of documented assessment rather than a health outcome. Therefore, CMS believes the classification of this measure to be a process measure. |
Renal Physicians Association |
|
! |
1667/328
|
N/A |
Effective Clinical Care |
Registry |
Intermediate Outcome |
Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level < 10 g/dL: Percentage of calendar months within a 12-month period during which patients aged 17 years and younger with a diagnosis of End Stage Renal Disease (ESRD) receiving hemodialysis or peritoneal dialysis have a hemoglobin level < 10 g/dL.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #328 for the 2017 Performance Period. |
Renal Physicians Association |
|
! |
N/A/329 |
N/A |
Effective Clinical Care |
Registry |
Outcome |
Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis: Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) who initiate maintenance hemodialysis during the measurement period, whose mode of vascular access is a catheter at the time maintenance hemodialysis is initiated.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #329 for the 2017 Performance Period.
|
Renal Physicians Association |
|
!! |
N/A/330 |
N/A |
Patient Safety |
Registry |
Outcome |
Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days: Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) receiving maintenance hemodialysis for greater than or equal to 90 days whose mode of vascular access is a catheter.
Comments: CMS received several comments supporting our decision to include this measure in the MIPS quality measure set. One commenter support its inclusion because the measure addresses patient safety criteria.
Response: CMS agrees with the commenter that the measure addresses patient safety, especially as it relates to the population of patients with ESRD that require hemodialysis maintenance.
Final Decision: CMS is finalizing Q #330 for the 2017 Performance Period. |
Renal Physicians Association |
|
!! |
N/A/331 |
N/A |
Efficiency and Cost Reduction |
Registry |
Process |
Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse): Percentage of patients, aged 18 years and older, with a diagnosis of acute sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms.
Comment: Commenter believes this measure should not be assigned as an efficiency and cost reduction as a domain but instead should be designated as resource use.
Response: CMS would like to note that “resource use” is not an NQS domain. Additionally, the domain efficiency and cost reduction is inclusive of resource use criteria. CMS does not agree that the domain should be reassigned.
Final Decision: CMS is finalizing Q #331 for the 2017 Performance Period. The domain for this measure remains Efficiency and Cost Reduction.
|
American Academy of Otolaryngology-Head and Neck Surgery |
|
!! |
N/A/332 |
N/A |
Efficiency and Cost Reduction |
Registry |
Process |
Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use): Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulante, as a first line antibiotic at the time of diagnosis.
Comment: CMS received a comment supporting our decision to include this measure in the MIPS quality measure set but commenter believes the measure should be substantively modified because the measure is no longer aligned with IDSA recommendations.
Response: CMS thanks the commenters for their support of the measure. This measure is not owned by CMS and, therefore, cannot be modified without coordinating with the measure owner. CMS will share measure modification requests with the measure owner prior to any modifications being made and, as necessary, proposed in future rulemaking. CMS will finalize the measure in 2017 without the recommended changes and may consider these changes for future rulemaking.
Final Decision: CMS is finalizing Q #332 for the 2017 Performance Period.
|
American Academy of Otolaryngology-Head and Neck Surgery |
|
!! |
N/A/333 |
N/A |
Efficiency and Cost Reduction |
Registry |
Efficiency |
Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse): Percentage of patients aged 18 years and older with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis.
Comments: CMS received a comment supporting our decision to include this measure in the MIPS quality measure set.
Response: CMS thanks the commenters for their support of the measure.
Final Decision: CMS is finalizing Q #333 for the 2017 Performance Period.
|
American Academy of Otolaryngology-Head and Neck Surgery |
|
!! |
N/A/334 |
N/A |
Efficiency and Cost Reduction |
Registry |
Efficiency |
Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse): Percentage of patients aged 18 years and older with a diagnosis of chronic sinusitis who had more than one CT scan of the paranasal sinuses ordered or received within 90 days after the date of diagnosis.
Comments: CMS received a comment supporting our decision to include this measure in the MIPS quality measure set because commenter believes it may discourage inappropriate use of CT scans to diagnose acute sinusitis.
Response: CMS thanks the commenters for their support of the measure. CMS agrees with the commenter that this measure, which is an overuse measure, is intended to decrease inappropriate use of CT scans.
Final Decision: CMS is finalizing Q #334 for the 2017 Performance Period.
|
American Academy of Otolaryngology-Head and Neck Surgery |
|
!! |
N/A/335 |
N/A |
Patient Safety |
Registry |
Outcome |
Maternity Care: Elective Delivery or Early Induction Without Medical Indication at ≥ 37 and < 39 Weeks (Overuse): Percentage of patients, regardless of age, who gave birth during a 12-month period who delivered a live singleton at ≥ 37 and < 39 weeks of gestation completed who had elective deliveries or early inductions without medical indication.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #335 for the 2017 Performance Period.
|
Centers for Medicare and Medicaid Services |
|
! |
N/A/336 |
N/A |
Communication and Care Coordination |
Registry |
Process |
Maternity Care: Post-Partum Follow-Up and Care Coordination: Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for post-partum care within 8 weeks of giving birth who received a breast feeding evaluation and education, post-partum depression screening, post-partum glucose screening for gestational diabetes patients, and family and contraceptive planning.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #336 for the 2017 Performance Period. |
Centers for Medicare and Medicaid Services |
|
|
N/A/337 |
N/A |
Effective Clinical Care |
Registry |
Process |
Tuberculosis (TB) Prevention for Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier: Percentage of patients whose providers are ensuring active tuberculosis prevention either through yearly negative standard tuberculosis screening tests or are reviewing the patient’s history to determine if they have had appropriate management for a recent or prior positive test.
Comments: CMS received a comment supporting our decision to include this measure in the MIPS quality measure set. However the commenter requested that CMS modify the measure.
Response: CMS thanks the commenters for their support of the measure. This measure is not owned by CMS and, therefore, cannot be modified without coordinating with the measure owner. CMS will share measure modification requests with the measure owner prior to any modifications being made and, as necessary, proposed in future rulemaking. CMS will finalize the measure in 2017 without the recommended changes and may consider these changes for future rulemaking.
Final Decision: CMS is finalizing Q #337 for the 2017 Performance Period.
|
American Academy of Dermatology |
|
* § ! |
2082/338 |
N/A |
Effective Clinical Care |
Registry |
Outcome |
HIV Viral Load Suppression: The percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year.
Comments: CMS received a comment supporting our decision to include this measure in the MIPS quality measure set.
Response: CMS thanks the commenters for their support of the measure.
Final Decision: CMS is finalizing Q #338 for the 2017 Performance Period. CMS proposed in Table G of the Appendix of the proposed rule (81 FR 28557) and is finalizing a change to the data submission method for this measure from Measures Group only to Registry only. As part of a Measures Group, this measure was part of a metric that provided relevant content for a specific condition. Since MIPS does not include Measures Groups, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
Health Resources and Services Administration |
|
* § ! |
2079/340 |
N/A |
Efficiency and Cost Reduction |
Registry |
Process |
HIV Medical Visit Frequency: Percentage of patients, regardless of age with a diagnosis of HIV who had at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical visits.
Comments: CMS received a comment supporting our decision to include this measure in the MIPS quality measure set.
Response: CMS thanks the commenters for their support of the measure.
Final Decision: CMS is finalizing Q #340 for the 2017 Performance Period. CMS proposed in Table G of the Appendix of the proposed rule (81 FR 28557) and is finalizing a change to the data submission method for this measure from Measures Group only to Registry only. As part of a Measures Group, this measure was part of a metric that provided relevant content for a specific condition. Since MIPS does not include Measures Groups, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
|
Health Resources and Services Administration |
|
! |
N/A/342 |
N/A |
Person and Caregiver-Centered Experience and Outcomes |
Registry |
Outcome |
Pain Brought Under Control Within 48 Hours: Patients aged 18 and older who report being uncomfortable because of pain at the initial assessment (after admission to palliative care services) that report pain was brought to a comfortable level within 48 hours.
Comments: CMS received several comments supporting the inclusion of the measure but the commenters suggested modifications to the measure that would change the time metric and denominator exclusions.
Response: Since this measure has not been tested with the substantive modifications suggested, CMS will work with the measure owner to review feasibility of commenter’s recommendations and may consider the recommendations for future rulemaking.
Final Decision: CMS is finalizing Q #342 for the 2017 Performance Period.
|
National Hospice and Palliative Care Organization |
|
§ ! |
N/A/343 |
N/A |
Effective Clinical Care |
Registry |
Outcome |
Screening Colonoscopy Adenoma Detection Rate Measure: The percentage of patients age 50 years or older with at least one conventional adenoma or colorectal cancer detected during screening colonoscopy.
Comments: CMS received a comment supporting our decision to include this measure in the MIPS quality measure set because the commenter believes it aligns with USPSTF clinical recommendations.
Response: CMS thanks the commenters for their support of the measure. We agree that this reflects current clinical guidelines.
Final Decision: CMS is finalizing Q #343 for the 2017 Performance Period. |
American Society for Gastrointestinal Endoscopy/ American Gastroenterological Association/ American College of Gastroenterology |
|
! |
N/A/344 |
N/A |
Effective Clinical Care |
Registry |
Outcome |
Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2): Percent of asymptomatic patients undergoing CAS who are discharged to home no later than post-operative day #2.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #344 for the 2017 Performance Period.
|
Society for Vascular Surgeons |
|
! |
1543/345 |
N/A |
Effective Clinical Care |
Registry |
Outcome |
Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS): Percent of asymptomatic patients undergoing CAS who experience stroke or death following surgery while in the hospital.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #345 for the 2017 Performance Period.
|
Society for Vascular Surgeons |
|
! |
1540/346 |
N/A |
Effective Clinical Care
|
Registry |
Outcome |
Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Endarterectomy (CEA): Percent of asymptomatic patients undergoing CEA who experience stroke or death following surgery while in the hospital.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #346 for the 2017 Performance Period.
|
Society for Vascular Surgeons |
|
! |
1534/347 |
N/A |
Patient Safety |
Registry |
Outcome |
Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) Who Die While in Hospital: Percent of patients undergoing endovascular repair of small or moderate infrarenal abdominal aortic aneurysms (AAA) who die while in the hospital.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #347 for the 2017 Performance Period.
|
Society for Vascular Surgeons |
|
! |
N/A/348 |
N/A |
Patient Safety |
Registry |
Outcome |
HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate: Patients with physician-specific risk-standardized rates of procedural complications following the first time implantation of an ICD.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #348 for the 2017 Performance Period.
|
The Heart Rhythm Society |
|
* ! |
N/A/350 |
N/A |
Communication and Care Coordination |
Registry |
Process |
Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy: Percentage of patients regardless of age undergoing a total knee replacement with documented shared decision-making with discussion of conservative (non-surgical) therapy (e.g. non-steroidal anti-inflammatory drugs (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #350 for the 2017 Performance Period. CMS is finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28558) to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. Additionally, CMS is finalizing its proposal to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis, CMS believes the classification of this measure to be a process measure in order to match the clinical action of shared decision-making. |
American Association of Hip and Knee Surgeons |
|
* ! |
N/A/351 |
N/A |
Patient Safety |
Registry |
Process |
Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation: Percentage of patients regardless of age undergoing a total knee replacement who are evaluated for the presence or absence of venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure (e.g. history of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), Myocardial Infarction (MI), Arrhythmia and Stroke).
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #351 for the 2017 Performance Period. CMS is finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28559) to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. Additionally, CMS is finalizing its proposal to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis, CMS believes the classification of this measure to be a process measure. |
American Association of Hip and Knee Surgeons |
|
* ! |
N/A/352 |
N/A |
Patient Safety |
Registry |
Process |
Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet: Percentage of patients regardless of age undergoing a total knee replacement who had the prophylactic antibiotic completely infused prior to the inflation of the proximal tourniquet
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #352 for the 2017 Performance Period. CMS is finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28559) to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. Additionally, CMS is finalizing its proposal to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis, CMS believes the classification of this measure to be a process measure.
|
American Association of Hip and Knee Surgeons |
|
* ! |
N/A/353 |
N/A |
Patient Safety |
Registry |
Process
|
Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report: Percentage of patients regardless of age undergoing a total knee replacement whose operative report identifies the prosthetic implant specifications including the prosthetic implant manufacturer, the brand name of the prosthetic implant and the size of each prosthetic implant.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #353 for the 2017 Performance Period. CMS is finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28560) to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. Additionally, CMS is finalizing it proposal to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis, CMS believes the classification of this measure to be a process measure. |
American Association of Hip and Knee Surgeons |
|
* ! |
N/A/354 |
N/A |
Patient Safety |
Registry |
Outcome |
Anastomotic Leak Intervention: Percentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #354 for the 2017 Performance Period. This measure remains an outcome measure. CMS proposed in Table G of the Appendix of the proposed rule (81 FR 28560) and is finalizing a change to the data submission method for this measure from Measures Group only to Registry only. As part of a Measures Group, this measure was part of a metric that provided relevant content for a specific condition. Since MIPS does not include Measures Groups, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
American College of Surgeons
|
|
* ! |
N/A/355 |
N/A |
Patient Safety |
Registry |
Outcome |
Unplanned Reoperation within the 30 Day Postoperative Period: Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #355 for the 2017 Performance Period. CMS proposed in Table G of the Appendix of the proposed rule (81 FR 28561) and is finalizing a change to the data submission method for this measure from Measures Group only to Registry only. As part of a Measures Group, this measure was part of a metric that provided relevant content for a specific condition. Since MIPS does not include Measures Groups, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
|
American College of Surgeons |
|
* ! |
N/A/356 |
N/A |
Effective Clinical Care |
Registry |
Outcome |
Unplanned Hospital Readmission within 30 Days of Principal Procedure: Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #356 for the 2017 Performance Period. CMS proposed in Table G of the Appendix of the proposed rule (81 FR 28561) and is finalizing a change to the data submission method for this measure from Measures Group only to Registry only. As part of a Measures Group, this measure was part of a metric that provided relevant content for a specific condition. Since MIPS does not include Measures Groups, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
|
American College of Surgeons |
|
* ! |
N/A/357 |
N/A |
Effective Clinical Care |
Registry |
Outcome |
Surgical Site Infection (SSI): Percentage of patients aged 18 years and older who had a surgical site infection (SSI).
Comments: A commenter requested this measure be added to several specialty measure sets.
Response: We will address all specialty set comments in Table E of the appendix.
Final Decision: CMS is finalizing Q #357 for the 2017 Performance Period. CMS proposed in Table G of the Appendix of the proposed rule (81 FR 28562) and is finalizing a change to the data submission method for this measure from Measures Group only to Registry only. As part of a Measures Group, this measure was part of a metric that provided relevant content for a specific condition. Since MIPS does not include Measures Groups, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
American College of Surgeons |
|
! |
N/A/358 |
N/A |
Person and Caregiver-Centered Experience and Outcomes |
Registry |
Process |
Patient-Centered Surgical Risk Assessment and Communication: Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #358 for the 2017 Performance Period.
|
American College of Surgeons |
|
* ! |
N/A/359 |
N/A |
Communication and Care Coordination |
Registry |
Process |
Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging Description: Percentage of computed tomography (CT) imaging reports for all patients, regardless of age, with the imaging study named according to a standardized nomenclature and the standardized nomenclature is used in institution’s computer systems.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #359 for the 2017 Performance Period. CMS proposed in Table G of the Appendix of the proposed rule (81 FR 28562) and is finalizing a change to the data submission method for this measure from Measures Group only to Registry only. As part of a Measures Group, this measure was part of a metric that provided relevant content for a specific condition. Since MIPS does not include Measures Groups, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
|
American College of Radiology |
|
* !! |
N/A/360 |
N/A |
Patient Safety |
Registry |
Process |
Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies: Percentage of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion studies) imaging reports for all patients, regardless of age, that document a count of known previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion) studies that the patient has received in the 12-month period prior to the current study.
Comments: A commenter requested this measure be removed from a specialty measure set. Several commenters supported the inclusion of the measure in the MIPS quality measure set. One commenter also supported the designation of “high priority” for this measure
Response: We will address all specialty set comments in Table E of the appendix. CMS thanks the commenters for their support of the measure and its designation of high priority for 2017 MIPS.
Final Decision: CMS is finalizing Q #360 for the 2017 Performance Period. CMS proposed in Table G of the Appendix of the proposed rule (81 FR 28563) and is finalizing a change to the data submission method for this measure from Measures Group only to Registry only. As part of a Measures Group, this measure was part of a metric that provided relevant content for a specific condition. Since MIPS does not include Measures Groups, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
|
American College of Radiology |
|
* ! |
N/A/361 |
N/A |
Patient Safety |
Registry |
Structure |
Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry: Percentage of total computed tomography (CT) studies performed for all patients, regardless of age, that are reported to a radiation dose index registry that is capable of collecting at a minimum selected data elements.
Comments: CMS received several comments supporting our decision to include this measure in the MIPS quality measure set.
Response: CMS thanks the commenters for their support of the measure.
Final Decision: CMS is finalizing Q #361 for the 2017 Performance Period. CMS proposed in Table G of the Appendix of the proposed rule (81 FR 28563) and is finalizing a change to the data submission method for this measure from Measures Group only to Registry only. As part of a Measures Group, this measure was part of a metric that provided relevant content for a specific condition. Since MIPS does not include Measures Groups, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
American College of Radiology |
|
* ! |
N/A/362 |
N/A |
Communication and Care Coordination |
Registry |
Structure |
Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison Purposes: Percentage of final reports for computed tomography (CT) studies performed for all patients, regardless of age, which document that Digital Imaging and Communications in Medicine (DICOM) format image data are available to non-affiliated external healthcare facilities or entities on a secure, media free, reciprocally searchable basis with patient authorization for at least a 12-month period after the study.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #362 for the 2017 Performance Period. CMS proposed in Table G of the Appendix of the proposed rule (81 FR 28564) and is finalizing a change to the data submission method for this measure from Measures Group only to Registry only. As part of a Measures Group, this measure was part of a metric that provided relevant content for a specific condition. Since MIPS does not include Measures Groups, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
|
American College of Radiology |
|
* ! |
N/A/363 |
N/A |
Communication and Care Coordination |
Registry |
Structure |
Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Studies Through a Secure, Authorized, Media-Free, Shared Archive: Percentage of final reports of computed tomography (CT) studies performed for all patients, regardless of age, which document that a search for Digital Imaging and Communications in Medicine (DICOM) format images was conducted for prior patient CT imaging studies completed at non-affiliated external healthcare facilities or entities within the past 12-months and are available through a secure, authorized, media free, shared archive prior to an imaging study being performed.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #363 for the 2017 Performance Period. CMS proposed in Table G of the Appendix of the proposed rule (81 FR 28565) and is finalizing a change to the data submission method for this measure from Measures Group only to Registry only. As part of a Measures Group, this measure was part of a metric that provided relevant content for a specific condition. Since MIPS does not include Measures Groups, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure
|
American College of Radiology |
|
* !! |
N/A/364 |
N/A |
Communication and Care Coordination |
Registry |
Process |
Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines: Percentage of final reports for computed tomography (CT) imaging studies of the thorax for patients aged 18 years and older with documented follow-up recommendations for incidentally detected pulmonary nodules (e.g., follow-up CT imaging studies needed or that no follow-up is needed) based at a minimum on nodule size AND patient risk factors
CMS did not receive specific comments regarding this measure. Final Decision: CMS is finalizing Q #364 for the 2017 Performance Period. CMS proposed in Table G of the Appendix of the proposed rule (81 FR 28565) and is finalizing a change to the data submission method for this measure from Measures Group only to Registry only. As part of a Measures Group, this measure was part of a metric that provided relevant content for a specific condition. Since MIPS does not include Measures Groups, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure.
|
American College of Radiology |
|
|
0108/366 |
136v6 |
Effective Clinical Care |
EHR |
Process |
ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication: Percentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported. a. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase. b. Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.
Comment: A commenter requested this measure be removed from a specialty measure set.
Response: We will address all specialty set comments in Table E of the appendix.
Final Decision: CMS is finalizing Q #366 for the 2017 Performance Period. |
National Committee for Quality Assurance |
|
|
N/A/367 |
169v5 |
Effective Clinical Care |
EHR |
Process |
Bipolar Disorder and Major Depression: Appraisal for Alcohol or Chemical Substance Use: Percentage of patients with depression or bipolar disorder with evidence of an initial assessment that includes an appraisal for alcohol or chemical substance use.
Comments: CMS received a comment supporting our decision to include this measure in the MIPS quality measure set. Commenter cited evidence that this measure aligns with clinical recommendations of the American Psychiatric Association.
Response: CMS appreciates the commenter’s support for the inclusion of this measure. CMS agrees with the commenter and further thinks this measure adds value to the MIPS quality measure set.
Final Decision: CMS is finalizing Q #367 for the 2017 Performance Period.
|
Centers for Medicare & Medicaid Services |
|
|
N/A/369 |
158v5 |
Effective Clinical Care |
EHR |
Process |
Pregnant Women that had HBsAg Testing: This measure identifies pregnant women who had a HBsAg (hepatitis B) test during their pregnancy.
Comment: A commenter stated that this measure is no longer being maintained by the measure steward via the EHR. Other commenters supported the inclusion of the measure in the MIPS quality measure set.
Response: CMS contacted the measure steward for this measure and confirmed that this measure continues to be maintained by the measure steward via the EHR submission mechanism.
Final Decision: CMS is finalizing Q #369 for the 2017 Performance Period.
|
Optum |
|
* § ! |
0710/370 |
159v5 |
Effective Clinical Care |
Web Interface, Registry, EHR |
Outcome |
Depression Remission at Twelve Months: Patients age 18 and older with major depression or dysthymia and an initial Patient Health Questionnaire (PHQ-9) score greater than nine who demonstrate remission at twelve months (+/- 30 days after an index visit) defined as a PHQ-9 score less than five. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment.
Comments: CMS received a comment recommending that we remove the measure from the program because the commenter does not believe the measure aligns with clinical care of psychiatry. In contrast, we received other comments supporting the inclusion of the measure and requesting that the measure be included in the behavioral and family medicine specialty measure sets.
Response: We will address all specialty set comments in Table E of the appendix.
Final Decision: CMS is finalizing Q #370 for the 2017 Performance Period. CMS is finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28566) to revise the measure description to provide clarity for reporting. This does not change the intent of the measure but merely provides clarity to ensure consistent reporting for eligible clinicians. Additionally, CMS is finalizing its proposal to change this measure type designation from intermediate outcome measure to outcome measure. This measure was previously finalized in PQRS as an intermediate outcome measure. However, upon further review and analysis, CMS believes the classification of this measure to be an outcome measure in order to match the outcome of depression remission. Finally, we are adding the measure to the behavioral and family medicine specialty measure sets.
|
Minnesota Community Measurement |
|
|
0712/371 |
160v5 |
Effective Clinical Care |
EHR |
Process |
Depression Utilization of the PHQ-9 Tool: Patients age 18 and older with the diagnosis of major depression or dysthymia who have a Patient Health Questionnaire (PHQ-9) tool administered at least once during a 4 month period in which there was a qualifying visit.
Comment: CMS received a comment requesting the inclusion of this measure in the behavioral specialty measure set. Commenter also recommends this measure be removed because the commenter believes NQF # 0418 and #105 are more relevant metrics for depression.
Response: CMS disagrees with commenter that this measure is not relevant to depression assessment. PHQ-9 is a valuable tool in depression assessment and should be used as the preferable tool for depression. CMS believes this measure is relevant for the MIPS quality measure set and should not be removed for the 2017 performance period. CMS may consider removal of this measure in future rulemaking. Furthermore, NQF #105 will also be included in the MIPS quality measure set, therefore, CMS recommends providers report the more appropriate measure. We also note that we will address all specialty set comments in Table E of the appendix.
Final Decision: CMS is finalizing Q #371 for the 2017 Performance Period.
|
Minnesota Community Measurement |
|
|
N/A/372 |
82v4 |
Community/Population Health |
EHR |
Process |
Maternal Depression Screening: The percentage of children who turned 6 months of age during the measurement year, who had a face-to-face visit between the clinician and the child during child’s first 6 months, and who had a maternal depression screening for the mother at least once between 0 and 6 months of life.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #372 for the 2017 Performance Period.
|
National Committee for Quality Assurance |
|
! |
N/A/373 |
65v6 |
Effective Clinical Care |
EHR |
Intermediate Outcome |
Hypertension: Improvement in Blood Pressure: Percentage of patients aged 18-85 years of age with a diagnosis of hypertension whose blood pressure improved during the measurement period.
Comment: CMS received a comment that did not support the inclusion of this measure in the MIPS for 2017. In contrast, another commenter supported the measure inclusion of the measure but asked that the measure be modified.
Request: CMS thanks the commenter for their support of the measure. We would also note that suggestions for the revision of the measure have been shared with our technical expert panel for further review. If our technical expert panel recommends the revision, CMS will test the revised measure and make it available for public comment according the Measure Management System Blueprint. CMS will finalize the measure in 2017 without the recommended changes and may consider these changes for future rulemaking once this process is complete.
Final Decision: CMS is finalizing Q #373 for the 2017 Performance Period.
|
Centers for Medicare & Medicaid Services |
|
! |
N/A/374 |
50v5 |
Communication and Care Coordination |
EHR |
Process |
Closing the Referral Loop: Receipt of Specialist Report: Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred.
Comments: CMS received a comment supporting our decision to include this measure in the MIPS quality measure set with specific modifications for the measure.
Response: CMS thanks the commenters for their support of the measure. We would also note that suggestions for the revision of the measure have been shared with our technical expert panel for further review. If our technical expert panel recommends the revision, CMS will test the revised measure and make it available for public comment according to the Measure Management System Blueprint. CMS will finalize the measure in 2017 without the recommended changes and may consider these changes for future rulemaking once this process is complete.
Final Decision: CMS is finalizing Q #374 for the 2017 Performance Period. |
Centers for Medicare & Medicaid Services |
|
* ! |
N/A/375 |
66v 5 |
Person and Caregiver-Centered Experience and Outcomes |
EHR |
Process |
Functional Status Assessment for Total Knee Replacement: Percentage of patients 18 years of age and older with primary total knee arthroplasty (TKA) who completed baseline and follow-up patient-reported functional status assessments.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #375 for the 2017 Performance Period. CMS proposed in Table G of the Appendix of the proposed rule (81 FR 28566) and is finalizing a revision to the title and description of the measure to align with the intent of the measure. This does not change the intent of the measure but merely provides clarity to ensure consistent reporting for eligible clinicians.
|
Centers for Medicare & Medicaid Services |
|
* ! |
N/A/376 |
56v5 |
Person and Caregiver-Centered Experience and Outcomes |
EHR |
Process |
Functional Status Assessment for Total Hip Replacement: Percentage of patients 18 years of age and older with primary total hip arthroplasty (THA) who completed baseline and follow-up (patient-reported) functional status assessments.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #376 for the 2017 Performance Period. CMS is finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28567) to revise the title and description of the measure to align with the intent of the measure. This change does not change the intent of the measure but merely provides clarity to ensure consistent reporting for eligible clinicians. |
Centers for Medicare & Medicaid Services |
|
* ! |
N/A/377 |
90v6 |
Person and Caregiver-Centered Experience and Outcomes |
EHR |
Process |
Functional Status Assessments for Patients with Congestive Heart Failure: Percentage of patients 65 years of age and older with congestive heart failure who completed initial and follow-up patient-reported functional status assessments.
Comments: CMS received a comment noting that this measure is based on outdated evidence and should not be included in the program. Commenter also said that the measure is burdensome for clinicians to document functional status based on administration of an assigned assessment instrument.
Response: Since there is a need for further research and because there is not enough evidence to determine best practices for implementing and interpreting patient-reported health assessments in clinical practice, CMS will implement the measure as proposed.
Final Decision: CMS is finalizing Q #377 for the 2017 Performance Period. CMS is finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28567) to revise the title and description of the measure to add clarity in response to clinician feedback. This does not change the intent of the measure but merely provides clarity to ensure consistent reporting for eligible clinicians.
|
Centers for Medicare & Medicaid Services |
|
! |
N/A/378 |
75v 5 |
Community/Population Health |
EHR |
Outcome |
Children Who Have Dental Decay or Cavities: Percentage of children, age 0-20 years, who have had tooth decay or cavities during the measurement period.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #378 for the 2017 Performance Period.
|
Centers for Medicare & Medicaid Services |
|
|
N/A/379 |
74v6 |
Effective Clinical Care |
EHR |
Process |
Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists: Percentage of children, age 0-20 years, who received a fluoride varnish application during the measurement period.
Comments: A commenter requested this measure be added to a specialty measure set. In particular, the commenter asked that the CMS pediatric core measure set align with CHIPRA core set.
Response: We will address all specialty set comments in Table E of the appendix. However, regarding the specific request of the CHIPRA core measures, CMS has aligned its pediatric core measure set with the CHIPRA core set where practicable.
Final Decision: CMS is finalizing Q #379 for the 2017 Performance Period.
|
Centers for Medicare & Medicaid Services |
|
! |
1365/382 |
177v5 |
Patient Safety |
EHR |
Process |
Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment: Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk.
Comment: A commenter requested this measure be removed from a specialty measure set.
Response: We will address all specialty set comments in Table E of the appendix
Final Decision: CMS is finalizing Q #382 for the 2017 Performance Period.
|
Physician Consortium for Performance Improvement Foundation (PCPI®) |
|
! |
1879/383 |
N/A |
Patient Safety |
Registry |
Intermediate Outcome |
Adherence to Antipsychotic Medications for Individuals with Schizophrenia: Percentage of individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months).
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #383 for the 2017 Performance Period.
|
National Committee for Quality Assurance |
|
! |
N/A/384 |
N/A |
Effective Clinical Care |
Registry |
Outcome |
Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery: Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment who did not require a return to the operating room within 90 days of surgery.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #384 for the 2017 Performance Period.
|
American Academy of Ophthalmology |
|
! |
N/A/385 |
N/A |
Effective Clinical Care |
Registry |
Outcome |
Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery: Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment and achieved an improvement in their visual acuity, from their preoperative level, within 90 days of surgery in the operative eye.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #385 for the 2017 Performance Period.
|
American Academy of Ophthalmology |
|
! |
N/A/386 |
N/A |
Person and Caregiver-Centered Experience and Outcomes |
Registry |
Process |
Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences: Percentage of patients diagnosed with Amyotrophic Lateral Sclerosis (ALS) who were offered assistance in planning for end of life issues (e.g. advance directives, invasive ventilation, hospice) at least once annually.
Comment: CMS received a comment supporting our decision to include this measure in the MIPS quality measure set. One commenter stated that this measure should target neurologists and yet another commenter stated that this measure may not be appropriate for general neurologists.
Response: This measure is already included in the neurology specialty measure set which makes it available for neurologists to report. This measure is also stewarded by the specialists targeted by the measure.
Final Decision: CMS is finalizing Q #386 for the 2017 Performance Period.
|
American Academy of Neurology |
|
|
N/A/387 |
N/A |
Effective Clinical Care |
Registry |
Process |
Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users: Percentage of patients regardless of age who are active injection drug users who received screening for HCV infection within the 12 month reporting period.
Comment: CMS received several comments supporting our decision to include this measure in the MIPS quality measure set. One commenter supports the inclusion because it aligns with AASLD and IDSA recommendations for testing, managing and treating hepatitis C.
Response: CMS thanks the commenters for their support of the measure. CMS believes this is a very important measure that appropriately addresses a high priority issue such as HCV screening and drug use.
Final Decision: CMS is finalizing Q #387 for the 2017 Performance Period. |
Physician Consortium for Performance Improvement Foundation (PCPI®) |
|
! |
N/A/388 |
N/A |
Patient Safety |
Registry |
Outcome |
Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy: Percentage of patients aged 18 years and older who had cataract surgery performed and had an unplanned rupture of the posterior capsule requiring vitrectomy.
Comment: CMS received a comment asking that we do not remove this measure from the MIPS measure set but instead they support including this measure.
Response: CMS would like to clarify that this measure was not proposed for removal. It was, instead proposed for inclusion. Furthermore, we appreciate the commenter’s support for the inclusion of the measure.
Final Decision: CMS is finalizing Q #388 for the 2017 Performance Period.
|
American Academy of Ophthalmology |
|
! |
N/A/389 |
N/A |
Effective Clinical Care |
Registry |
Outcome |
Cataract Surgery: Difference Between Planned and Final Refraction: Percentage of patients aged 18 years and older who had cataract surgery performed and who achieved a final refraction within +/- 0.5 diopters of their planned (target) refraction.
Comment: CMS received a comment asking that we do not remove this measure from the MIPS measure set but instead they support including this measure.
Response: CMS would like to clarify that this measure was not proposed for removal. It was, instead proposed for inclusion. Furthermore, we appreciate the commenter’s support for the inclusion of the measure.
Final Decision: CMS is finalizing Q #389 for the 2017 Performance Period.
|
American Academy of Ophthalmology |
|
! |
N/A/390 |
N/A |
Person and Caregiver-Centered Experience and Outcomes |
Registry |
Process |
Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options: Percentage of patients aged 18 years and older with a diagnosis of hepatitis C with whom a physician or other qualified healthcare professional reviewed the range of treatment options appropriate to their genotype and demonstrated a shared decision making approach with the patient. To meet the measure, there must be documentation in the patient record of a discussion between the physician or other qualified healthcare professional and the patient that includes all of the following: treatment choices appropriate to genotype, risks and benefits, evidence of effectiveness, and patient preferences toward treatment.
Comments: CMS received several comments supporting our decision to include this measure in the MIPS quality measure set. One commenter requested the measure be modified. Another commenter supports the measure because they believe that it encourages shared decision-making.
Response: CMS appreciates the commenters that supported the inclusion of the measure in the MIPS quality measure set for 2017. CMS agrees with the commenter that this measure encourages shared-decision making regarding treatmenat options for HepC. CMS would also like to note this measure is not owned by CMS and, therefore, cannot be modified without coordinating with the measure owner. CMS will share measure modification requests with the measure owner prior to any modifications being made and, as necessary, proposed in future rulemaking. CMS will finalize the measure for the 2017 performance period without the recommended changes and may consider these changes for future rulemaking.
Final Decision: CMS is finalizing Q #390 for the 2017 Performance Period.
|
American Gastroenterological Association/American Society for Gastrointestinal Endoscopy/American College of Gastroenterology |
|
! |
0576/391 |
N/A |
Communication and Care Coordination |
Registry |
Process |
Follow-Up After Hospitalization for Mental Illness (FUH): The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported: - The percentage of discharges for which the patient received follow-up within 30 days of discharge - The percentage of discharges for which the patient received follow-up within 7 days of discharge.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #391 for the 2017 Performance Period.
|
National Committee for Quality Assurance |
|
! |
2474/392 |
N/A |
Patient Safety |
Registry |
Outcome |
HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation: Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation This measure is reported as four rates stratified by age and gender: • Reporting Age Criteria 1: Females 18-64 years of age • Reporting Age Criteria 2: Males 18-64 years of age • Reporting Age Criteria 3: Females 65 years of age and older • Reporting Age Criteria 4: Males 65 years of age and older
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #392 for the 2017 Performance Period. |
The Heart Rhythm Society |
|
! |
N/A/393 |
N/A |
Patient Safety |
Registry |
Outcome |
HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision: Infection rate following CIED device implantation, replacement, or revision.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #393 for the 2017 Performance Period. |
The Heart Rhythm Society |
|
|
1407/394 |
N/A |
Community/Population Health |
Registry |
Process |
Immunizations for Adolescents: The percentage of adolescents 13 years of age who had the recommended immunizations by their 13th birthday.
Comments: CMS received a comment supporting our decision to include this measure in the MIPS quality measure set. A commenter also supported the inclusion of this measure in a specialty measure set.
Response: We will address all specialty set comments in Table E of the appendix.
Final Decision: CMS is finalizing Q #394 for the 2017 Performance Period.
|
National Committee for Quality Assurance |
|
! |
N/A/395 |
N/A |
Communication and Care Coordination |
Claims, Registry |
Outcome |
Lung Cancer Reporting (Biopsy/Cytology Specimens): Pathology reports based on biopsy and/or cytology specimens with a diagnosis of primary non-small cell lung cancer classified into specific histologic type or classified as NSCLC-NOS with an explanation included in the pathology report.
Comments: CMS received comments requesting that this measure be categorized as an outcome measure rather than a process measure.
Response: CMS reviewed details of the measure and CMS agrees with commenter’s assessment. Therefore, CMS is finalizing this measure as an outcome measure.
Final Decision: CMS is finalizing Q #395 for the 2017 Performance Period.
|
College of American Pathologists |
|
! |
N/A/396 |
N/A |
Communication and Care Coordination |
Claims, Registry |
Outcome |
Lung Cancer Reporting (Resection Specimens): Pathology reports based on resection specimens with a diagnosis of primary lung carcinoma that include the pT category, pN category and for non-small cell lung cancer, histologic type.
Comments: CMS received comments requesting that this measure be categorized as an outcome measure rather than a process measure.
Response: CMS reviewed details of the measure and CMS agrees with the commenter’s assessment. Therefore, CMS is finalizing this measure as an outcome measure.
Final Decision: CMS is finalizing Q #396 for the 2017 Performance Period.
|
College of American Pathologists |
|
! |
N/A/397 |
N/A |
Communication and Care Coordination |
Claims, Registry |
Outcome |
Melanoma Reporting: Pathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness and ulceration and for pT1, mitotic rate.
Comments: CMS received comments requesting that this measure be categorized as an outcome measure rather than a process measure.
Response: CMS reviewed details of the measure and CMS agrees with commenter’s assessment. Therefore, CMS is finalizing this measure as an outcome measure.
Final Decision: CMS is finalizing Q #397 for the 2017 Performance Period.
|
College of American Pathologists |
|
! |
N/A/398 |
N/A |
Effective Clinical Care |
Registry |
Outcome |
Optimal Asthma Control: Composite measure of the percentage of pediatric and adult patients whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools
Comment: We received several comments that did not support inclusion of this measure. One commenter noted that the measure is not appropriately risk-adjusted and needs to be revised for SES in asthma patients. Another commenter requested removal saying this measure would penalize physicians in high-risk areas. Finally, a commenter noted a discrepancy with this measure in other tables in the appendix of the proposed rule.
Response: CMS recognizes that risk-adjustment is important and agrees that the measure should be reviewed further for the feasibility of making this modification. However, this measure is not owned by CMS and, therefore, cannot be modified without coordinating with the measure owner. CMS will share measure modification requests with the measure owner prior to any modifications being made and, as necessary, proposed in future rulemaking. CMS will finalize the measure for the 2017 performance period without the recommended changes and may consider these changes for future rulemaking. CMS also appreciates the commenter finding the discrepancy in the measure type, CMS has revised all tables within the appendix of this final rule with comment and corrected the measure type to be outcome measure.
Final Decision: CMS is finalizing Q #398 for the 2017 Performance Period. This measure remains an outcome measure.
|
Minnesota Community Measurement |
|
§ |
N/A/400 |
N/A |
Effective Clinical Care |
Registry |
Process |
One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk: Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis OR birthdate in the years 1945-1965 who received one-time screening for hepatitis C virus (HCV) infection.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #400 for the 2017 Performance Period.
|
Physician Consortium for Performance Improvement Foundation (PCPI®) |
|
§ |
N/A/401 |
N/A |
Effective Clinical Care |
Registry |
Process |
Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis: Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12 month reporting period.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #401 for the 2017 Performance Period.
|
American Gastroenterological Association/ American Society for Gastrointestinal Endoscopy/American College of Gastroenterology |
|
|
N/A/402 |
N/A |
Community/Population Health |
Registry |
Process |
Tobacco Use and Help with Quitting Among Adolescents: The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #402 for the 2017 Performance Period. |
National Committee for Quality Assurance |
|
! |
N/A/403‡ |
N/A |
Person and Caregiver-Centered Experience and Outcomes |
Registry |
Process |
Adult Kidney Disease: Referral to Hospice: Percentage of patients aged 18 years and older with a diagnosis of end-stage renal disease (ESRD) who withdraw from hemodialysis or peritoneal dialysis who are referred to hospice care.
Comment: CMS received a comment supporting our decision to include this measure in the MIPS quality measure set. Commenter requests that CMS substantively modify the measure.
Response: This measure is not owned by CMS and, therefore, cannot be modified without coordinating with the measure owner. CMS will share measure modification requests with the measure owner prior to any modifications being made and, as necessary, proposed in future rulemaking. CMS will finalize the measure for the 2017 performance period without the recommended changes and may consider these changes for future rulemaking.
Final Decision: CMS is finalizing Q #403 for the 2017 Performance Period. |
Renal Physicians Association |
|
! |
N/A/404‡ |
N/A |
Effective Clinical Care |
Registry |
Intermediate Outcome |
Anesthesiology Smoking Abstinence: The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure.
Comments: CMS received a comment requesting modifications to the measure.
Response: This measure is not owned by CMS and, therefore, cannot be modified without coordinating with the measure owner. CMS will share measure modification requests with the measure owner prior to any modifications being made and, as necessary, proposed in future rulemaking. CMS will finalize the measure for the 2017 performance period without the recommended changes and may consider these changes for future rulemaking.
Final Decision: CMS is finalizing Q #404 for the 2017 Performance Period.
|
American Society of Anesthesiologists |
|
|
N/A/405‡ |
N/A |
Effective Clinical Care |
Claims, Registry |
Process |
Appropriate Follow-up Imaging for Incidental Abdominal Lesions: Percentage of final reports for abdominal imaging studies for asymptomatic patients aged 18 years and older with one or more of the following noted incidentally with follow‐up imaging recommended: •Liver lesion < 0.5 cm •Cystic kidney lesion < 1.0 cm •Adrenal lesion < 1.0 cm
Comment: CMS received a comment that stated this measure is very similar to Q #406 but is not indicated as appropriate use. The commenter believes the two measures (Q #405 and Q #406) should be consistent in categorization where both are appropriate use.
Response: After reviewing measure Q #405 and comparing the two measures, CMS agrees with the commenter that the measures should be designated as an appropriate use measure.
Final Decision: CMS is finalizing Q #405 for the 2017 Performance Period. This measure is an appropriate use measure.
|
American College of Radiology |
|
!! |
N/A/406 ‡ |
N/A |
Effective Clinical Care |
Claims, Registry |
Process |
Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients: Percentage of final reports for computed tomography (CT) magnetic resonance imaging (MRI) or magnetic resonance angiogram (MRA) studies of the chest or neck or ultrasound of the neck for patients aged 18 years and older with no known thyroid disease with a thyroid nodule < 1.0 cm noted incidentally with follow-up imaging recommended.
Comment: CMS received a comment that stated this measure is very similar to #405 but the two measures are not consistent in their designation of appropriate use. The commenter believes the two measures (#405 and #406) should be consistent where both are appropriate use.
Response: After reviewing measure #405 and comparing the two measures, CMS agrees with commenter that the measures should be consistent and they should be designated as appropriate use.
Final Decision: CMS is finalizing Q #406 for the 2017 Performance Period. This measure remains an appropriate use measure.
|
American College of Radiology |
|
!! |
N/A/407‡ |
N/A |
Effective Clinical Care |
Claims, Registry |
Process |
Appropriate Treatment of MSSA Bacteremia: Percentage of patients with sepsis due to MSSA bacteremia who received beta-lactam antibiotic (e.g. nafcillin, oxacillin or cefazolin) as definitive therapy.
Comments: CMS received several comments supporting our decision to include this measure in the MIPS quality measure set. One commenter requested modifications to the measure. While another commenter supported the measure because the commenter believes it prevents vancomycin overuse and encourages effective care.
Response: CMS thanks the commenters for their support of this measure. CMS would also note that this measure is not owned by CMS and, therefore, cannot be modified without coordinating with the measure owner. CMS will share measure modification requests with the measure owner prior to any modifications being made and, as necessary, proposed in future rulemaking. CMS will finalize the measure in 2017 without the recommended changes and may consider these changes for future rulemaking. CMS especially appreciates the commenter’s agreement that the measure encourages effective care and prevents overuse. CMS agrees with the commenter’s belief.
Final Decision: CMS is finalizing Q #407 for the 2017 Performance Period.
|
Infectious Disease Society of America |
|
|
N/A/408‡ |
N/A |
Effective Clinical Care |
Registry |
Process |
Opioid Therapy Follow-up Evaluation: All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record.
Comment: CMS received several comments supporting the inclusion of the measure in the MIPS quality measure set for the 2017 performance period.One commenter especially noted that this measure aligns with CDC recommendations.
Response: CMS thanks the commenters for their support of the measure. It is our intent that we align with up-to-date clinical and policy recommendations. As recommendations change, CMS will be responsive as much as practicable.
Final Decision: CMS is finalizing Q #408 for the 2017 Performance Period.
|
American Academy of Neurology |
|
! |
N/A/409‡ |
N/A |
Effective Clinical Care |
Registry |
Outcome |
Clinical Outcome Post Endovascular Stroke Treatment: Percentage of patients with a mRs score of 0 to 2 at 90 days following endovascular stroke intervention.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #409 for the 2017 Performance Period.
|
Society of Interventional Radiology |
|
! |
N/A/410‡ |
N/A |
Person and Caregiver-Centered Experience and Outcomes |
Claims, Registry |
Outcome |
Psoriasis: Clinical Response to Oral Systemic or Biologic Medications: Percentage of psoriasis patients receiving oral systemic or biologic therapy who meet minimal physician- or patient-reported disease activity levels. It is implied that establishment and maintenance of an established minimum level of disease control as measured by physician- and/or patient-reported outcomes will increase patient satisfaction with and adherence to treatment.
Comment: CMS received a comment that requested CMS not include claims as a data submission method for this measure.
Response: CMS believes that removing claims from this measure without first proposing this change, would not allow public stakeholders to address the impact of this change. Additionally, CMS has not researched the impact that this substantive change would have on affected MIPS eligible clinicians. CMS will review the impact of this comment and may propose the removal of claims in future rulemaking.
Final Decision: CMS is finalizing Q #410 for the 2017 Performance Period. This measure remains a measure than can be reported using the claims and registry submission mechanisms.
|
American Academy of Dermatology |
|
! |
0711/411‡ |
N/A |
Effective Clinical Care |
Registry |
Outcome |
Depression Remission at Six Months: Adult patients age 18 years and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at six months defined as a PHQ-9 score less than 5. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment. This measure additionally promotes ongoing contact between the patient and provider as patients who do not have a follow-up PHQ-9 score at six months (+/- 30 days) are also included in the denominator
Comment: CMS received several comments on this measure. A commenter requested this measure be added to a specialty measure set. A commenter also asked that this measure be designated as Effective Clinical Care. Another commenter noted that this measure does not provide enough time to assess depression remission and noted there should be a more robust assessment of patients’ depression. Yet another commenter supported the measure but thought the measure should be revised.
Response: We will address all specialty set comments in Table E of the appendix. CMS has reviewed the measure and agrees with the commenter that this measure should be designated as “effective clinical care”. Additionally, this measure is not owned by CMS and, therefore, cannot be modified without coordinating with the measure owner. CMS will share measure modification requests with the measure owner prior to any modifications being made and, as necessary, proposed in future rulemaking. CMS will finalize the measure for the 2017 performance period without the recommended changes and may consider these changes for future rulemaking. Finally, CMS recognizes that there are multiple tools used to assess depression remission at various timeframes. However, CMS believes this measure appropriately addresses depression remission and that the timeframe of the assessment is appropriate according to the field.
Final Decision: CMS is finalizing Q #411 for the 2017 Performance Period. The domain for this measure has changed to Effective Clinical Care.
|
Minnesota Community Measurement |
|
|
N/A/412‡ |
N/A |
Effective Clinical Care |
Registry |
Process |
Documentation of Signed Opioid Treatment Agreement: All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record.
Comment: CMS received comments requesting this measure be revised to align with CDC recommendations.
Response: This measure is not owned by CMS and, therefore, cannot be modified without coordinating with the measure owner. CMS will share measure modification requests with the measure owner prior to any modifications being made and, as necessary, proposed in future rulemaking. CMS will finalize the measure for the 2017 performance period without the recommended changes and may consider these changes for future rulemaking.
Final Decision: CMS is finalizing Q #412 for the 2017 Performance Period.
|
American Academy of Neurology |
|
! |
N/A/413‡ |
N/A |
Effective Clinical Care |
Registry |
Intermediate Outcome |
Door to Puncture Time for Endovascular Stroke Treatment: Percentage of patients undergoing endovascular stroke treatment who have a door to puncture time of less than two hours.
Comment: One commenter noted that the benchmark or target for this measure is unobtainable in one state or unreachable in a majority of the country.
Response: CMS would note that eligible clinicians are able to choose the appropriate measures for their practice and clinical flow. If a MIPS eligible clinician does not find this measure to be attainable in their state or area of the country, the MIPS eligible clinician should choose a more appropriate measure to report.
Final Decision: CMS would like to note that measures implemented in the program undergo a thorough review and testing for feasibility. Additionally, measure concepts are reviewed by technical expert panels (TEP) that include stakeholders in the field. These subject matter experts review gap analyses and clinical performance gaps against the current clinical guidelines to ensure not only feasibility but current science. Based on the guidance from the TEP, CMS believes the targets set in the measure are attainable and based on current guidelines. CMS is finalizing Q #413 for the 2017 Performance Period.
|
Society of Interventional Radiology |
|
|
N/A/414‡ |
N/A |
Effective Clinical Care |
Registry |
Process |
Evaluation or Interview for Risk of Opioid Misuse: All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAAP-R) or patient interview documented at least once during Opioid Therapy in the medical record
Comments: One commenter supported CMS for including this measure for the 2017 performance period but requested that the measure be modified to include additional encounter codes and dosage clarification. CMS also received comments requesting that we remove this measure from the emergency medicine specialty measure set. The commenters noted that ED visit codes are not listed in the encounter CPT codes, so the measure would never be triggered during an ED visit. In addition, the commenters noted that the measure refers to “prescribed opiates for longer than six weeks’ duration”, which is an extremely rare occurrence for an emergency physician.
Response: Regarding the inclusion of the measure for the 2017 performance period, CMS will finalize the measure for the 2017 performance period. However, we will work with the measure owner on the appropriateness of the recommended substantive changes to the measure. CMS may consider these modifications in future rulemaking. Regarding the inclusion of this measure in the emergency medicine set, CMS reviewed the measure specifications of this measure and agrees with the commenters that this measure is not appropriate for ED use as it does not include ED codes. CMS is removing this measure from the emergency medicine specialty measure set.
Final Decision: CMS is finalizing Q #414 for the 2017 Performance Period. CMS is removing this measure from the emergency medicine specialty measure set. |
American Academy of Neurology |
|
! |
N/A/415‡ |
N/A |
Efficiency and Cost Reduction |
Claims, Registry |
Efficiency |
Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older: Percentage of emergency department visits for patients aged 18 years and older who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #415 for the 2017 Performance Period.
|
American College of Emergency Physicians |
|
!! |
N/A/416‡ |
N/A |
Efficiency and Cost Reduction |
Claims, Registry |
Efficiency |
Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 through 17 Years: Percentage of emergency department visits for patients aged 2 through 17 years who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the Pediatric Emergency Care Applied Research Network (PECARN) prediction rules for traumatic brain injury.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #416 for the 2017 Performance Period.
|
American College of Emergency Physicians |
|
! |
1523/417‡ |
N/A |
Patient Safety |
Registry |
Outcome |
Rate of Open Repair of Small or Moderate Abdominal Aortic Aneurysms (AAA) Where Patients Are Discharged Alive: Percentage of patients undergoing open repair of small or moderate abdominal aortic aneurysms (AAA) who are discharged alive.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #417 for the 2017 Performance Period.
|
Society for Vascular Surgeons |
|
|
0053/418‡ |
N/A |
Effective Clinical Care |
Claims, Registry |
Process |
Osteoporosis Management in Women Who Had a Fracture: The percentage of women age 50-85 who suffered a fracture and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis in the six months after the fracture
Comment: CMS received a comment supporting our decision to include this measure in the MIPS quality measure set but the commenter requested that CMS revise the measure. . Response: This measure is not owned by CMS and, therefore, cannot be modified without coordinating with the measure owner. CMS will share measure modification requests with the measure owner prior to any modifications being made and, as necessary, proposed in future rulemaking. CMS will finalize the measure for the 2017 performance period without the recommended changes and may consider these changes for future rulemaking.
Final Decision: CMS is finalizing Q #418 for the 2017 Performance Period.
|
National Committee for Quality Assurance |
|
!! |
N/A/419‡ |
N/A |
Efficiency and Cost Reduction |
Claims, Registry |
Efficiency |
Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination: Percentage of patients with a diagnosis of primary headache disorder whom advanced brain imaging was not ordered.
Comment: CMS received a comment supporting our decision to include this measure in the MIPS quality measure set but the commenter requested that CMS revise the measure. The commenter believes that this measure will prevent overuse of neuroimaging. . Response: CMS thanks the comments for their support and agrees the measure will discourage overuse of neuroimaging.
Final Decision: CMS is finalizing Q #419 for the 2017 Performance Period.
|
American Academy of Neurology |
|
* |
N/A/420‡ |
N/A |
Effective Clinical Care |
Registry |
Outcome |
Varicose Vein Treatment with Saphenous Ablation: Outcome Survey: Percentage of patients treated for varicose veins (CEAP C2-S) who are treated with saphenous ablation (with or without adjunctive tributary treatment) that report an improvement on a disease specific patient reported outcome survey instrument after treatment.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #420 for the 2017 Performance Period. CMS is finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28568) to change this measure type designation from process measure to outcome measure. This measure was previously finalized in PQRS as a process measure. However, upon further review and analysis of the measure specification, CMS is finalizing tis proposal to revise the classification of this measure to outcome measure because it assesses improvement on a patient reported outcome survey instrument. |
Society of Interventional Radiology |
|
* |
N/A/421‡ |
N/A |
Effective Clinical Care |
Registry |
Process |
Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal: Percentage of patients in whom a retrievable IVC filter is placed who, within 3 months post-placement, have a documented assessment for the appropriateness of continued filtration, device removal or the inability to contact the patient with at least two attempts.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #421 for the 2017 Performance Period. CMS is also finalizing its proposal in Table G of the Appendix of the proposed rule (81 FR 28568) to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis of the measure specification, CMS is finalizing its proposal to revise the classification of this measure to process measure in order to match the clinical action of appropriate care assessment.
|
Society of Interventional Radiology |
|
! |
2063/422 ‡ |
N/A |
Patient Safety |
Claims, Registry |
Process |
Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury: Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #422 for the 2017 Performance Period. This measure remains a process measure.
|
American Urogynecologic Society |
|
|
0465/423‡ |
N/A |
Effective Clinical Care |
Claims, Registry |
Process |
Perioperative Anti-platelet Therapy for Patients Undergoing Carotid Endarterectomy: Percentage of patients undergoing carotid endarterectomy (CEA) who are taking an anti-platelet agent within 48 hours prior to surgery and are prescribed this medication at hospital discharge following surgery.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #423 for 2017 Performance Period. This measure remains a process measure.
|
Society for Vascular Surgeons |
|
! |
2681/424‡ |
N/A |
Patient Safety |
Registry |
Outcome |
Perioperative Temperature Management: Percentage of patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time.
Comment: CMS received a comment requesting that the measure type for this measure be changed from process to outcome. After reviewing the measure more closely, CMS consulted NQF and the measure owner to determine the appropriate designation.
Response: After reviewing the measure more closely, CMS consulted NQF and the measure owner to determine the appropriate designation for the measure type. CMS will change the measure type from process to outcome which is consistent with the measure specifications.
Final Decision: CMS is finalizing Q #424 for 2017 Performance Period. This measure is finalized as an outcome measure.
|
American Society of Anesthesiologists |
|
|
N/A/425 |
N/A |
Effective Clinical Care |
Claims, Registry |
Process |
Photodocumentation of Cecal Intubation: The rate of screening and surveillance colonoscopies for which photodocumentation of landmarks of cecal intubation is performed to establish a complete examination
CMS proposed this measure for removal in Table H of the Appendix of the proposed rule (81 FR 28531) because CMS believed this measure is related to one of the conditions covered under the Core Quality Measure Collaborative but is not included in the core measure set.
Comments: CMS received several comments requesting that CMS not remove this measure from the program until performance data can be collected.
Response: CMS agrees that it would be premature to remove the measure from the program without adequate data to justify removal based on performance. Therefore, CMS will not finalize this measure for removal.
Final Decision: We are not finalizing our proposal to remove Q #425 for the 2017 Performance Period. Under section 1848(q)(2)(D)(vii) of the Act, existing quality measures shall be included in the final list of quality measures unless removed. Accordingly, CMS is finalizing Q #425 for the 2017 Performance Period. |
American Society for Gastrointestinal Endoscopy/American Gastroenterological Association/American College of Gastroenterology |
|
! |
N/A/426‡ |
N/A |
Communication and Care Coordination |
Registry |
Process |
Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU): Percentage of patients, regardless of age, who are under the care of an anesthesia practitioner and are admitted to a PACU in which a post-anesthetic formal transfer of care protocol or checklist which includes the key transfer of care elements is utilized.
Comments: CMS received a comment that supported the inclusion of this measure in MIPS with substantive changes.
Response: While CMS appreciates the commenter’s support for inclusion, CMS would like to clarify that the measure has not been tested with these significant modifications included. CMS can consider these modifications in future rulemaking. CMS is finalizing the measure for inclusion in MIPS for the 2017 Performance Period without substantive changes.
Final Decision: CMS is finalizing Q #426 for 2017 Performance Period.
|
American Society of Anesthesiologists |
|
! |
N/A/427‡ |
N/A |
Communication and Care Coordination |
Registry |
Process |
Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU): Percentage of patients, regardless of age, who undergo a procedure under anesthesia and are admitted to an Intensive Care Unit (ICU) directly from the anesthetizing location, who have a documented use of a checklist or protocol for the transfer of care from the responsible anesthesia practitioner to the responsible ICU team or team member.
Comments: CMS received a comment that supported the inclusion of this measure in MIPS with substantive changes, including requesting that the measure contain a performance exclusion code with documentation for why performance was not met.
Response: While CMS appreciates the commenter’s support for inclusion, CMS would like to clarify that the measure has not been tested with these significant modifications included. CMS can consider these modifications in future rulemaking. CMS is finalizing the measure for inclusion in MIPS for the 2017 Performance Period without substantive changes.
Final Decision: CMS is finalizing Q #427 for 2017 Performance Period.
|
American Society of Anesthesiologists |
|
|
N/A/428‡ |
N/A |
Effective Clinical Care |
Registry |
Process |
Pelvic Organ Prolapse: Preoperative Assessment of Occult Stress Urinary Incontinence: Percentage of patients undergoing appropriate preoperative evaluation for the indication of stress urinary incontinence per ACOG/AUGS/AUA guidelines.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #428 for 2017 Performance Period. CMS continues to believe this measure is appropriate for the measures set and is finalizing the measure for inclusion in MIPS for the 2017 Performance Period.
|
American Urogynecologic Society |
|
! |
N/A/429‡ |
N/A |
Patient Safety |
Claims, Registry |
Process |
Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy: Percentage of patients who are screened for uterine malignancy prior to vaginal closure or obliterative surgery for pelvic organ prolapse.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #429 for the 2017 Performance Period. CMS continues to believe this measure is appropriate for the measures set.
|
American Urogynecologic Society |
|
! |
N/A/430‡ |
N/A |
Patient Safety |
Registry |
Process |
Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy: Percentage of patients, aged 18 years and older, who undergo a procedure under an inhalational general anesthetic, AND who have three or more risk factors for post-operative nausea and vomiting (PONV), who receive combination therapy consisting of at least two prophylactic pharmacologic antiemetic agents of different classes preoperatively or intraoperatively.
Comments: CMS received a comment that supported the inclusion of this measure in MIPSMIPS with substantive changes. Specifically, the commenter believed that this measure was too limited in its scope, because it would prevent CRNAs who performed procedures that did not use an inhalation general anesthetic from reporting the measure. Commenter noted that the top 3 most common procedures fell into this category. Secondly, commenter stated that the following wording in the numerator needed to change in order to avoid medical errors that could put patients at risk: "...agents of different classes preoperatively AND intraoperatively" needs to be changed to "...agents of different classes preoperatively OR intraoperatively."
Response: While CMS appreciates the commenter’s support for inclusion, CMS would like to clarify that the measure has not been tested with these significant modifications included. CMS can consider these modifications in future rulemaking. CMS is finalizing the measure for inclusion in MIPS for the 2017 Performance Period without substantive changes.
Final Decision: CMS is finalizing Q #430 for the 2017 Performance Period.
|
American Society of Anesthesiologists |
|
|
2152/431‡ |
N/A |
Community/Population Health |
Registry |
Process |
Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling: Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #431 for 2017 Performance Period. CMS continues to believe this measure is appropriate for the measures set.
|
Physician Consortium for Performance Improvement Foundation (PCPI®)
|
|
! |
N/A/432‡ |
N/A |
Patient Safety |
Registry |
Outcome |
Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair: Percentage of patients undergoing any surgery to repair pelvic organ prolapse who sustains an injury to the bladder recognized either during or within 1 month after surgery.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #432 for the 2017 Performance Period. CMS continues to believe this measure is appropriate for the measures set.
|
American Urogynecologic Society |
|
! |
N/A/433‡ |
N/A |
Patient Safety |
Registry |
Outcome |
Proportion of Patients Sustaining a Bowel Injury at the Time of any Pelvic Organ Prolapse Repair: Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by a bowel injury at the time of index surgery that is recognized intraoperatively or within 1 month after surgery
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #433 for 2017 Performance Period. CMS continues to believe this measure is appropriate for the measures set.
|
American Urogynecologic Society |
|
! |
N/A/434‡ |
N/A |
Patient Safety |
Registry |
Outcome |
Proportion of Patients Sustaining A Ureter Injury at the Time of any Pelvic Organ Prolapse Repair: Percentage of patients undergoing pelvic organ prolapse repairs who sustain an injury to the ureter recognized either during or within 1 month after surgery.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #434 for 2017 Performance Period. CMS continues to believe this measure is appropriate for the measures set.
|
American Urogynecologic Society |
|
! |
N/A/435‡ |
N/A |
Effective Clinical Care |
Claims, Registry |
Outcome |
Quality Of Life Assessment For Patients With Primary Headache Disorders: Percentage of patients with a diagnosis of primary headache disorder whose health related quality of life (HRQoL) was assessed with a tool(s) during at least two visits during the 12 month measurement period AND whose health related quality of life score stayed the same or improved.
Comments: CMS received a comment that did not support the inclusion of this measure in MIPS because the commenter did not believe the assessment tool is appropriate.
Response: While CMS appreciates the commenter’s recommendation, the substantive change to this measure should be proposed through rulemaking. CMS would like to clarify that the measure has not been tested with these significant modifications included. CMS can consider these modifications in future rulemaking. CMS is finalizing the measure for inclusion in MIPS for the 2017 Performance Period without substantive changes.
Final Decision: CMS is finalizing Q #435 for 2017 Performance Period.
|
American Academy of Neurology |
|
|
N/A/436‡ |
N/A |
Effective Clinical Care |
Claims, Registry |
Process |
Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques: Percentage of final reports for patients aged 18 years and older undergoing CT with documentation that one or more of the following dose reduction techniques were used: • Automated exposure control • Adjustment of the mA and/or kV according to patient size • Use of iterative reconstruction technique
Comments: CMS received a comment supporting the inclusion of this measure but requested that CMS substantively modify the measure to clarify that either specifying the dose lowering technique utilized or inputting a general statement in the radiation report fulfills the requirements of this measure
Response: While CMS appreciates the commenter’s support for inclusion of the measure, CMS would like to clarify that the measure has not been tested with these significant modifications included. CMS can consider these modifications in future rulemaking. CMS is finalizing the measure for inclusion in MIPS for the 2017 Performance Period without substantive changes.
Final Decision: CMS is finalizing Q #436 for 2017 Performance Period.
|
American College of Radiology |
|
! |
N/A/437‡ |
N/A |
Patient Safety |
Claims, Registry |
Outcome |
Rate of Surgical Conversion from Lower Extremity Endovascular Revasculatization Procedure: Inpatients assigned to endovascular treatment for obstructive arterial disease, the percent of patients who undergo unplanned major amputation or surgical bypass within 48 hours of the index procedure.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #437 for 2017 Performance Period.
|
Society of Interventional Radiology |
|
|
N/A/438‡ |
N/A |
Effective Clinical Care |
Web Interface, Registry |
Process |
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease: Percentage of the following patients—all considered at high risk of cardiovascular events—who were prescribed or were on statin therapy during the measurement period: • Adults aged ≥ 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR • Adults aged ≥21 years with a fasting or direct low-density lipoprotein cholesterol (LDL-C) level ≥ 190 mg/dL; OR • Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL
Comments: CMS received a comment supporting the inclusion of this measure but requested that CMS significantly modify the measure to include high to moderate intensity based on risk.
Response: While CMS appreciates the commenter’s support for inclusion of the measure, CMS would like to clarify that the measure has not been tested with these significant modifications included. CMS can consider these modifications in future rulemaking. CMS is finalizing the measure for inclusion in MIPS for the 2017 Performance Period without substantive changes.
Final Decision: CMS is finalizing Q #438 for 2017 Performance Period.
|
Centers for Medicare & Medicaid Services |
|
§ !! |
N/A/439‡ |
N/A |
Efficiency and Cost Reduction |
Registry |
Efficiency |
Age Appropriate Screening Colonoscopy: The percentage of patients greater than 85 years of age who received a screening colonoscopy from January 1 to December 31.
Comments: CMS received a comment supporting the inclusion of this measure.
Response: CMS appreciates the commenter’s support and will finalize the measure for the inclusion in MIPS for the 2017 Performance Period.
Final Decision: CMS is finalizing Q #439 for 2017 Performance Period.
|
American Gastroenterological Association/ American Society for Gastrointestinal Endoscopy/ American College of Gastroenterology |
|
+ ! |
N/A/440 |
|
Communication and Care Coordination |
Registry |
Process |
Basal Cell Carcinoma (BCC)/Squamous Cell Carcinoma: Biopsy Reporting Time – Pathologist to Clinician: Percentage of biopsies with a diagnosis of cutaneous Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC) (including in situ disease) in which the pathologist communicates results to the clinician within 7 days of biopsy date
Comments: CMS received a comment supporting the inclusion of this measure.
Response: CMS appreciates the commenter’s support and will finalize the measure for the inclusion in MIPS for the 2017 Performance Period.
Final Decision: CMS is finalizing Q #440 for 2017 performance period. Specifically, CMS is finalizing its proposal in Table D of the Appendix of the proposed rule (81 FR 28450) to implement the NMSC measure to address a clinical performance gap of communication between pathologists and clinicians regarding final biopsy reports. CMS believes this measure is relevant for pathologists which is a specialty that does not have many relevant measures they can report. During the Measures Application Partnership (MAP) review, the MAP supported this measure and encourages further development. Please note that the measure title and description have changed from what was proposed. Proposed Title: Non-melanoma Skin Cancer (NMSC): Biopsy Reporting Time – Pathologist: Proposed Description: Length of time taken from when the pathologist completes the final biopsy report to when s/he sends the final report to the biopsying physician. This measure evaluates the reporting time between pathologist and biopsying clinician.
|
American Academy of Dermatology |
|
+ ! |
N/A/441 |
|
Effective Clinical Care |
Registry |
Intermediate Outcome |
Ischemic Vascular Disease All or None Outcome Measure (Optimal Control): The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization's total IVD denominator. All-or-None Outcome Measure (Optimal Control) - Using the IVD denominator optimal results include: Most recent blood pressure (BP) measurement is less than 140/90 mm Hg -- And Most recent tobacco status is Tobacco Free -- And Daily Aspirin or Other Antiplatelet Unless Contraindicated -- And Statin Use.
Comments: CMS received comments opposing the inclusion of this measure, specifically due to the measure not being aligned with clinical guidelines.
Response: This measure has been updated to align with JNC-8 recommendations as practicable. While CMS agrees that the measure does not address all aspects of the new recommendations, we believe the portions of the recommendation addressed are significant in improving healthcare quality. Additionally, the field does not fully agree on how patient preference and risk can be accurately identified and measured. Until then, CMS will implement sections of the recommendation that are feasible.
Final Decision: CMS is finalizing Q #441 for 2017 performance period. Specifically, CMS is finalizing its proposal in Table D of the Appendix of the proposed rule (81 FR 28450) to implement the All or None (Composite) measure because it provides benefits to both the patient and the practitioner. CMS believes this measure closely reflects the interests and likely desires of the patient which is a high priority of CMS. Secondly, this measure is an outcome measure that represents a systems perspective emphasizing the importance of optimal care through a patient's entire healthcare experience. During the Measures Application Partnership (MAP) review, the MAP conditionally supported this measure for implementation in 2017. However, the MAP would like to see a future measure that includes patient compliance as part of the composite.
|
Wisconsin Collaborative for Healthcare Quality (WCHQ) |
|
+ § |
0071/442 |
|
Effective Clinical Care |
Registry |
Process |
Persistent Beta Blocker Treatment After a Heart Attack: The percentage of patients 18 years of age and older during the measurement year who were hospitalized and discharged from July 1 of the year prior to the measurement year to June 30 of the measurement year with a diagnosis of acute myocardial infarction (AMI) and who received were prescribed persistent beta-blocker treatment for six months after discharge.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #442 for 2017 performance period. CMS will continue to finalize the measure because it aligns with the CQMC measures. Specifically, CMS, as part of the CQMC, is finalizing its proposal in Table D of the Appendix of the proposed rule (81 FR 28451) to implement this measure to fulfill a set of condition-specific core measures. CMS believes the CQMC fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is finalized as a core measure to specifically address cardiovascular care. Furthermore, CMS is utilizing its authority to finalize measures that were not reviewed by the MAP.
|
National Committee for Quality Assurance |
|
+ § !! |
N/A/443 |
|
Patient Safety |
Registry |
Process |
Non-Recommended Cervical Cancer Screening in Adolescent Females: The percentage of adolescent females 16–20 years of age screened unnecessarily for cervical cancer.
Comments: CMS received a comment supporting the inclusion of this measure.
Response: CMS appreciates the commenter’s support and will finalize the measure because it aligns with the CQMC measures.
Final Decision: CMS is finalizing Q #443 for the 2017 performance period. Specifically, CMS, as part of the CQMC, is finalizing its proposal in Table D of the Appendix of the proposed rule (81 FR 28452) to implement this measure to fulfill a set of condition-specific core measures. CMS believes the CQMC fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is finalized as a core measure to specifically address care coordination and patient safety within primary care. Furthermore, CMS is utilizing its authority to finalize measures that were not reviewed by the MAP.
|
National Committee for Quality Assurance |
|
+ § ! |
1799/444 |
|
Efficiency and Cost Reduction |
Registry |
Process |
Medication
Management for People with Asthma (MMA):
The
percentage of patients 5-64 years of age during the measurement
year who were identified as having persistent asthma and were
dispensed appropriate medications that they remained on for at
least 75% of their treatment period. Comments: CMS received several comments to not include this measure but continue to include PQRS measure #311 instead.
Response: CMS will continue to finalize this measure because it aligns with the CQMC. PQRS measure #311 is closely related to the NQF #1799 but is not a measure within the CQMC and is being finalized for removal.
Final Decision: CMS is finalizing Q #444 for the 2017 performance period. Specifically, CMS, as part of the CQMC, is finalizing its proposal in Table D of the Appendix of the proposed rule (81 FR 28452) to implement this measure to fulfill a set of condition-specific core measures. CMS believes the CQMC fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is finalized as a core measure to specifically address pulmonary care within primary care. Furthermore, CMS is utilizing its authority to finalize measures that were not reviewed by the MAP.
|
National Committee for Quality Assurance |
|
+ § ! |
0119/445 |
|
Effective Clinical Care |
Registry |
Outcome |
Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG): Percent of patients aged 18 years and older undergoing isolated CABG who die, including both 1) all deaths occurring during the hospitalization in which the CABG was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #445 for 2017 performance period. CMS will continue to finalize the measure because it aligns with the CQMC measures. Specifically, CMS, as part of the CQMC, is finalizing its proposal in Table D of the Appendix of the proposed rule (81 FR 28453) to implement this measure to fulfill a set of condition-specific core measures. CMS believes the CQMC fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is finalized as a core measure to specifically address chronic cardiovascular condition. Furthermore, CMS is utilizing its authority to finalize propose measures that were not reviewed by the MAP.
|
The Society of Thoracic Surgeons |
|
+ § ! |
0733/446 |
|
Patient Safety |
Registry |
Outcome |
Operative Mortality Stratified by the Five STS-EACTS Mortality Categories: Percent of patients undergoing index pediatric and/or congenital heart surgery who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days (including patients transferred to other acute care facilities), and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, stratified by the five STAT Mortality Levels, a multi-institutional validated complexity stratification tool
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q # 446 for the 2017 performance period. CMS will finalize the measure because it aligns with CQMC measures. Specifically, CMS, as part of the CQMC, is finalizing its proposal in Table D of the Appendix of the proposed rule (81 FR 28454) to implement this measure to fulfill a set of condition-specific core measures. CMS believes the CQMC fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is finalized as a core measure to specifically address pediatric heart surgery. Furthermore, CMS is utilizing its authority to finalize measures that were not reviewed by the MAP.
|
The Society of Thoracic Surgeons |
|
+ § |
1395/447 |
|
Community/Population Health |
Registry |
Process |
Chlamydia Screening and Follow-up: The percentage of female adolescents 16 years of age who had a chlamydia screening test with proper follow-up during the measurement period
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #447 for 2017 performance period. CMS will finalize the measure because it aligns with the CQMC measures. Specifically, CMS, as part of the CQMC, is finalizing its proposal in Table D of the Appendix of the proposed rule (81 FR 28454) to implement this measure to fulfill a set of condition-specific core measures. CMS believes the CQMC fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is finalized as a core measure to specifically address obstetrics and gynecology conditions. Furthermore, CMS is utilizing its authority to finalize measures that were not reviewed by the MAP.
|
National Committee for Quality Assurance |
|
+ § ! |
0567/448 |
|
Patient Safety |
Registry |
Process |
Appropriate Work Up Prior to Endometrial Ablation: Percentage of women, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy and results documented before undergoing an endometrial ablation
Comments: CMS received a comment asking that CMS not include this measure because the measure is not tested at the clinician level.
Response: CMS has verified with the measure owner this measure includes testing at the clinician and group practice level. CMS will continue to finalize the measure because it aligns with the CQMC measures.
Final Decision: CMS is finalizing Q #448 for the 2017 performance period. Specifically, CMS, as part of the CQMC, is finalizing its proposal in Table D of the Appendix of the proposed rule (81 FR 28455) to implement this measure to fulfill a set of condition-specific core measures. CMS believes the CQMC fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is finalized as a core measure to specifically address obstetrics and gynecology conditions. Furthermore, CMS is utilizing its authority to finalize measures that were not reviewed by the MAP.
|
Centers for Medicare & Medicaid Services |
|
+ § !! |
1857/449 |
|
Efficiency and Cost Reduction |
Registry |
Process |
HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment with HER2-Targeted Therapies: Proportion of female patients (aged 18 years and older) with breast cancer who are human epidermal growth factor receptor 2 (HER2)/neu negative who are not administered HER2-targeted therapies
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #449 for the 2017 performance period. CMS will finalize the measure because it aligns with the CQMC measures. Specifically, CMS, as part of the CQMC, is finalizing its proposal in Table D of the Appendix of the proposed rule (81 FR 28455) to implement this measure to fulfill a set of condition-specific core measures. CMS believes the CQMC fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is finalized as a core measure to specifically address medical oncology and breast cancer. Furthermore, CMS is utilizing its authority to finalize measures that were not reviewed by the MAP.
|
American Society of Clinical Oncology |
|
+ § !! |
1858/450 |
NA |
Efficiency and Cost Reduction |
Registry |
Process |
Trastuzumab Received By Patients With AJCC Stage I (T1c) – III And HER2 Positive Breast Cancer Receiving Adjuvant Chemotherapy: Proportion of female patients (aged 18 years and older) with AJCC stage I (T1c) – III, human epidermal growth factor receptor 2 (HER2) positive breast cancer receiving adjuvant chemotherapy who are also receiving trastuzumab
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q # 450 for the 2017 performance period. CMS will finalize the measure because it aligns with the CQMC measures. Specifically, CMS, as part of the CQMC, is finalizing its proposal in Table D of the Appendix (81 FR 28456) to implement this measure to fulfill a set of condition-specific core measures. CMS believes the CQMC fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is finalized as a core measure to specifically address medical oncology and breast cancer. Furthermore, CMS is utilizing its authority to finalize measures that were not reviewed by the MAP.
|
American Society of Clinical Oncology |
|
+ § |
1859/451 |
|
Effective Clinical Care |
Registry |
Process |
KRAS Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy: Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy for whom KRAS gene mutation testing was performed
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #451 for the 2017 performance period. CMS will finalize the measure because it aligns with the CQMC measures. Specifically, CMS, as part of the CQMC, is finalizing its proposal in Table D of the Appendix of the proposed rule (81 FR 28456) to implement this measure to fulfill a set of condition-specific core measures. CMS believes the CQMC fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is finalized as a core measure to specifically address medical oncology and breast cancer. Furthermore, CMS is utilizing its authority to finalize measures that were not reviewed by the MAP.
|
American Society of Clinical Oncology |
|
+ § !! |
1860/452 |
|
Patient Safety |
Registry |
Process |
Patients with Metastatic Colorectal Cancer and KRAS Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies: Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer and KRAS gene mutation spared treatment with anti-EGFR monoclonal antibodies.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #452 for the 2017 performance period. CMS will finalize the measure because it aligns with the CQMC measures. Specifically, CMS, as part of the CQMC, is finalizing its proposal in Table D of the Appendix of the proposed rule (81 FR 28457) to implement this measure to fulfill a set of condition-specific core measures. CMS believes the CQMC fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is finalized as a core measure to specifically address medical oncology and breast cancer. Furthermore, CMS is utilizing its authority to finalize measures that were not reviewed by the MAP.
|
American Society of Clinical Oncology |
|
+ § !! |
0210/453 |
|
Effective Clinical Care |
Registry |
Process |
Proportion Receiving Chemotherapy in the Last 14 Days of life: Proportion of patients who died from cancer receiving chemotherapy in the last 14 days of life
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #453 for the 2017 performance period. CMS will finalize the measure because it aligns with the CQMC measures. Specifically, CMS, as part of the CQMC, is finalizing its proposal in Table D of the Appendix of the proposed rule ( 81 FR 28457) to implement this measure to fulfill a set of condition-specific core measures. CMS believes the CQMC fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is finalized as a core measure to specifically address hospice and end of life metrics for medical oncology. Furthermore, CMS is utilizing its authority to finalize measures that were not reviewed by the MAP.
|
American Society of Clinical Oncology |
|
+ § !! |
0211/454 |
|
Effective Clinical Care |
Registry |
Outcome |
Proportion of Patients who Died from Cancer with more than One Emergency Department Visit in the Last 30 Days of Life: Proportion of patients who died from cancer with more than one emergency room visit in the last 30 days of life
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #454 for the 2017 performance period. CMS will finalize the measure because it aligns with the CQMC measures. Specifically, CMS, as part of the CQMC, is finalizing its proposal in Table D of the Appendix of the proposed rule (81 FR 28458) to implement this measure to fulfill a set of condition-specific core measures. CMS believes the CQMC fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is finalized as a core measure to specifically address hospice and end of life metrics for medical oncology. Furthermore, CMS is utilizing its authority to finalize measures that were not reviewed by the MAP.
|
American Society of Clinical Oncology |
|
+ § !! |
0213/455 |
|
Effective Clinical Care |
Registry |
Outcome |
Proportion Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life: Proportion of patients who died from cancer admitted to the ICU in the last 30 days of life.
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #455 for the 2017 performance period. CMS will finalize the measure because it aligns with the CQMC measures. Specifically, CMS, as part of the CQMC, is finalizing its proposal in Table D of the Appendix of the proposed rule (81 FR 28458) to implement this measure to fulfill a set of condition-specific core measures. CMS believes the CQMC fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is finalized as a core measure to specifically address hospice and end of life metrics for medical oncology. Furthermore, CMS is utilizing its authority to finalize measures that were not reviewed by the MAP.
|
American Society of Clinical Oncology |
|
+ § !! |
0215/456 |
|
Effective Clinical Care |
Registry |
Process |
Proportion Not Admitted To Hospice: Proportion of patients who died from cancer not admitted to hospice
CMS did not receive specific comments regarding this measure.
Final Decision: CMS is finalizing Q #456 for the 2017 performance period. CMS will finalize the measure because it aligns with the CQMC measures. Specifically, CMS, as part of the CQMC, is finalizing its proposal in Table D of the Appendix (81 FR 28459) to implement proposes this measure to fulfill a set of condition-specific core measures. CMS believes the CQMC fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is finalized as a core measure to specifically address hospice and end of life metrics for medical oncology. Furthermore, CMS is utilizing its authority to finalize measures that were not reviewed by the MAP.
|
American Society of Clinical Oncology |
|
+ § !! |
0216/457 |
|
Effective Clinical Care |
Registry |
Outcome |
Proportion Admitted to Hospice for less than 3 days: Proportion of patients who died from cancer, and admitted to hospice and spent less than 3 days there.
Comments: CMS received comments that did not support inclusion, stating that the measure de-incentivizes admitting patients appropriately to hospice even if they are in their last few days of life.
Response: CMS will continue to finalize the measure because it aligns with the CQMC measures. The intent of this measure is to ensure timely referral to hospice care. It is not intended to de-incentivize admittance into hospice. Our hope is that Q#0216 and Q#0215 would be analyzed in somewhat of a composite manner in order to verify this negative impact does not occur.
Final Decision: CMS is finalizing Q #457 for the 2017 performance period. Specifically, CMS, as part of the CQMC, is finalizing its proposal in Table D of the Appendix of the proposed rule (81 FR 28459) to implement this measure to fulfill a set of condition-specific core measures. CMS believes the CQMC fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is finalized as a core measure to specifically address hospice and end of life metrics for medical oncology. Furthermore, CMS is utilizing its authority to finalize measures that were not reviewed by the MAP. |
American Society of Clinical Oncology |
|
|
1789/458 |
|
Communication and Care Coordination |
N/A (Administrative Claims) |
Outcome |
All-Cause Hospital Readmission Measure: The 30-day All-Cause Hospital Readmission measure is a risk-standardized readmission rate for beneficiaries age 65 or older who were hospitalized at a short-stay acute care hospital and experienced an unplanned readmission for any cause to an acute care hospital within 30 days of discharge.
Comments: CMS received comments that supported the inclusion of this measure in 2017 measure set. CMS also received comments stating that the measure is only applicable to primary care clinicians.
Response: CMS recognizes that this measure may be more relevant to some MIPS eligible clinicians than others. This measure will only be scored for MIPS eligible clinicians and groups who have beneficiaries attributed to them and that meet the minimum case size requirements. In addition, while we had proposed to adopt this measure only for groups of 10 or more eligible clinicians, as discussed in section II.E.5.b of this final rule with comment period, we are finalizing this measure only for groups of 15 or more eligible clinicians to ensure a uniform definition of a “small practice” across the Quality Payment Program.
Final Decision: CMS is finalizing Q # 458 for the 2017 performance period. |
Yale University |
|
¥ Measure details including titles, descriptions and measure owner information may vary during a particular program year. This is due to the timing of measure specification preparation and the measure versions used by the various reporting options/methods. Please refer to the measure specifications that apply for each of the reporting options/methods for specific measure details.
TABLE B: Quality Measures That Are Calculated for 2017 MIPS Performance That Do Not Require Data Submission
MIPS ID Number |
NQF/ PQRS |
CMS E-Measure ID |
National Quality Strategy Domain |
Measure Type |
Measure Title and Description¥ |
Measure Steward |
Proposals Finalized |
||||||
|
1789/458 |
N/A |
Communication and Care Coordination |
Outcome |
All-cause Hospital Readmission Measure: The 30-day All-Cause Hospital Readmission measure is a risk-standardized readmission rate for beneficiaries age 65 or older who were hospitalized at a short-stay acute care hospital and experienced an unplanned readmission for any cause to an acute care hospital within 30 days of discharge.
Comments: CMS received comments that supported the inclusion of this measure in 2017 measure set. CMS also received comments stating that the measure is only applicable to primary care clinicians.
Response: CMS recognizes that this measure may be more relevant to some MIPS eligible clinicians than others. This measure will only be scored for MIPS eligible clinicians and groups who have beneficiaries attributed to them and that meet the minimum case size requirements. In addition, while we had proposed to adopt this measure only for groups of 10 or more eligible clinicians, as discussed in section II.E.5.b of this final rule with comment period, we are finalizing this measure only for groups of 16 or more eligible clinicians to ensure a uniform definition of a “small practice” across the Quality Payment Program.
Final Decision CMS is finalizing this measure for 2017.
|
Yale University |
Proposals Not Finalized |
||||||
|
N/A |
N/A |
Communication and Care Coordination |
Outcome |
Acute Conditions Composite:
Comments: CMS received numerous comments regarding the appropriateness of this measure as it does not specifically address clinicians that serve a large number of high-risk patients.
Response: CMS has been working with measure developers to include risk-adjustment as part of this measure. However, until this measure is fully tested with the risk-adjustment portion included, CMS is not finalizing its proposal to implement this measure for 2017.
Final Decision: This measure is not being finalized for the 2017 performance period. |
Agency for Healthcare Research & Quality |
|
N/A |
N/A |
Communication and Care Coordination |
Outcome |
Chronic Conditions Composite:
Comments: CMS received numerous comments regarding the appropriateness of this measure as it does not specifically address clinicians that serve a large number of high-risk patients.
Response: CMS has been working with measure developers to include risk-adjustment as part of this measure. However, until this measure is fully tested with the risk-adjustment portion included, CMS is not finalizing its proposal to implement this measure for 2017.
Final Decision: This measure is not being finalized for the 2017 performance period.
|
Agency for Healthcare Research & Quality |
¥ Measure details including titles, descriptions and measure owner information may vary during a particular program year. This is due to the timing of measure specification preparation and the measure versions used by the various reporting options/methods. Please refer to the measure specifications that apply for each of the reporting options/methods for specific measure details.
TABLE B: Quality Measures That Are Calculated for 2017 MIPS Performance That Do Not Require Data Submission
MIPS ID Number |
NQF/ PQRS |
CMS E-Measure ID |
National Quality Strategy Domain |
Measure Type |
Measure Title and Description¥ |
Measure Steward |
Proposals Finalized |
||||||
|
1789/458 |
N/A |
Communication and Care Coordination |
Outcome |
All-cause Hospital Readmission Measure: The 30-day All-Cause Hospital Readmission measure is a risk-standardized readmission rate for beneficiaries age 65 or older who were hospitalized at a short-stay acute care hospital and experienced an unplanned readmission for any cause to an acute care hospital within 30 days of discharge.
Comments: CMS received comments that supported the inclusion of this measure in 2017 measure set. CMS also received comments stating that the measure is only applicable to primary care clinicians.
Response: CMS recognizes that this measure may be more relevant to some MIPS eligible clinicians than others. This measure will only be scored for MIPS eligible clinicians and groups who have beneficiaries attributed to them and that meet the minimum case size requirements. In addition, while we had proposed to adopt this measure only for groups of 10 or more eligible clinicians, as discussed in section II.E.5.b of this final rule with comment period, we are finalizing this measure only for groups of 16 or more eligible clinicians to ensure a uniform definition of a “small practice” across the Quality Payment Program.
Final Decision CMS is finalizing this measure for 2017.
|
Yale University |
Proposals Not Finalized |
||||||
|
N/A |
N/A |
Communication and Care Coordination |
Outcome |
Acute Conditions Composite:
Comments: CMS received numerous comments regarding the appropriateness of this measure as it does not specifically address clinicians that serve a large number of high-risk patients.
Response: CMS has been working with measure developers to include risk-adjustment as part of this measure. However, until this measure is fully tested with the risk-adjustment portion included, CMS is not finalizing its proposal to implement this measure for 2017.
Final Decision: This measure is not being finalized for the 2017 performance period. |
Agency for Healthcare Research & Quality |
|
N/A |
N/A |
Communication and Care Coordination |
Outcome |
Chronic Conditions Composite:
Comments: CMS received numerous comments regarding the appropriateness of this measure as it does not specifically address clinicians that serve a large number of high-risk patients.
Response: CMS has been working with measure developers to include risk-adjustment as part of this measure. However, until this measure is fully tested with the risk-adjustment portion included, CMS is not finalizing its proposal to implement this measure for 2017.
Final Decision: This measure is not being finalized for the 2017 performance period.
|
Agency for Healthcare Research & Quality |
NOTE: “TABLE C: Individual Quality Cross-Cutting Measures for the MIPS to Be Available to Meet the Reporting Criteria Via Claims, Registry, and EHR Beginning in 2017” has been removed per policy change -
TABLE D: Finalized New Measures for MIPS Reporting in 2017
Title |
Basal Cell Carcinoma (BCC)/Squamous Cell Carcinoma: Biopsy Reporting Time - Pathologist |
NQF #:/Quality # |
N/A/440 |
Description: |
Percentage of biopsies with a diagnosis of cutaneous Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC) (including in situ disease) in which the pathologist communicates results to the clinician within 7 days of biopsy date |
Measure Steward: |
American Academy of Dermatology |
Numerator: |
Number of final pathology reports diagnosing cutaneous basal cell carcinoma or squamous cell carcinoma (to include in situ disease) sent from the Pathologist/Dermatopathologist to the biopsying clinician for review within 5 business days from the time when the tissue specimen was received by the pathologist |
Denominator: |
All pathology reports generated by the Pathologist/Dermatopathologist consistent with cutaneous basal cell carcinoma or squamous cell carcinoma (to include in situ disease) |
Exclusions: |
Pathologists/Dermatopathologists providing a second opinion on a biopsy |
Measure Type: |
Process |
Measure Domain: |
Communication and Care Coordination |
Data Submission Method: |
Claims, Registry |
Rationale: |
CMS is finalizing its proposal to implement the NMSC measure to address a clinical performance gap of communication between pathologists and clinicians regarding final biopsy reports. CMS believes this measure is relevant for pathologists which is a specialty that does not have many relevant measures they can report. During the Measures Application Partnership (MAP) review, the MAP supports this measure and encourages further development. |
Title |
Ischemic Vascular Disease All or None Outcome Measure (Optimal Control) |
NQF#/Quality #: |
N/A/441 |
Description: |
The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization's total IVD denominator. All-or-None Outcome Measure (Optimal Control) - Using the IVD denominator optimal results include: Most recent blood pressure (BP) measurement is less than 140/90 mm Hg -- And Most recent tobacco status is Tobacco Free -- And Daily Aspirin or Other Antiplatelet Unless Contraindicated -- And Statin Use |
Measure Steward: |
Wisconsin Collaborative for Healthcare Quality (WCHQ) |
Numerator: |
Most recent BP is less than 140/90 mm Hg And Most recent tobacco status is Tobacco Free (NOTE: If there is No Documentation of Tobacco Status the patient is not compliant for this measure) And Daily Aspirin or Other Antiplatelet Unless Contraindicated And Statin Use |
Denominator: |
Patients with CAD or a CAD Risk-Equivalent Condition 18-75 years of age and alive as of the last day of the Measurement Period. A minimum of two CAD or CAD Risk-Equivalent Condition coded office visits OR one Acute Coronary Event (AMI, PCI, CABG) from a hospital visit and must be seen by a PCP / Cardiologist for two office visits in 24 months and one office visit in 12 months |
Exclusions: |
History of Gastrointestinal Bleed or Intra-cranial Bleed or documentation of active anticoagulant use during the MP for the Aspirin/Other Anticoagulant component (numerator) of the measure. Inpatient Stays, Emergency Room Visits, Urgent Care Visits, and Patient Self-Reported BP’s (Home and Health Fair BP results) for the Blood Pressure Control component (numerator) of the composite measure |
Measure Type: |
Intermediate Outcome |
Measure Domain: |
Effective Clinical Care |
Data Submission Method: |
Registry |
Rationale: |
CMS is finalizing its proposal to implement the All or None (Composite) measure because it provides benefits to both the patient and the practitioner. CMS believes this measure closely reflects the interests and likely desires of the patient which is a high priority of CMS. Secondly, this measure is an outcome measure that represents a systems perspective emphasizing the importance of optimal care through a patient's entire healthcare experience. During the Measures Application Partnership (MAP) review, the MAP conditionally supports this measure for implementation in 2017. However, the MAP would like to see a future measure that includes patient compliance as part of the composite. |
Title |
Persistent Beta Blocker Treatment After a Heart Attack |
NQF#/Quality #: |
0071/442 |
Description: |
The percentage of patients 18 years of age and older during the measurement year who were hospitalized and discharged from July 1 of the year prior to the measurement year to June 30 of the measurement year with a diagnosis of acute myocardial infarction (AMI) and who received were prescribed persistent beta-blocker treatment for six months after discharge |
Measure Steward: |
National Committee for Quality Assurance |
Numerator: |
Patients who had a 180-day course of treatment with beta-blockers post discharge |
Denominator: |
Patients 18 years of age and older by the end of the measurement year who were discharged alive from an acute inpatient setting with an AMI from 6 months prior to the beginning of the measurement year through the 6 months after the beginning of the measurement year |
Exclusions: |
Exclude
patients who are identified as having an intolerance or allergy to
beta-blocker therapy. Look as far back as possible in the
patient’s history for evidence of a contraindication to
beta-blocker therapy |
Measure Type: |
Process |
Measure Domain: |
Effective Clinical Care |
Data Submission Method: |
Registry |
Rationale: |
CMS, as part of the CQMC, is finalizing its proposal to implement this measure to fulfill a set of condition-specific core measures. CMS believes the CQMC fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is finalized as a core measure to specifically address cardiovascular care. Furthermore, CMS is utilizing its authority to finalize measures that were not reviewed by the Measures Application Partnership (MAP). |
Title |
Non-Recommended Cervical Cancer Screening in Adolescent Females |
NQF#/Quality #: |
N/A/443 |
Description: |
The percentage of adolescent females 16–20 years of age screened unnecessarily for cervical cancer |
Measure Steward: |
National Committee for Quality Assurance |
Numerator: |
Cervical cytology (Cervical Cytology Value Set) or an HPV test (HPV Tests Value Set) performed during the measurement year |
Denominator: |
Adolescent females 16-20 years as of December 31 of the measurement year |
Exclusions: |
A history of cervical cancer (Cervical Cancer Value Set), HIV (HIV Value Set) or immunodeficiency (Disorders of the Immune System Value Set) any time during the member’s history through December 31 of the measurement year |
Measure Type: |
Process |
Measure Domain: |
Patient Safety |
Data Submission Method: |
Registry |
Rationale: |
CMS, as part of the CQMC, is finalizing its proposal to implement this measure to fulfill a set of condition-specific core measures. CMS believes the CQMC fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is finalized as a core measure to specifically address care coordination and patient safety within primary care. Furthermore, CMS is utilizing its authority to finalize measures that were not reviewed by the Measures Application Partnership (MAP). |
Title |
Medication Management for People with Asthma (MMA) |
NQF#/Quality #: |
1799/444 |
Description: |
The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment period |
Measure Steward: |
National Committee for Quality Assurance |
Numerator: |
Medication
Compliance 50%: The number of patients who achieved a PDC* of at
least 50% for their asthma controller medications during the
measurement year |
Denominator: |
Patients 5–64 years of age during the measurement year who were identified as having persistent asthma |
Exclusions: |
1)
Exclude patients who had any diagnosis of Emphysema (Emphysema
Value Set, Other Emphysema Value Set), COPD (COPD Value Set),
Chronic Bronchitis (Obstructive Chronic Bronchitis Value Set,
Chronic Respiratory Conditions Due To Fumes/Vapors Value Set),
Cystic Fibrosis (Cystic Fibrosis Value Set) or Acute Respiratory
Failure (Acute Respiratory Failure Value Set) any time during the
patient’s history through the end of the measurement year
(e.g., December 31) |
Measure Type: |
Process |
Measure Domain: |
Efficiency and Cost Reduction |
Data Submission Method |
Registry |
Rationale: |
CMS, as part of the CQMC, is finalizing its proposal to implement this measure to fulfill a set of condition-specific core measures. CMS believes the CQMC fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is finalized as a core measure to specifically address pulmonary care within primary care. Furthermore, CMS is utilizing its authority to finalize measures that were not reviewed by the Measures Application Partnership (MAP). |
Title |
Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG) |
NQF#/Quality #: |
0119/445 |
Description: |
Percent of patients aged 18 years and older undergoing isolated CABG who die, including both 1) all deaths occurring during the hospitalization in which the CABG was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure |
Measure Steward: |
The Society of Thoracic Surgeons |
Numerator: |
Number of patients undergoing isolated CABG who die, including both 1) all deaths occurring during the hospitalization in which the operation was performed, even if after 30 days, and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure |
Denominator: |
All patients undergoing isolated CABG |
Exclusions: |
N/A |
Measure Type: |
Outcome |
Measure Domain: |
Effective Clinical Care |
Data Submission Method: |
Registry |
Rationale: |
CMS, as part of the CQMC, is finalizing its proposal to implement this measure to fulfill a set of condition-specific core measures. CMS believes the CQMC fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is finalized as a core measure to specifically address chronic cardiovascular condition. Furthermore, CMS is utilizing its authority to finalize propose measures that were not reviewed by the Measures Application Partnership (MAP). |
Title |
Operative Mortality Stratified by the Five STS-EACTS Mortality Categories |
NQF#/Quality #: |
0733/446 |
Description: |
Percent of patients undergoing index pediatric and/or congenital heart surgery who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days (including patients transferred to other acute care facilities), and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, stratified by the five STAT Mortality Levels, a multi-institutional validated complexity stratification tool |
Measure Steward: |
The Society of Thoracic Surgeons |
Numerator: |
Number of patients undergoing index pediatric and/or congenital heart surgery who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days (including patients transferred to other acute care facilities), and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, stratified by the five STAT Mortality Levels, a multi-institutional validated complexity stratification tool |
Denominator: |
All patients undergoing index pediatric and/or congenital heart surgery |
Exclusions: |
N/A |
Measure Type: |
Outcome |
Measure Domain: |
Patient Safety |
Data Submission Method: |
Registry |
Rationale: |
CMS, as part of the CQMC, is finalizing its proposal to implement this measure to fulfill a set of condition-specific core measures. CMS believes the CQMC fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is finalized as a core measure to specifically address pediatric heart surgery. Furthermore, CMS is utilizing its authority to finalize measures that were not reviewed by the Measures Application Partnership (MAP). |
Title |
Chlamydia Screening and Follow-up |
NQF#/Quality #: |
1395/447 |
Description: |
The percentage of female adolescents 16 years of age who had a chlamydia screening test with proper follow-up during the measurement period |
Measure Steward: |
National Committee for Quality Assurance |
Numerator: |
Adolescents who had documentation of a chlamydia screening test with proper follow-up by the time they turn 18 years of age |
Denominator: |
Sexually active female adolescents with a visit who turned 18 years of age during the measurement year |
Exclusions: |
N/A |
Measure Type: |
Process |
Measure Domain: |
Community/Population Health |
Data Submission Method: |
Registry |
Rationale: |
CMS, as part of the CQMC, is finalizing its proposal to implement this measure to fulfill a set of condition-specific core measures. CMS believes the CQMC fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is finalized as a core measure to specifically address obstetrics and gynecology conditions. Furthermore, CMS is utilizing its authority to finalize measures that were not reviewed by the Measures Application Partnership (MAP). |
Title |
Appropriate Work Up Prior to Endometrial Ablation |
NQF#/Quality #: |
0567/448 |
Description: |
Percentage of women, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy and results documented before undergoing an endometrial ablation |
Measure Steward: |
Health Benchmarks – IMS Health |
Numerator: |
Women who received endometrial sampling or hysteroscopy with biopsy during the year prior to the index date (inclusive of the index date) |
Denominator: |
Continuously enrolled women who had an endometrial ablation procedure during the measurement year |
Exclusions: |
Women who had an endometrial ablation procedure during the year prior to the index date (exclusive of the index date) |
Measure Type: |
Process |
Measure Domain: |
Patient Safety |
Data Submission Method: |
Registry |
Rationale: |
CMS, as part of the CQMC, is finalizing its proposal to implement this measure to fulfill a set of condition-specific core measures. CMS believes the CQMC fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is finalized as a core measure to specifically address obstetrics and gynecology conditions. Furthermore, CMS is utilizing its authority to finalize measures that were not reviewed by the Measures Application Partnership (MAP). |
Title |
HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment with HER2-Targeted Therapies |
NQF#/Quality #: |
1857/449 |
Description: |
Proportion of female patients (aged 18 years and older) with breast cancer who are human epidermal growth factor receptor 2 (HER2)/neu negative who are not administered HER2-targeted therapies |
Measure Steward: |
American Society of Clinical Oncology |
Numerator: |
Trastuzumab not administered during the initial course of treatment |
Denominator: |
Adult women with AJCC stage I (T1c) – III breast cancer that is HER-2 negative or HER-2 undocumented/unknown |
Exclusions: |
Patient transfer to practice after initiation of chemotherapy |
Measure Type: |
Process |
Measure Domain: |
Efficiency and Cost Reduction |
Data Submission Method: |
Registry |
Rationale: |
CMS, as part of the CQMC, is finalizing its proposal to implement this measure to fulfill a set of condition-specific core measures. CMS believes the CQMC fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is finalized as a core measure to specifically address medical oncology and breast cancer. Furthermore, CMS is utilizing its authority to finalize measures that were not reviewed by the Measures Application Partnership (MAP). |
Title |
Trastuzumab Received By Patients With AJCC Stage I (T1c) – III And HER2 Positive Breast Cancer Receiving Adjuvant Chemotherapy: |
NQF#/Quality #: |
1858/450 |
Description: |
Proportion of female patients (aged 18 years and older) with AJCC stage I (T1c) – III, human epidermal growth factor receptor 2 (HER2) positive breast cancer receiving adjuvant chemotherapy who are also receiving trastuzumab |
Measure Steward: |
American Society of Clinical Oncology |
Numerator: |
Trastuzumab not administered during the initial course of treatment |
Denominator: |
Adult women with AJCC stage I (T1c) – III breast cancer that is HER-2 negative or HER-2 undocumented/unknown |
Exclusions: |
Patient transfer to practice after initiation of chemotherapy |
Measure Type: |
Process |
Measure Domain: |
Efficiency and Cost Reduction |
Data Submission Method: |
Registry |
Rationale: |
CMS, as part of the CQMC, is finalizing its proposal to implement this measure to fulfill a set of condition-specific core measures. CMS believes the CQMC fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is finalized as a core measure to specifically address medical oncology and breast cancer. Furthermore, CMS is utilizing its authority to finalize measures that were not reviewed by the Measures Application Partnership (MAP). |
Title |
KRAS Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy: |
NQF#/Quality #: |
1859/451 |
Description: |
Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy for whom KRAS gene mutation testing was performed |
Measure Steward: |
American Society of Clinical Oncology |
Numerator: |
KRAS gene mutation testing performed before initiation of anti-EGFR MoAb |
Denominator: |
Adult patients with metastatic colorectal cancer who receive anti-EGFR monoclonal antibody therapy |
Exclusions: |
Patient transfer to practice after initiation of chemotherapy |
Measure Type: |
Process |
Measure Domain: |
Effective Clinical Care |
Data Submission Method: |
Registry |
Rationale: |
CMS, as part of the CQMC, is finalizing its proposal to implement this measure to fulfill a set of condition-specific core measures. CMS believes the CQMC fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is finalized as a core measure to specifically address medical oncology and breast cancer. Furthermore, CMS is utilizing its authority to finalize measures that were not reviewed by the Measures Application Partnership (MAP). |
Title |
Patients with Metastatic Colorectal Cancer and KRAS Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies: |
NQF#/Quality #: |
1860/452 |
Description: |
Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer and KRAS gene mutation spared treatment with anti-EGFR monoclonal antibodies |
Measure Steward: |
American Society of Clinical Oncology |
Numerator: |
Anti-EGFR monoclonal antibody therapy not received |
Denominator: |
Adult patients with metastatic colorectal cancer who have a KRAS gene mutation |
Exclusions: |
Patient
transfer to practice after initiation of chemotherapy |
Measure Type: |
Process |
Measure Domain: |
Patient Safety |
Data Submission Method: |
Registry |
Rationale: |
CMS, as part of the CQMC, is finalizing its proposal to implement this measure to fulfill a set of condition-specific core measures. CMS believes the CQMC fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is finalized as a core measure to specifically address medical oncology and breast cancer. Furthermore, CMS is utilizing its authority to finalize measures that were not reviewed by the Measures Application Partnership (MAP). |
Title |
Proportion Receiving Chemotherapy in the Last 14 Days of life: |
NQF#/Quality #: |
0210/453 |
Description: |
Proportion of patients who died from cancer receiving chemotherapy in the last 14 days of life |
Measure Steward: |
American Society of Clinical Oncology |
Numerator: |
Patients who died from cancer and received chemotherapy in the last 14 days of life |
Denominator: |
Patients who died from cancer |
Exclusions: |
N/A |
Measure Type: |
Process |
Measure Domain: |
Effective Clinical Care |
Data Submission Method: |
Registry |
Rationale: |
CMS, as part of the CQMC, is finalizing its proposal to implement this measure to fulfill a set of condition-specific core measures. CMS believes the CQMC fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is finalized as a core measure to specifically address hospice and end of life metrics for medical oncology. Furthermore, CMS is utilizing its authority to finalize measures that were not reviewed by the Measures Application Partnership (MAP). |
Title |
Proportion of Patients who Died from Cancer with more than One Emergency Department Visit in the Last 30 Days of Life: |
NQF#/Quality #: |
0211/454 |
Description: |
Proportion of patients who died from cancer with more than one emergency room visit in the last 30 days of life |
Measure Steward: |
American Society of Clinical Oncology |
Numerator: |
Patients who died from cancer and had >1 ER visit in the last 30 days of life |
Denominator: |
Patients who died from cancer |
Exclusions: |
N/A |
Measure Type: |
Outcome |
Measure Domain: |
Effective Clinical Care |
Data Submission Method: |
Registry |
Rationale: |
CMS, as part of the CQMC, is finalizing its proposal to implement this measure to fulfill a set of condition-specific core measures. CMS believes the CQMC fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is finalized as a core measure to specifically address hospice and end of life metrics for medical oncology. Furthermore, CMS is utilizing its authority to finalize measures that were not reviewed by the Measures Application Partnership (MAP). |
Title |
Proportion Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life |
NQF#/Quality #: |
0213/455 |
Description: |
Proportion of patients who died from cancer admitted to the ICU in the last 30 days of life |
Measure Steward: |
American Society of Clinical Oncology |
Numerator: |
Patients who died from cancer and were admitted to the ICU in the last 30 days of life |
Denominator: |
Patients who died from cancer |
Exclusions: |
N/A |
Measure Type: |
Outcome |
Measure Domain: |
Effective Clinical Care |
Data Submission Method: |
Registry |
Rationale: |
CMS, as part of the CQMC, is finalizing its proposal to implement this measure to fulfill a set of condition-specific core measures. CMS believes the CQMC fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is finalized as a core measure to specifically address hospice and end of life metrics for medical oncology. Furthermore, CMS is utilizing its authority to finalize measures that were not reviewed by the Measures Application Partnership (MAP). |
Title |
Proportion Not Admitted to Hospice |
NQF#:/Quality # |
0215/456 |
Description: |
Proportion of patients who died from cancer not admitted to hospice |
Measure Steward: |
American Society of Clinical Oncology |
Numerator: |
Patients who died from cancer without being admitted to hospice |
Denominator: |
Patients who died from cancer |
Exclusions: |
N/A |
Process Type: |
Process |
Measure Domain: |
Effective Clinical Care |
Data Submission Method: |
Registry |
Rationale: |
CMS, as part of the CQMC, is finalizing its proposal to implement proposes this measure to fulfill a set of condition-specific core measures. CMS believes the CQMC fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is finalized as a core measure to specifically address hospice and end of life metrics for medical oncology. Furthermore, CMS is utilizing its authority to finalize measures that were not reviewed by the Measures Application Partnership (MAP). |
Title |
Proportion Admitted to Hospice for less than 3 days |
NQF#:/Quality # |
0216/457 |
Description: |
Proportion of patients who died from cancer, and admitted to hospice and spent less than 3 days there |
Measure Steward: |
American Society of Clinical Oncology |
Numerator: |
Patients who died from cancer and spent fewer than three days in hospice |
Denominator: |
Patients who died from cancer who were admitted to hospice |
Exclusions: |
N/A |
Measure Type: |
Outcome |
Measure Domain: |
Effective Clinical Care |
Data Submission Method: |
Registry |
Rationale: |
CMS, as part of the CQMC, is finalizing its proposal to implement this measure to fulfill a set of condition-specific core measures. CMS believes the CQMC fills measure gaps, condition-specific performance gaps and ensures the collaborative agreement between CMS and private health insurers. This measure is finalized as a core measure to specifically address hospice and end of life metrics for medical oncology. Furthermore, CMS is utilizing its authority to finalize measures that were not reviewed by the Measures Application Partnership (MAP). |
TABLE E: 2017 Finalized MIPS Specialty Measure Sets
[Discussion of CMS’S approach to adding previously identified cross-cutting measures to specialty measure sets.]
MIPS ID Number |
NQF/ PQRS |
CMS E-Measure ID |
Data Submission Method |
Measure Type |
National Quality Strategy Domain |
Measure Title and Description¥ |
Measure Steward |
|||||||
|
||||||||||||||
|
0041/110 |
147v6 |
Claims, Web Interface, Registry, EHR |
Process |
Community/ Population Health |
Preventive Care and Screening: Influenza Immunization
Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization |
Physician Consortium for Performance Improvement Foundation (PCPI®) |
|||||||
|
0043/111 |
127v5 |
Claims, Web Interface, Registry, EHR |
Process |
Community/ Population Health |
Pneumonia Vaccination Status for Older Adults
Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine |
National Committee for Quality Assurance |
|||||||
|
0419/130 |
68v6 |
Claims, Registry, EHR, |
Process |
Patient Safety |
Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration.
|
Centers for Medicare & Medicaid Services |
|||||||
* § |
0405/160 |
52v5 |
EHR |
Process |
Effective Clinical Care |
HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis
Percentage of patients aged 6 weeks and older with a diagnosis of HIV/AIDS who were prescribed Pneumocystis Jiroveci Pneumonia (PCP) prophylaxis |
National Committee for Quality Assurance |
|||||||
|
0028/ 226 |
138v5 |
Claims, Registry, EHR, ,Web Interface |
Process |
Community/Population Health |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user. |
Physician Consortium for Performance Improvement Foundation (PCPI®) |
|||||||
* |
N/A/317 |
22v5 |
Claims, Registry, EHR
|
Process |
Community/Population Health
|
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented:
Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.
|
Centers for Medicare & Medicaid Services |
|||||||
!! |
N/A/331 |
N/A |
Registry |
Process |
Efficiency and Cost Reduction |
Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse)
Percentage of patients, aged 18 years and older, with a diagnosis of acute sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms |
American Academy of Otolaryngology-Head and Neck Surgery |
|||||||
!! |
N/A/ 332 |
N/A |
Registry |
Process |
Efficiency and Cost Reduction
|
Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)
Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulante, as a first line antibiotic at the time of diagnosis |
American Academy of Otolaryngology-Head and Neck Surgery |
|||||||
!! |
N/A/ 333 |
N/A |
Registry |
Efficiency |
Efficiency and Cost Reduction |
Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse)
Percentage of patients aged 18 years and older with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis |
American Academy of Otolaryngology-Head and Neck Surgery
|
|||||||
!! |
N/A/ 334 |
N/A
|
Registry |
Efficiency |
Efficiency and Cost Reduction |
Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse)
Percentage of patients aged 18 years and older with a diagnosis of chronic sinusitis who had more than one CT scan of the paranasal sinuses ordered or received within 90 days after the date of diagnosis |
American Academy of Otolaryngology-Head and Neck Surgery |
|||||||
|
NA/ 374 |
50v5 |
EHR |
Process |
Communication and Care Coordination |
Closing the Referral Loop: Receipt of Specialist Report
Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred. |
Centers for Medicare & Medicaid Services |
|||||||
! |
N/A/ 398 |
N/A |
Registry |
Outcome |
Effective Clinical Care |
Optimal Asthma Control
Composite measure of the percentage of pediatric and adult patients whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools |
Minnesota Community Measurement |
|||||||
|
NA/ 402 |
NA |
Registry |
Process |
Community/ Population Health |
Tobacco Use and Help with Quitting Among Adolescents
The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user |
National Committee for Quality Assurance |
|||||||
+ § ! |
1799/ 444 |
NA |
Registry |
Process |
Efficiency and Cost Reduction |
Medication Management for People with Asthma (MMA):
The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment period. |
National Committee for Quality Assurance |
|||||||
Comments: We received multiple comments requesting CMS separate Rheumatology into a different specialty measure set as these two specialties are not similar and the measures do not align across.
Response: Based on the comments and the references within each comment, CMS agrees that these specialties should not share a specialty measure set. Therefore, CMS is finalizing Allergy and Immunology as a separate set from Rheumatology. Additionally, CMS has revised the measure set from the proposed set per the following changes: 1) Addition of previously identified cross-cutting measures that are relevant for the specialty set (#128, #130, #226, #317, #374, #402) and 2) Removal of rheumatoid arthritis measures that are not appropriate for the revised measure set (#176, #177, #178, #179, #337). CMS believes the finalized specialty set reflects the relevant measures appropriate for Allergy and Immunology specialties.
Final Decision: CMS is finalizing the Allergy/Immunology Specialty measure set as indicated in the table above.
|
||||||||||||||
|
MIPS ID Number |
NQF/ PQRS |
CMS E-Measure ID |
Data Submission Method |
Measure Type |
National Quality Strategy Domain |
Measure Title and Description¥ |
Measure Steward |
||||||
|
|
|||||||||||||
|
|
0236/044 |
N/A |
Registry |
Process |
Effective Clinical Care |
Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery
Percentage of isolated Coronary Artery Bypass Graft (CABG) surgeries for patients aged 18 years and older who received a beta-blocker within 24 hours prior to surgical incision |
Centers for Medicare & Medicaid Services |
||||||
|
! |
N/A/ 076 |
N/A |
Claims, Registry |
Process |
Patient Safety |
Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections
Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed |
American Society of Anesthesiologists |
||||||
|
|
0419/130 |
68v6 |
Claims, Registry, EHR, |
Process |
Patient Safety |
Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration. |
Centers for Medicare & Medicaid Services |
||||||
|
|
NA/ 317 |
22v5 |
Claims, Registry, EHR, |
Process |
Community/ Population Health |
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated. |
Centers for Medicare & Medicaid Services |
||||||
|
! |
N/A/ 404 |
N/A |
Registry |
Intermediate Outcome |
Effective Clinical Care |
Anesthesiology Smoking Abstinence
The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure. |
American Society of Anesthesiologists |
||||||
|
! |
2681/424 |
N/A |
Registry |
Outcome |
Patient Safety |
Perioperative Temperature Management
Percentage of patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time |
American Society of Anesthesiologists |
||||||
|
! |
N/A/ 426 |
N/A |
Registry |
Process |
Communication and Care Coordination |
Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU)
Percentage of patients, regardless of age, who are under the care of an anesthesia practitioner and are admitted to a PACU in which a post-anesthetic formal transfer of care protocol or checklist which includes the key transfer of care elements is utilized |
American Society of Anesthesiologists |
||||||
|
! |
N/A/ 427 |
N/A |
Registry |
Process |
Communication and Care Coordination |
Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU)
Percentage of patients, regardless of age, who undergo a procedure under anesthesia and are admitted to an Intensive Care Unit (ICU) directly from the anesthetizing location, who have a documented use of a checklist or protocol for the transfer of care from the responsible anesthesia practitioner to the responsible ICU team or team member |
American Society of Anesthesiologists |
||||||
|
! |
N/A/ 430 |
N/A |
Registry |
Process |
Patient Safety |
Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy
Percentage of patients, aged 18 years and older, who undergo a procedure under an inhalational general anesthetic, AND who have three or more risk factors for post-operative nausea and vomiting (PONV), who receive combination therapy consisting of at least two prophylactic pharmacologic antiemetic agents of different classes preoperatively or intraoperatively |
American Society of Anesthesiologists |
||||||
|
Comments: Although CMS did not receive specific comments regarding changes to the Anesthesiology specialty measure set, we did receive comments that supported CMS’s decision to add the Anesthesiology measure set.
Response: We thank the commenters for their support. Additionally, CMS has revised the measure set from the proposed set per the following changes: 1) Addition of previously identified cross-cutting measures that are relevant for the specialty set (#128, #130, #317, #321) CMS believes the finalized specialty set reflects the relevant measures appropriate for the Anesthesiology specialty.
Final Decision: CMS is finalizing the Anesthesiology specialty measure set as indicated in the table above. |
|||||||||||||
MIPS ID Number |
NQF/ PQRS |
CMS E-Measure ID |
Data Submission Method |
Measure Type |
National Quality Strategy Domain |
Measure Title and Description¥ |
Measure Steward |
|
|||||||
§ |
0081/005 |
135v5 |
Registry, EHR |
Process |
Effective Clinical Care |
Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge |
Physician Consortium for Performance Improvement (PCPI®) Foundation |
* § |
0067/006 |
N/A |
Registry |
Process |
Effective Clinical Care |
Chronic Stable Coronary Artery Disease: Antiplatelet Therapy
Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12 month period who were prescribed aspirin or clopidogrel |
American Heart Association |
§ |
0070/007 |
145v5 |
Registry, EHR |
Process |
Effective Clinical Care |
Coronary Artery Disease (CAD): Beta-Blocker Therapy—Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)
Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have prior MI OR a current or prior LVEF < 40% who were prescribed beta-blocker therapy |
Physician Consortium for Performance Improvement Foundation (PCPI®) |
* § |
0083/008 |
144v5 |
Registry, EHR |
Process |
Effective Clinical Care |
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge |
Physician Consortium for Performance Improvement Foundation (PCPI®) |
|
0326/ 047 |
N/A |
Claims, Registry |
Process |
Communication and Care Coordination |
Care Plan
Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan. |
National Committee for Quality Assurance |
* § |
0066/118 |
N/A |
Registry |
Process |
Effective Clinical Care |
Chronic Stable Coronary Artery Disease: ACE Inhibitor or ARB Therapy--Diabetes or Left Ventricular Systolic Dysfunction (LVEF <40%)
Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy |
American Heart Association |
|
0421/128 |
69v5 |
Claims, Registry, EHR, Web Interface |
Process |
Community/ Population Health |
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter |
Centers for Medicare & Medicaid Services |
|
0419/130 |
68v6 |
Claims, Registry, EHR, |
Process |
Patient Safety |
Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration. |
Centers for Medicare & Medicaid Services |
* § |
0068/204 |
164v5 |
Claims, Web Interface, Registry, EHR |
Process |
Effective Clinical Care |
Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet
Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antiplatelet during the measurement period. |
National Committee for Quality Assurance |
|
0028/ 226 |
138v5 |
Claims, Registry, EHR, ,Web Interface |
Process |
Community/Population Health |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user. |
Physician Consortium for Performance Improvement Foundation (PCPI®) |
|
0018/ 236 |
165v5 |
Claims, Registry, EHR, Web Interface |
Intermediate Outcome |
Effective Clinical Care |
Controlling High Blood Pressure
Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90 mmHg) during the measurement period |
National Committee for Quality Assurance |
|
NA/ 317 |
22v5 |
Claims, Registry, EHR, |
Process |
Community/ Population Health |
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated. |
Centers for Medicare & Medicaid Services |
!! |
N/A/ 322 |
N/A |
Registry |
Efficiency |
Efficiency and Cost Reduction |
Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients
Percentage of stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), or cardiac magnetic resonance (CMR) performed in low risk surgery patients 18 years or older for preoperative evaluation during the 12-month reporting period |
American College of Cardiology |
!! |
N/A/ 323 |
N/A |
Registry |
Efficiency |
Efficiency and Cost Reduction |
Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI)
Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in patients aged 18 years and older routinely after percutaneous coronary intervention (PCI), with reference to timing of test after PCI and symptom status |
American College of Cardiology |
!! |
N/A/ 324 |
N/A |
Registry |
Efficiency |
Efficiency and Cost Reduction |
Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients
Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in asymptomatic, low coronary heart disease (CHD) risk patients 18 years and older for initial detection and risk assessment |
American College of Cardiology |
§ |
1525/326 |
N/A
|
Claims, Registry |
Process |
Effective Clinical Care |
Chronic Anticoagulation Therapy
Percentage of patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation (AF) or atrial flutter whose assessment of the specified thromboembolic risk factors indicate one or more high-risk factors or more than one moderate risk factor, as determined by CHADS2 risk stratification, who are prescribed warfarin OR another oral anticoagulant drug that is FDA approved for the prevention of thromboembolism |
American College of Cardiology |
|
NA/ 374 |
50v5 |
EHR |
Process |
Communication and Care Coordination |
Closing the Referral Loop: Receipt of Specialist Report
Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred. |
Centers for Medicare & Medicaid Services |
|
NA/ 402 |
NA |
Registry |
Process |
Community/ Population Health |
Tobacco Use and Help with Quitting Among Adolescents
The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user |
National Committee for Quality Assurance |
|
2152/ 431 |
NA |
Registry |
Process |
Community/ Population Health |
Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user. |
Physician Consortium for Performance Improvement Foundation (PCPI®)
|
|
N/A/438 |
N/A |
Web Interface, Registry |
Process |
Effective Clinical Care |
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
Percentage of the following patients—all considered at high risk of cardiovascular events—who were prescribed or were on statin therapy during the measurement period: • Adults aged ≥ 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR • Adults aged ≥21 years with a fasting or direct low-density lipoprotein cholesterol (LDL-C) level ≥ 190 mg/dL; OR • Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL
|
Centers for Medicare & Medicaid Services |
3a. Electrophysiology Cardiac Specialist |
|||||||
! |
N/A/ 348 |
N/A |
Registry |
Outcome |
Patient Safety |
HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate
Patients with physician-specific risk-standardized rates of procedural complications following the first time implantation of an ICD
|
The Heart Rhythm Society |
! |
2474/392 |
N/A |
Registry |
Outcome |
Patient Safety |
HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation
Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation
This measure is reported as four rates stratified by age and gender: • Reporting Age Criteria 1: Females less than 65 years of age • Reporting Age Criteria 2: Males less than 65 years of age • Reporting Age Criteria 3: Females 65 years of age and older • Reporting Age Criteria 4: Males 65 years of age and older |
The Heart Rhythm Society |
! |
N/A/ 393 |
N/A |
Registry |
Outcome |
Patient Safety |
HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision
Infection rate following CIED device implantation, replacement, or revision |
The Heart Rhythm Society |
CMS did not receive specific comments regarding changes to the Cardiology specialty measure set.
Response: We have revised the measure set from the proposed set by adding previously identified cross-cutting measures that are relevant for the specialty set (#047, #128, #130, #226, #236, #317, #374, #402, and #431). CMS believes the finalized specialty set reflects the relevant measures appropriate for the Cardiology specialty
Final Decision: CMS is finalizing the Cardiology specialty measure set as indicated in the table above. |
|||||||
MIPS ID Number |
NQF/ PQRS |
CMS E-Measure ID |
Data Submission Method |
Measure Type |
National Quality Strategy Domain |
Measure Title and Description¥ |
Measure Steward |
||||
|
|||||||||||
|
0326/ 047 |
N/A |
Claims, Registry |
Process |
Communication and Care Coordination |
Care Plan
Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan. |
National Committee for Quality Assurance |
||||
|
0421/128 |
69v5 |
Claims, Registry, EHR, Web Interface |
Process |
Community/ Population Health |
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter |
Centers for Medicare & Medicaid Services |
||||
|
0419/130 |
68v6 |
Claims, Registry, EHR, |
Process |
Patient Safety |
Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration. |
Centers for Medicare & Medicaid Services |
||||
§ !!
|
0659/185 |
N/A |
Claims, Registry |
Process |
Communication and Care Coordination |
Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use
Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior adenomatous polyp(s) in previous colonoscopy findings, who had an interval of 3 or more years since their last colonoscopy |
Gastroenterological Association/ 'American Society for Gastrointestinal Endoscopy/ American College of Gastroenterology |
||||
|
0028/ 226 |
138v5 |
Claims, Registry, EHR, ,Web Interface |
Process |
Community/Population Health |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user. |
Physician Consortium for Performance Improvement Foundation (PCPI®) |
||||
§ |
N/A/271 |
N/A |
Registry |
Process |
Effective Clinical Care |
Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury – Bone Loss Assessment:
Percentage of patients aged 18 years and older with an inflammatory bowel disease encounter who were prescribed prednisone equivalents greater than or equal to 10 mg/day for 60 or greater consecutive days or a single prescription equating to 600mg prednisone or greater for all fills and were documented for risk of bone loss once during the reporting year or the previous calendar year.
|
American Gastroenterological Association |
||||
|
N/A/275 |
N/A |
Registry |
Process |
Effective Clinical Care |
Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy: Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status assessed and results interpreted within one year prior to receiving a first course of anti-TNF (tumor necrosis factor) therapy.
|
American Gastroenterological Association |
||||
* |
N/A/317 |
22v5 |
Claims, Registry, EHR
|
Process |
Community/Population Health
|
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented: Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.
|
Centers for Medicare & Medicaid Services |
||||
§ !! |
0658/320 |
N/A |
Claims, Registry |
Process |
Communication and Care Coordination |
Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients
Percentage of patients aged 50 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report |
American Gastroenterological Association/ 'American Society for Gastrointestinal Endoscopy/ American College of Gastroenterology |
||||
§ ! |
N/A/ 343 |
N/A |
Registry |
Outcome |
Effective Clinical Care |
Screening Colonoscopy Adenoma Detection Rate Measure
The percentage of patients age 50 years or older with at least one conventional adenoma or colorectal cancer detected during screening colonoscopy |
American College of Gastroenterology |
||||
|
NA/ 374 |
50v5 |
EHR |
Process |
Communication and Care Coordination |
Closing the Referral Loop: Receipt of Specialist Report
Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred. |
Centers for Medicare & Medicaid Services |
||||
! |
N/A/ 390 |
N/A |
Registry |
Process |
Person and Caregiver-Centered Experience and Outcomes |
Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options
Percentage of patients aged 18 years and older with a diagnosis of hepatitis C with whom a physician or other qualified healthcare professional reviewed the range of treatment options appropriate to their genotype and demonstrated a shared decision making approach with the patient
To meet the measure, there must be documentation in the patient record of a discussion between the physician or other qualified healthcare professional and the patient that includes all of the following: treatment choices appropriate to genotype, risks and benefits, evidence of effectiveness, and patient preferences toward treatment |
American Gastroenterological Association/American Society for Gastrointestinal Endoscopy/American College of Gastroenterology |
||||
§ |
N/A/401 |
N/A |
Registry |
Process |
Effective Clinical Care |
Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis
Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12 month reporting period
|
American Gastroenterological Association/ American Society for Gastrointestinal Endoscopy/American College of Gastroenterology |
||||
|
NA/ 402 |
NA |
Registry |
Process |
Community/ Population Health |
Tobacco Use and Help with Quitting Among Adolescents
The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user |
National Committee for Quality Assurance |
||||
|
2152/431 |
NA |
Registry |
Process |
Community/ Population Health |
Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user. |
Physician Consortium for Performance Improvement Foundation (PCPI®)
|
||||
§ !! |
N/A/ 439 |
N/A |
Registry |
Efficiency |
Efficiency and Cost Reduction |
Age Appropriate Screening Colonoscopy
The percentage of patients greater than 85 years of age who received a screening colonoscopy from January 1 to December 31 |
American Gastroenterological Association/ American Society for Gastrointestinal Endoscopy/ American College of Gastroenterology |
||||
Comments: CMS received several specific comments regarding changes to the Gastroenterology specialty measure set. For instance, several commenters requested that Inflammatory Bowel Disease (IBD) measures (#271, #275) be added to the measure set because they are applicable to gastroenterology specialty. Another commenter recommended removal of #113 as these patients are usually screened by the primary care provider and referred to the specialist after screening.
Response: In response to the comments, CMS has revised the measure set from the proposed set with the following changes: 1) addition of previously identified cross-cutting measures that are relevant for the specialty set (#047, #128, #130, #226, #317, #374, #402, #431), , 2) removal of #113 per the commenter’s recommendation as we agree with their assessment, and 3) addition of IBD measures per the commenters’ recommendation as they are applicable to the Gastroenterology specialty (#271, #275). CMS believes the finalized specialty set reflects the relevant measures appropriate for the Gastroenterology specialty.
Final Decision: CMS is finalizing the Gastroenterology specialty measure set as indicated in the table above. |
|||||||||||
MIPS ID Number |
NQF/ PQRS |
CMS E-Measure ID |
Data Submission Method |
Measure Type |
National Quality Strategy Domain |
Measure Title and Description¥ |
Measure Steward |
|
|||||||
|
0419/130 |
68v6 |
Claims, Registry, EHR, |
Process |
Patient Safety |
Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration. |
Centers for Medicare & Medicaid Services |
! |
0650/ 137 |
N/A |
Registry |
Structure |
Communication and Care Coordination |
Melanoma: Continuity of Care – Recall System
Percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered, at least once within a 12 month period, into a recall system that includes:
|
American Academy of Dermatology |
! |
N/A/ 138 |
N/A |
Registry |
Process |
Communication and Care Coordination |
Melanoma: Coordination of Care
Percentage of patients visits, regardless of age, with a new occurrence of melanoma, who have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis |
American Academy of Dermatology |
!! |
0562/ 224 |
N/A |
Registry |
Process |
Efficiency and Cost Reduction |
Melanoma: Overutilization of Imaging Studies in Melanoma
Percentage of patients, regardless of age, with a current diagnosis of stage 0 through IIC melanoma or a history of melanoma of any stage, without signs or symptoms suggesting systemic spread, seen for an office visit during the one-year measurement period, for whom no diagnostic imaging studies were ordered. |
American Academy of Dermatology |
|
0028/ 226 |
138v5 |
Claims, Registry, EHR, ,Web Interface |
Process |
Community/Population Health |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user. |
Physician Consortium for Performance Improvement Foundation (PCPI®) |
! |
N/A/ 265 |
N/A |
Registry |
Process |
Communication and Care Coordination |
Biopsy Follow-Up
Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient by the performing physician |
American Academy of Dermatology |
* |
N/A/317 |
22v5 |
Claims, Registry, EHR |
Process
|
Community/Population Health
|
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.
|
Centers for Medicare & Medicaid Services |
|
N/A/ 337 |
N/A |
Registry |
Process |
Effective Clinical Care |
Tuberculosis (TB) Prevention for Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier
Percentage of patients whose providers are ensuring active tuberculosis prevention either through yearly negative standard tuberculosis screening tests or are reviewing the patient’s history to determine if they have had appropriate management for a recent or prior positive test |
American Academy of Dermatology |
|
NA/ 374 |
50v5 |
EHR |
Process |
Communication and Care Coordination |
Closing the Referral Loop: Receipt of Specialist Report
Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred. |
Centers for Medicare & Medicaid Services |
|
NA/ 402 |
NA |
Registry |
Process |
Community/ Population Health |
Tobacco Use and Help with Quitting Among Adolescents
The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user |
National Committee for Quality Assurance |
! |
N/A/ 410 |
|
Registry |
Outcome |
Person and Caregiver Centered Experience and Outcomes |
Psoriasis: Clinical Response to Oral Systemic or Biologic Medications
Percentage of psoriasis patients receiving oral systemic or biologic therapy who meet minimal physician- or patient-reported disease activity levels. It is implied that establishment and maintenance of an established minimum level of disease control as measured by physician- and/or patient-reported outcomes will increase patient satisfaction with and adherence to treatment. |
American Academy of Dermatology |
Comment: Although CMS received a comment requesting that CMS remove two measures from the specialty measure set, the commenter did not specifically identify which two measures were inappropriate for the Dermatology specialty measure set.
Response: CMS reviewed the measure set for its relevance to dermatology. CMS has revised the measure set from the proposed set by adding previously identified cross-cutting measures that are relevant for the specialty set (#130, #226, #317, #374, #402) CMS believes the finalized specialty set reflects the relevant measures appropriate for the dermatology specialty.
Final Decision: CMS is finalizing the Dermatology specialty measure set as indicated in the table above.
|
|||||||
MIPS ID Number |
NQF/ PQRS |
CMS E-Measure ID |
Data Submission Method |
Measure Type |
National Quality Strategy Domain |
Measure Title and Description¥ |
Measure Steward |
|
|||||||
|
0326/ 047 |
N/A |
Claims, Registry |
Process |
Communication and Care Coordination |
Care Plan
Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
|
National Committee for Quality Assurance |
* !! |
N/A/ 066 |
146v5 |
Registry, EHR |
Process |
Efficiency and Cost Reduction |
Appropriate Testing for Children with Pharyngitis
Percentage of children 3-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode |
National Committee for Quality Assurance |
!! |
0653/ 091 |
N/A |
Claims, Registry |
Process |
Effective Clinical Care |
Acute Otitis Externa (AOE): Topical Therapy
Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations |
American Academy of Otolaryngology-Head and Neck Surgery |
!! |
0654/ 093 |
N/A |
Claims, Registry |
Process |
Efficiency and Cost Reduction |
Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use
Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy |
American Academy of Otolaryngology-Head and Neck Surgery |
§ !! |
0058/ 116 |
N/A |
Registry |
Process |
Efficiency and Cost Reduction |
Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis: Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription |
National Committee for Quality Assurance |
|
0419/130 |
68v6 |
Claims, Registry, EHR, |
Process |
Patient Safety |
Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration. |
Centers for Medicare & Medicaid Services |
|
0028/ 226 |
138v5 |
Claims, Registry, EHR, ,Web Interface |
Process |
Community/Population Health |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user. |
Physician Consortium for Performance Improvement Foundation (PCPI®) |
|
0651/ 254 |
N/A |
Claims, Registry |
Process |
Effective Clinical Care |
Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain
Percentage of pregnant female patients aged 14 to 50 who present to the emergency department (ED) with a chief complaint of abdominal pain or vaginal bleeding who receive a trans-abdominal or trans-vaginal ultrasound to determine pregnancy location |
American College of Emergency Physicians |
|
N/A/ 255 |
N/A |
Claims, Registry |
Process |
Effective Clinical Care |
Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure
Percentage of Rh-negative pregnant women aged 14-50 years at risk of fetal blood exposure who receive Rh-Immunoglobulin (Rhogam) in the emergency department (ED) |
American College of Emergency Physicians |
* |
N/A/317 |
22v5 |
Claims, Registry, EHR |
Process
|
Community/Population Health
|
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.
|
Centers for Medicare & Medicaid Services |
|
NA/ 374 |
50v5 |
EHR |
Process |
Communication and Care Coordination |
Closing the Referral Loop: Receipt of Specialist Report
Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred. |
Centers for Medicare & Medicaid Services |
|
NA/ 402 |
NA |
Registry |
Process |
Community/ Population Health |
Tobacco Use and Help with Quitting Among Adolescents
The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user |
National Committee for Quality Assurance |
! |
N/A/ 415 |
N/A |
Claims, Registry |
Efficiency |
Efficiency and Cost Reduction |
Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older
Percentage of emergency department visits for patients aged 18 years and older who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT. |
American College of Emergency Physicians |
!! |
N/A/ 416 |
N/A |
Claims, Registry |
Efficiency |
Efficiency and Cost Reduction |
Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 through 17 Years
Percentage of emergency department visits for patients aged 2 through 17 years who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the Pediatric Emergency Care Applied Research Network prediction rules for traumatic brain injury |
American College of Emergency Physicians
|
|
2152/431 |
NA |
Registry |
Process |
Community/ Population Health |
Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user. |
Physician Consortium for Performance Improvement Foundation (PCPI®)
|
Comments: CMS received a comment to remove #254 and #255 from the measure set because the commenter believed reporting the measures would be burdensome for clinicians.
Response: CMS believes these measures should remain in the specialty measure set because we believe the measure is applicable to some emergency medicine clinicians. We want to keep these measures available, but as discussed in section II.E.5.b of this final rule with comment period, clinicians are not required to report on every measure in this set, only 6 of them. Additionally, CMS has revised the measure set from the proposed set by adding previously identified cross-cutting measures that are relevant for the specialty set (#047, #130, #226, #317, #374, #402, and #431). Finally, CMS also removed measure #414 from the measure set as this measure is not reflective of emergency medicine routine service and the measure does not include ED codes within the denominator. CMS believes the finalized specialty set reflects the relevant measures appropriate for the emergency medicine specialty.
Final Decision: CMS is finalizing the Emergency specialty measure set as indicated in the table above. |
|||||||
MIPS ID Number |
NQF/ PQRS |
CMS E-Measure ID |
Data Submission Method |
Measure Type |
National Quality Strategy Domain |
Measure Title and Description¥ |
Measure Steward |
|
|||||||
* § ! |
0059/001 |
122v5 |
Claims, Web Interface, Registry, EHR |
Intermediate Outcome |
Effective Clinical Care |
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period |
National Committee for Quality Assurance |
§ |
0081/005 |
135v5 |
Registry, EHR |
Process |
Effective Clinical Care |
Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge |
Physician Consortium for Performance Improvement (PCPI®) Foundation |
§ |
0070/007 |
145v5 |
Registry, EHR |
Process |
Effective Clinical Care |
Coronary Artery Disease (CAD): Beta-Blocker Therapy—Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)
Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have prior MI OR a current or prior LVEF < 40% who were prescribed beta-blocker therapy |
Physician Consortium for Performance Improvement Foundation (PCPI®) |
* § |
0083/008 |
144v5 |
Registry, EHR |
Process |
Effective Clinical Care |
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge |
Physician Consortium for Performance Improvement Foundation (PCPI®) |
|
105/ 009 |
128v5 |
EHR |
Process |
Effective Clinical Care |
Anti-Depressant Medication Management
Percentage of patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on antidepressant medication treatment. Two rates are reported a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks) b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months) |
National Committee for Quality Assurance |
|
0326/ 047 |
N/A |
Claims, Registry |
Process |
Communication and Care Coordination |
Care Plan
Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
|
National Committee for Quality Assurance |
! |
N/A/ 050 |
N/A |
Claims, Registry |
Process |
Person and Caregiver-Centered Experience and Outcomes |
Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older
Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months |
National Committee for Quality Assurance |
!! |
0069/065 |
154v5 |
Registry, EHR |
Process |
Efficiency and Cost Reduction |
Appropriate Treatment for Children with Upper Respiratory Infection (URI)
Percentage of children 3 months through 18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode |
National Committee for Quality Assurance |
* !! |
N/A/066 |
146v5 |
Registry, EHR |
Process |
Efficiency and Cost Reduction |
Appropriate Testing for Children with Pharyngitis
Percentage of children 3-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode |
National Committee for Quality Assurance |
!! |
0654/093 |
N/A |
Claims, Registry |
Process |
Efficiency and Cost Reduction |
Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use
Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy |
American Academy of Otolaryngology-Head and Neck Surgery |
! |
N/A/ 109 |
N/A |
Claims, Registry |
Process |
Person and Caregiver-Centered Experience and Outcomes |
Osteoarthritis (OA): Function and Pain Assessment
Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain |
American Academy of Orthopedic Surgeons |
|
0041/110 |
147v6 |
Claims, Web Interface, Registry, EHR |
Process |
Community/ Population Health |
Preventive Care and Screening: Influenza Immunization
Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization |
Physician Consortium for Performance Improvement Foundation (PCPI®) |
* § |
2372/112 |
125v5 |
Claims, Web Interface, Registry, EHR |
Process |
Effective Clinical Care |
Breast Cancer Screening
Percentage of women 50 -74 years of age who had a mammogram to screen for breast cancer |
National Committee for Quality Assurance |
§ |
0034/113 |
130v5 |
Claims, Web Interface, Registry, EHR |
Process |
Effective Clinical Care |
Colorectal Cancer Screening
Percentage of patients 50 - 75 years of age who had appropriate screening for colorectal cancer |
National Committee for Quality Assurance |
§ !! |
0058/116 |
N/A |
Registry |
Process |
Efficiency and Cost Reduction |
Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis: Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription |
National Committee for Quality Assurance |
§ |
0055/117 |
131v5 |
Claims, Web Interface, Registry, EHR |
Process |
Effective Clinical Care |
Diabetes: Eye Exam
Percentage of patients 18 - 75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal exam (no evidence of retinopathy) in the 12 months prior to the measurement period |
National Committee for Quality Assurance |
* § |
0062/119 |
134v4 |
Registry, EHR
|
Process |
Effective Clinical Care |
Diabetes: Medical Attention for Nephropathy: The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period
Rationale: CMS is finalizing MIPS #119 for 2017 Performance Period.
|
National Committee for Quality Assurance |
|
0421/128 |
69v5 |
Claims, Registry, EHR, Web Interface |
Process |
Community/ Population Health |
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter |
Centers for Medicare & Medicaid Services |
|
0419/130 |
68v6 |
Claims, Registry, EHR, |
Process |
Patient Safety |
Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration. |
Centers for Medicare & Medicaid Services |
* |
0418/134 |
2v6
|
Claims, Web Interface, Registry, EHR |
Process |
Community/ Population Health |
Preventive Care and Screening: Screening for Depression and Follow-Up Plan
Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen |
Centers for Medicare & Medicaid Services |
! |
0101/154 |
N/A |
Claims, Registry |
Process |
Patient Safety |
Falls: Risk Assessment
Percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls completed within 12 months |
National Committee for Quality Assurance |
! |
0101/155 |
N/A |
Claims, Registry |
Process |
Communication and Care Coordination |
Falls: Plan of Care
Percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months |
National Committee for Quality Assurance |
* § |
0056/163 |
123v5 |
EHR |
Process |
Effective Clinical Care |
Comprehensive Diabetes Care: Foot Exam
The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a foot exam (visual inspection and sensory exam with mono filament and a pulse exam) during the measurement year |
National Committee for Quality Assurance |
! |
NA/ 181 |
N/A |
Claims, Registry |
Process |
Patient Safety |
Elder Maltreatment Screen and Follow-Up Plan
Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening Tool on the date of encounter AND a documented follow-up plan on the date of the positive screen |
Centers for Medicare & Medicaid Services |
* § |
0068/204 |
164v5 |
Claims, Web Interface, Registry, EHR |
Process |
Effective Clinical Care |
Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet
Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antiplatelet during the measurement period |
National Committee for Quality Assurance |
|
0028/ 226 |
138v5 |
Claims, Registry, EHR, ,Web Interface |
Process |
Community/Population Health |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user. |
Physician Consortium for Performance Improvement Foundation (PCPI®) |
|
0018/ 236 |
165v5 |
Claims, Registry, EHR, Web Interface |
Intermediate Outcome |
Effective Clinical Care |
Controlling High Blood Pressure
Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90 mmHg) during the measurement period |
National Committee for Quality Assurance |
* § |
0032/309 |
124v5 |
EHR |
Process |
Effective Clinical Care |
Cervical Cancer Screening
Percentage of women 21–64 years of age who were screened for cervical cancer using either of the following criteria: • Women age 21–64 who had cervical cytology performed every 3 years • Women age 30–64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years
|
National Committee for Quality Assurance |
§ !! |
0052/312 |
166v6 |
EHR |
Process |
Efficiency and Cost Reduction |
Use of Imaging Studies for Low Back Pain
Percentage of patients 18-50 years of age with a diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis |
National Committee for Quality Assurance |
* |
N/A/317 |
22v5 |
Claims, Registry, EHR |
Process
|
Community/Population Health
|
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.
|
Centers for Medicare & Medicaid Services |
§ ! |
0005 & 0006/321 |
N/A |
CMS-approved Survey Vendor |
Patient Engagement/Experience |
Person and Caregiver-Centered Experience and Outcomes |
CAHPS for MIPS Clinician/Group Survey:
Summary Survey Measures may include: • Getting Timely Care, Appointments, and Information; • How well Providers Communicate; • Patient’s Rating of Provider; • Access to Specialists; • Health Promotion and Education; • Shared Decision-Making; • Health Status and Functional Status; • Courteous and Helpful Office Staff; • Care Coordination; • Between Visit Communication; • Helping You to Take Medication as Directed; and • Stewardship of Patient Resources.
|
|
§ |
1525/326 |
N/A |
Claims, Registry |
Process |
Effective Clinical Care |
Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy
Percentage of patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation (AF) or atrial flutter whose assessment of the specified thromboembolic risk factors indicate one or more high-risk factors or more than one moderate risk factor, as determined by CHADS2 risk stratification, who are prescribed warfarin OR another oral anticoagulant drug that is FDA approved for the prevention of thromboembolism |
American College of Cardiology |
!! |
N/A/ 331 |
N/A |
Registry |
Process |
Efficiency and Cost Reduction |
Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse)
Percentage of patients, aged 18 years and older, with a diagnosis of acute sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms |
American Academy of Otolaryngology-Head and Neck Surgery |
!! |
N/A/ 332 |
N/A |
Registry |
Process |
Efficiency and Cost Reduction |
Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)
Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulante, as a first line antibiotic at the time of diagnosis |
American Academy of Otolaryngology-Head and Neck Surgery |
!! |
N/A/ 333 |
N/A |
Registry |
Efficiency |
Efficiency and Cost Reduction |
Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse)
Percentage of patients aged 18 years and older with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis |
American Academy of Otolaryngology-Head and Neck Surgery |
!! |
N/A/ 334 |
N/A |
Registry |
Efficiency |
Efficiency and Cost Reduction |
Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse)
Percentage of patients aged 18 years and older with a diagnosis of chronic sinusitis who had more than one CT scan of the paranasal sinuses ordered or received within 90 days after the date of diagnosis |
American Academy of Otolaryngology-Head and Neck Surgery |
|
N/A/ 337 |
N/A |
Registry |
Process |
Effective Clinical Care |
Tuberculosis (TB) Prevention for Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier
Percentage of patients whose providers are ensuring active tuberculosis prevention either through yearly negative standard tuberculosis screening tests or are reviewing the patient’s history to determine if they have had appropriate management for a recent or prior positive test |
American Academy of Dermatology |
* § ! |
2082/338 |
N/A |
Registry |
Outcome |
Effective Clinical Care |
HIV Viral Load Suppression
The percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year |
Health Resources and Services Administration |
! |
N/A/ 342 |
N/A |
Registry |
Outcome |
Person and Caregiver-Centered Experience and Outcomes |
Pain Brought Under Control Within 48 Hours
Patients aged 18 and older who report being uncomfortable because of pain at the initial assessment (after admission to palliative care services) who report pain was brought to a comfortable level within 48 hours |
National Hospice and Palliative Care Organization |
* § ! |
0710/370 |
159v5 |
Web Interface, Registry, EHR |
Outcome
|
Effective Clinical Care |
Depression Remission at Twelve Months:
Patients age 18 and older with major depression or dysthymia and an initial Patient Health Questionnaire (PHQ-9) score greater than nine who demonstrate remission at twelve months (+/- 30 days after an index visit) defined as a PHQ-9 score less than five. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment.
|
Minnesota Community Measurement |
|
N/A/ 387 |
N/A |
Registry |
Process |
Effective Clinical Care |
Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users
Percentage of patients regardless of age who are active injection drug users who received screening for HCV infection within the 12 month reporting period |
Physician Consortium for Performance Improvement Foundation (PCPI®) |
|
1407/394 |
N/A |
Registry |
Process |
Community/ Population Health |
Immunizations for Adolescents
The percentage of adolescents 13 years of age who had the recommended immunizations by their 13th birthday |
National Committee for Quality Assurance |
! |
N/A/ 398 |
N/A |
Registry |
Outcome |
Effective Clinical Care |
Optimal Asthma Control
Composite measure of the percentage of pediatric and adult patients whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools |
Minnesota Community Measurement |
§ |
N/A/ 400 |
N/A |
Registry |
Process |
Effective Clinical Care |
One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk
Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis OR birthdate in the years 1945-1965 who received one-time screening for hepatitis C virus (HCV) infection |
Physician Consortium for Performance Improvement Foundation (PCPI®) |
§ |
N/A/401 |
N/A |
Registry |
Process |
Effective Clinical Care |
Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis
Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12 month reporting period |
American Gastroenterological Association/ American Society for Gastrointestinal Endoscopy/American College of Gastroenterology |
|
NA/ 402 |
NA |
Registry |
Process |
Community/ Population Health |
Tobacco Use and Help with Quitting Among Adolescents
The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user |
National Committee for Quality Assurance |
|
N/A/ 408 |
N/A |
Registry |
Process |
Effective Clinical Care |
Opioid Therapy Follow-up Evaluation
All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record |
American Academy of Neurology |
|
N/A/ 412 |
N/A |
Registry |
Process |
Effective Clinical Care |
Documentation of Signed Opioid Treatment Agreement
All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record |
American Academy of Neurology |
|
N/A/ 414 |
N/A |
Registry |
Process |
Effective Clinical Care |
Evaluation or Interview for Risk of Opioid Misuse
All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAAP-R) or patient interview documented at least once during Opioid Therapy in the medical record |
American Academy of Neurology |
|
0053/418 |
N/A |
Claims, Registry |
Process |
Effective Clinical Care |
Osteoporosis Management in Women Who Had a Fracture
The percentage of women age 50-85 who suffered a fracture and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis in the six months after the fracture |
National Committee for Quality Assurance |
|
2152/431 |
NA |
Registry |
Process |
Community/ Population Health |
Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user. |
Physician Consortium for Performance Improvement Foundation (PCPI®)
|
|
N/A/438 |
N/A |
Web Interface, Registry |
Process |
Effective Clinical Care |
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
Percentage of the following patients—all considered at high risk of cardiovascular events—who were prescribed or were on statin therapy during the measurement period: • Adults aged ≥ 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR • Adults aged ≥21 years with a fasting or direct low-density lipoprotein cholesterol (LDL-C) level ≥ 190 mg/dL; OR • Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL |
Centers for Medicare & Medicaid Services |
+ § |
0071/442 |
N/A |
Registry
|
Process
|
Effective Clinical Care |
Persistent Beta Blocker Treatment After a Heart Attack
The percentage of patients 18 years of age and older during the measurement year who were hospitalized and discharged from July 1 of the year prior to the measurement year to June 30 of the measurement year with a diagnosis of acute myocardial infarction (AMI) and who received were prescribed persistent beta-blocker treatment for six months after discharge |
National Committee for Quality Assurance |
+ § !! |
N/A/443 |
N/A |
Registry |
Process |
Patient Safety |
Non-Recommended Cervical Cancer Screening in Adolescent Females
The percentage of adolescent females 16–20 years of age screened unnecessarily for cervical cancer |
National Committee for Quality Assurance |
+ § ! |
1799/444 |
NA |
Registry |
Process |
Efficiency and Cost Reduction |
Medication Management for People with Asthma (MMA):
The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment period. |
National Committee for Quality Assurance |
Comments: CMS received specific comments to add several individual measures and cross-cutting measures to the measure set because the commenters believed the additional measures were appropriate for providers within the general practice and family medicine specialties. Commenters specifically asked that measures #007, #008, #046, #047, #110, #119, #163, #204, #226, #236, #309, #321, #370, #442, #443 and #444 be added to the measure set.
Response: Upon further review of the recommendations provided by commenters, CMS has revised the measure set from the proposed set by adding these relevant measures to the measures set (#007,# 008, #047, # 110, # 119, #163, #204, #226, #309, #321, #370, #442, #443, and #444). CMS did not include measure #46 in the General Practice measure set because we are including measure #130, a cross-cutting measure, which is closely related to this measure, to the set. In addition, CMS has added previously identified cross-cutting measures that are relevant for the specialty set (#047, #128, #130, #226, #317, #402, and #431). CMS believes the finalized specialty set reflects the relevant measures appropriate for the family medicine/general practice specialty.
Final Decision: CMS is finalizing the general practice and family medicine specialty measure set as indicated in the table above.
|
|||||||
MIPS ID Number |
NQF/ PQRS |
CMS E-Measure ID |
Data Submission Method |
Measure Type |
National Quality Strategy Domain |
Measure Title and Description¥ |
Measure Steward |
|
|||||||
* § ! |
0059/001 |
122v5 |
Claims, Web Interface, Registry, EHR |
Intermediate Outcome |
Effective Clinical Care |
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period |
National Committee for Quality Assurance |
§ |
0081/005 |
135v5 |
Registry, EHR |
Process |
Effective Clinical Care |
Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge |
Physician Consortium for Performance Improvement (PCPI®) Foundation |
|
105/ 009 |
128v5 |
EHR |
Process |
Effective Clinical Care |
Anti-Depressant Medication Management
Percentage of patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on antidepressant medication treatment. Two rates are reported a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks) b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months) |
National Committee for Quality Assurance |
|
0326/ 047 |
N/A |
Claims, Registry |
Process |
Communication and Care Coordination |
Care Plan
Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
|
National Committee for Quality Assurance |
! |
N/A/ 050 |
N/A |
Claims, Registry |
Process |
Person and Caregiver Centered Experience and Outcomes |
Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older
Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months |
National Committee for Quality Assurance |
! |
N/A/ 109 |
N/A |
Claims, Registry |
Process |
Person and Caregiver Centered Experience and Outcomes |
Osteoarthritis (OA): Function and Pain Assessment
Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain |
American Academy of Orthopedic Surgeons |
|
0041/110 |
147v6 |
Claims, Web Interface, Registry, EHR |
Process |
Community/ Population Health |
Preventive Care and Screening: Influenza Immunization
Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization |
Physician Consortium for Performance Improvement Foundation (PCPI®) |
* § |
2372/112 |
125v5 |
Claims, Web Interface, Registry, EHR |
Process |
Effective Clinical Care |
Breast Cancer Screening
Percentage of women 50 - 74 years of age who had a mammogram to screen for breast cancer |
National Committee for Quality Assurance |
§ |
0034/113 |
130v5 |
Claims, Web Interface, Registry, EHR |
Process |
Effective Clinical Care |
Colorectal Cancer Screening
Percentage of patients 50 - 75 years of age who had appropriate screening for colorectal cancer |
National Committee for Quality Assurance |
§ !! |
0058/116 |
N/A |
Registry |
Process |
Efficiency and Cost Reduction |
Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis: Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription |
National Committee for Quality Assurance |
§ |
0055/117 |
131v5 |
Claims, Web Interface, Registry, EHR |
Process |
Effective Clinical Care |
Diabetes: Eye Exam
Percentage of patients 18 - 75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal exam (no evidence of retinopathy) in the 12 months prior to the measurement period |
National Committee for Quality Assurance |
|
0421/128 |
69v5 |
Claims, Registry, EHR, Web Interface |
Process |
Community/ Population Health |
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter |
Centers for Medicare & Medicaid Services |
|
0419/130 |
68v6 |
Claims, Registry, EHR, |
Process |
Patient Safety |
Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration. |
Centers for Medicare & Medicaid Services |
* |
0418/134 |
2v6
|
Claims, Web Interface, Registry, EHR |
Process |
Community/ Population Health |
Preventive Care and Screening: Screening for Depression and Follow-Up Plan
Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen |
Centers for Medicare & Medicaid Services |
! |
0101/154 |
N/A |
Claims, Registry |
Process |
Patient Safety |
Falls: Risk Assessment
Percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls completed within 12 months |
National Committee for Quality Assurance |
! |
0101/155 |
N/A |
Claims, Registry |
Process |
Communication and Care Coordination |
Falls: Plan of Care
Percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months |
National Committee for Quality Assurance |
* § |
0056/163 |
123v5 |
EHR |
Process |
Effective Clinical Care |
Comprehensive Diabetes Care: Foot Exam
The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a foot exam (visual inspection and sensory exam with mono filament and a pulse exam) during the measurement year |
National Committee for Quality Assurance |
! |
N/A/ 181 |
N/A |
Claims, Registry |
Process |
Patient Safety |
Elder Maltreatment Screen and Follow-Up Plan
Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening Tool on the date of encounter AND a documented follow-up plan on the date of the positive screen |
Centers for Medicare & Medicaid Services |
* § |
0068/204 |
164v5 |
Claims, Web Interface, Registry, EHR |
Process |
Effective Clinical Care |
Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet
Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antiplatelet during the measurement period |
National Committee for Quality Assurance |
|
0028/ 226 |
138v5 |
Claims, Registry, EHR, ,Web Interface |
Process |
Community/Population Health |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user. |
Physician Consortium for Performance Improvement Foundation (PCPI®) |
|
0018/ 236 |
165v5 |
Claims, Registry, EHR, Web Interface |
Intermediate Outcome |
Effective Clinical Care |
Controlling High Blood Pressure
Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90 mmHg) during the measurement period |
National Committee for Quality Assurance |
* |
N/A/317 |
22v5 |
Claims, Registry, EHR |
Process
|
Community/Population Health
|
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.
|
Centers for Medicare & Medicaid Services |
§ |
1525/326 |
N/A |
Claims, Registry |
Process |
Effective Clinical Care |
Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy
Percentage of patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation (AF) or atrial flutter whose assessment of the specified thromboembolic risk factors indicate one or more high-risk factors or more than one moderate risk factor, as determined by CHADS2 risk stratification, who are prescribed warfarin OR another oral anticoagulant drug that is FDA approved for the prevention of thromboembolism |
American College of Cardiology |
!! |
N/A/ 331 |
N/A |
Registry |
Process |
Efficiency and Cost Reduction |
Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse)
Percentage of patients, aged 18 years and older, with a diagnosis of acute sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms |
American Academy of Otolaryngology-Head and Neck Surgery |
!! |
N/A/ 332 |
N/A |
Registry |
Process |
Efficiency and Cost Reduction |
Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)
Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulante, as a first line antibiotic at the time of diagnosis |
American Academy of Otolaryngology-Head and Neck Surgery |
!! |
N/A/ 333 |
N/A |
Registry |
Efficiency |
Efficiency and Cost Reduction |
Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse)
Percentage of patients aged 18 years and older with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis |
American Academy of Otolaryngology-Head and Neck Surgery |
!! |
N/A/ 334 |
N/A |
Registry |
Efficiency |
Efficiency and Cost Reduction |
Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse)
Percentage of patients aged 18 years and older with a diagnosis of chronic sinusitis who had more than one CT scan of the paranasal sinuses ordered or received within 90 days after the date of diagnosis |
American Academy of Otolaryngology-Head and Neck Surgery |
|
N/A/ 387 |
N/A |
Registry |
Process |
Effective Clinical Care |
Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users
Percentage of patients regardless of age who are active injection drug users who received screening for HCV infection within the 12 month reporting period |
Physician Consortium for Performance Improvement Foundation (PCPI®) |
§ |
N/A/ 400 |
N/A |
Registry |
Process |
Effective Clinical Care |
One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk
Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis OR birthdate in the years 1945-1965 who received one-time screening for hepatitis C virus (HCV) infection |
Physician Consortium for Performance Improvement Foundation (PCPI®) |
§ |
N/A/401 |
N/A |
Registry |
Process |
Effective Clinical Care |
Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis
Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12 month reporting period
|
American Gastroenterological Association/ American Society for Gastrointestinal Endoscopy/American College of Gastroenterology |
|
NA/ 402
|
NA |
Registry |
Process |
Community/ Population Health |
Tobacco Use and Help with Quitting Among Adolescents
The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user |
National Committee for Quality Assurance |
|
N/A/ 408 |
N/A |
Registry |
Process |
Effective Clinical Care |
Opioid Therapy Follow-up Evaluation
All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record |
American Academy of Neurology |
|
N/A/ 412 |
N/A |
Registry |
Process |
Effective Clinical Care |
Documentation of Signed Opioid Treatment Agreement
All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record |
American Academy of Neurology |
|
N/A/ 414 |
N/A |
Registry |
Process |
Effective Clinical Care |
Evaluation or Interview for Risk of Opioid Misuse
All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAAP-R) or patient interview documented at least once during Opioid Therapy in the medical record |
American Academy of Neurology
|
|
0053/418 |
N/A |
Claims, Registry |
Process |
Effective Clinical Care |
Osteoporosis Management in Women Who Had a Fracture
The percentage of women age 50-85 who suffered a fracture and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis in the six months after the fracture |
National Committee for Quality Assurance |
|
2152/431 |
NA |
Registry |
Process |
Community/ Population Health |
Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user. |
Physician Consortium for Performance Improvement Foundation (PCPI®)
|
|
N/A/438 |
N/A |
Web Interface, Registry |
Process |
Effective Clinical Care |
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
Percentage of the following patients—all considered at high risk of cardiovascular events—who were prescribed or were on statin therapy during the measurement period: • Adults aged ≥ 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR • Adults aged ≥21 years with a fasting or direct low-density lipoprotein cholesterol (LDL-C) level ≥ 190 mg/dL; OR • Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL |
Centers for Medicare & Medicaid Services |
Comments: CMS received several comments to add specific measures to the measure set because the commenters believed the additional measures were appropriate for providers within the internal medicine specialty. For instance, commenters requested that measures #110 and #438 be added to the Internal Medicine specialty set.
Response: Upon further review of the recommendations provided by commenters, CMS has revised the measure set from the proposed set by adding these relevant measures to the measures set (#110, #438). In addition, CMS has added previously identified cross-cutting measures that are relevant for the specialty set (#047, #128, #130, #226, #236, #317, #402, and #431). CMS believes the finalized specialty set reflects the relevant measures appropriate for the internal medicine specialty.
Final Decision: CMS is finalizing the internal medicine specialty measure set as indicated in the table above.
|
|||||||
MIPS ID Number |
NQF/ PQRS |
CMS E-Measure ID |
Data Submission Method |
Measure Type |
National Quality Strategy Domain |
Measure Title and Description¥ |
Measure Steward |
|
|||||||
|
0326/ 047 |
N/A |
Claims, Registry |
Process |
Communication and Care Coordination |
Care Plan
Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
|
National Committee for Quality Assurance |
|
N/A/ 048 |
N/A |
Claims, Registry |
Process |
Effective Clinical Care |
Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older
Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months |
National Committee for Quality Assurance |
! |
N/A/ 050 |
N/A |
Claims, Registry |
Process |
Person and Caregiver-Centered Experience and Outcomes |
Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older
Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months |
National Committee for Quality Assurance |
|
0041/110 |
147v6 |
Claims, Web Interface, Registry, EHR |
Process |
Community/ Population Health |
Preventive Care and Screening: Influenza Immunization
Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization |
Physician Consortium for Performance Improvement Foundation (PCPI®) |
* § |
2372/112 |
125v5 |
Claims, Web Interface, Registry, EHR |
Process |
Effective Clinical Care |
Breast Cancer Screening
Percentage of women 50 - 74 years of age who had a mammogram to screen for breast cancer |
National Committee for Quality Assurance |
|
0421/128 |
69v5 |
Claims, Registry, EHR, Web Interface |
Process |
Community/ Population Health |
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter |
Centers for Medicare & Medicaid Services |
|
0419/130 |
68v6 |
Claims, Registry, EHR, |
Process |
Patient Safety |
Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration.
|
Centers for Medicare & Medicaid Services |
|
0028/ 226 |
138v5 |
Claims, Registry, EHR, ,Web Interface |
Process |
Community/Population Health |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.
|
Physician Consortium for Performance Improvement Foundation (PCPI®) |
|
0018/ 236 |
165v5 |
Claims, Registry, EHR, Web Interface |
Intermediate Outcome |
Effective Clinical Care |
Controlling High Blood Pressure
Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90 mmHg) during the measurement period
|
National Committee for Quality Assurance |
! |
N/A/ 265 |
N/A |
Registry |
Process |
Communication and Care Coordination |
Biopsy Follow-Up
Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient by the performing physician |
American Academy of Dermatology |
* § |
0032/309 |
124v5 |
EHR |
Process |
Effective Clinical Care |
Cervical Cancer Screening
Percentage of women 21–64 years of age who were screened for cervical cancer using either of the following criteria: • Women age 21–64 who had cervical cytology performed every 3 years • Women age 30–64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years
|
National Committee for Quality Assurance |
|
0033/310 |
153v5 |
EHR |
Process |
Community/ Population Health |
Chlamydia Screening for Women
Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period |
National Committee for Quality Assurance |
* |
N/A/317 |
22v5 |
Claims, Registry, EHR |
Process
|
Community/Population Health
|
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.
|
Centers for Medicare & Medicaid Services |
|
NA/ 374 |
50v5 |
EHR |
Process |
Communication and Care Coordination |
Closing the Referral Loop: Receipt of Specialist Report
Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred. |
Centers for Medicare & Medicaid Services |
|
NA/ 402 |
NA |
Registry |
Process |
Community/ Population Health |
Tobacco Use and Help with Quitting Among Adolescents
The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user |
National Committee for Quality Assurance |
|
0053/418 |
N/A |
Claims, Registry |
Process |
Effective Clinical Care |
Osteoporosis Management in Women Who Had a Fracture
The percentage of women age 50-85 who suffered a fracture and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis in the six months after the fracture |
National Committee for Quality Assurance |
! |
2063/422 |
N/A |
Claims, Registry |
Process |
Patient Safety |
Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury
Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse |
American Urogynecologic Society |
|
2152/431 |
NA |
Registry |
Process |
Community/ Population Health |
Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user. |
Physician Consortium for Performance Improvement Foundation (PCPI®)
|
! |
N/A/ 432 |
N/A |
Registry |
Outcome |
Patient Safety |
Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair
Percentage of patients undergoing any surgery to repair pelvic organ prolapse who sustains an injury to the bladder recognized either during or within 1 month after surgery |
American Urogynecologic Society |
! |
N/A/ 433 |
N/A |
Registry |
Outcome |
Patient Safety |
Proportion of Patients Sustaining a Bowel Injury at the Time of any Pelvic Organ Prolapse Repair:
Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by a bowel injury at the time of index surgery that is recognized intraoperatively or within 1 month after surgery |
American Urogynecologic Society |
! |
N/A/ 434 |
N/A |
Registry |
Outcome |
Patient Safety |
Proportion of Patients Sustaining A Ureter Injury at the Time of any Pelvic Organ Prolapse Repair
Percentage of patients undergoing pelvic organ prolapse repairs who sustain an injury to the ureter recognized either during or within 1 month after surgery |
American Urogynecologic Society |
+ § |
1395/ 447 |
N/A |
Registry |
Process |
Community/ Population Health |
Chlamydia Screening and Follow-up
The percentage of female adolescents 16 years of age who had a chlamydia screening test with proper follow-up during the measurement period
|
National Committee for Quality Assurance |
+ § ! |
0567/ 448 |
N/A |
Registry
|
Process |
Patient Safety |
Appropriate Work Up Prior to Endometrial Ablation
Percentage of women, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy and results documented before undergoing an endometrial ablation |
Health Benchmarks-IMS Health |
+ § !! |
N/A/443 |
N/A |
Registry |
Process |
Patient Safety |
Non-Recommended Cervical Cancer Screening in Adolescent Females
The percentage of adolescent females 16–20 years of age screened unnecessarily for cervical cancer |
National Committee for Quality Assurance |
Comments: CMS received a comment to add measure #110 to the measure set because the commenter believed the additional measure is appropriate for providers within the Obstetrics and Gynecology specialty. CMS also received comments supporting the specialty measure set and the inclusion of measures #48, #50 within it.
Response: Upon further review of the recommendations provided by commenters, CMS has revised the measure set from the proposed set by adding measure #110. In addition, CMS has added previously identified cross-cutting measures that are relevant for the specialty set (#047, #128, #130, #226, #236, #317, #374, #402, and #431). CMS believes the finalized specialty set reflects the relevant measures appropriate for the Obstetrics and Gynecology specialty.
Final Decision: CMS is finalizing the Obstetrics and Gynecology specialty measure set as indicated in the table above. |
|||||||
MIPS ID Number |
NQF/ PQRS |
CMS E-Measure ID |
Data Submission Method |
Measure Type |
National Quality Strategy Domain |
Measure Title and Description¥ |
Measure Steward |
|
|||||||
|
0086/012 |
143v5
|
Claims, Registry, EHR |
Process |
Effective Clinical Care |
Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation
Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more office visits within 12 months |
Physician Consortium for Performance Improvement (PCPI®) Foundation |
|
0087/014 |
N/A |
Claims, Registry |
Process |
Effective Clinical Care |
Age-Related Macular Degeneration (AMD): Dilated Macular Examination
Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or hemorrhage AND the level of macular degeneration severity during one or more office visits within 12 months |
American Academy of Ophthalmology |
|
0088/018 |
167v5 |
EHR |
Process |
Effective Clinical Care |
Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy
Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy and the presence or absence of macular edema during one or more office visits within 12 months |
Physician Consortium for Performance Improvement (PCPI®) Foundation |
! |
0089/019
|
142v5 |
Claims, Registry, EHR |
Process |
Communication and Care Coordination |
Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months |
Physician Consortium for Performance Improvement (PCPI®) Foundation |
|
0326/ 047 |
N/A |
Claims, Registry |
Process |
Communication and Care Coordination |
Care Plan
Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
|
National Committee for Quality Assurance |
§ |
0055/117 |
131v5 |
Claims, Web Interface, Registry, EHR |
Process |
Effective Clinical Care |
Diabetes: Eye Exam
Percentage of patients 18 - 75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal exam (no evidence of retinopathy) in the 12 months prior to the measurement period |
National Committee for Quality Assurance |
|
0419/130 |
68v6 |
Claims, Registry, EHR, |
Process |
Patient Safety |
Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration.
|
Centers for Medicare & Medicaid Services |
|
0566/140 |
N/A |
Claims, Registry |
Process |
Effective Clinical Care |
Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement
Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) or their caregiver(s) who were counseled within 12 months on the benefits and/or risks of the Age-Related Eye Disease Study (AREDS) formulation for preventing progression of AMD |
American Academy of Ophthalmology |
! |
0563/141 |
N/A |
Claims, Registry |
Outcome |
Communication and Care Coordination |
Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care
Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 15% from the pre- intervention level) OR if the most recent IOP was not reduced by at least 15% from the pre- intervention level, a plan of care was documented within 12 months |
American Academy of Ophthalmology |
! |
0565/191 |
133v5 |
Registry, EHR |
Outcome |
Effective Clinical Care |
Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery
Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following the cataract surgery |
Physician Consortium for Performance Improvement Foundation (PCPI® |
! |
0564/192 |
132v5 |
Registry, EHR |
Outcome |
Patient Safety |
Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures
Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and had any of a specified list of surgical procedures in the 30 days following cataract surgery which would indicate the occurrence of any of the following major complications: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence |
Physician Consortium for Performance Improvement Foundation (PCPI® |
|
0028/ 226 |
138v5 |
Claims, Registry, EHR, ,Web Interface |
Process |
Community/Population Health |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.
|
Physician Consortium for Performance Improvement Foundation (PCPI®) |
! |
1536/303
|
N/A |
Registry |
Outcome |
Person Caregiver-Centered Experience and Outcomes |
Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery
Percentage of patients aged 18 years and older who had cataract surgery and had improvement in visual function achieved within 90 days following the cataract surgery, based on completing a pre-operative and post-operative visual function survey |
American Academy of Ophthalmology |
! |
N/A/304 |
N/A |
Registry |
Outcome |
Person Caregiver-Centered Experience and Outcomes |
Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery
Percentage of patients aged 18 years and older who had cataract surgery and were satisfied with their care within 90 days following the cataract surgery, based on completion of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey |
American Academy of Ophthalmology |
* |
N/A/317 |
22v5 |
Claims, Registry, EHR |
Process
|
Community/Population Health
|
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.
|
Centers for Medicare & Medicaid Services |
|
NA/ 374 |
50v5 |
EHR |
Process |
Communication and Care Coordination |
Closing the Referral Loop: Receipt of Specialist Report
Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred. |
Centers for Medicare & Medicaid Services |
! |
N/A/384 |
N/A |
Registry |
Outcome |
Effective Clinical Care |
Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery
Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment who did not require a return to the operating room within 90 days of surgery. |
American Academy of Ophthalmology |
! |
N/A/ 385 |
N/A |
Registry |
Outcome |
Effective Clinical Care |
Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery
Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment and achieved an improvement in their visual acuity, from their preoperative level, within 90 days of surgery in the operative eye |
American Academy of Ophthalmology |
! |
N/A/ 388 |
N/A |
Registry |
Outcome |
Patient Safety |
Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy
Percentage of patients aged 18 years and older who had cataract surgery performed and had an unplanned rupture of the posterior capsule requiring vitrectomy |
American Academy of Ophthalmology |
! |
N/A/ 389 |
N/A |
Registry |
Outcome |
Effective Clinical Care |
Cataract Surgery: Difference Between Planned and Final Refraction
Percentage of patients aged 18 years and older who had cataract surgery performed and who achieved a final refraction within +/- 0.5 diopters of their planned (target) refraction. |
American Academy of Ophthalmology |
|
NA/ 402 |
NA |
Registry |
Process |
Community/ Population Health |
Tobacco Use and Help with Quitting Among Adolescents
The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user |
National Committee for Quality Assurance |
CMS did not receive specific comments regarding changes to the measure set.
Response: CMS has added previously identified cross-cutting measures that are relevant for the specialty set (#047, #130, #226, #317, #374, and #402). CMS believes the finalized specialty set reflects the relevant measures appropriate for the Ophthalmology specialty.
Final Decision: CMS is finalizing the Ophthalmology specialty measure set as indicated in the table above.
|
|||||||
MIPS ID Number |
NQF/ PQRS |
CMS E-Measure ID |
Data Submission Method |
Measure Type |
National Quality Strategy Domain |
Measure Title and Description¥ |
Measure Steward |
||
|
|||||||||
!! |
0268/021 |
N/A |
Claims, Registry |
Process |
Patient Safety |
Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin
Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic, who had an order for a first OR second generation cephalosporin for antimicrobial prophylaxis |
American Society of Plastic Surgeons |
||
! |
0239/ 023 |
N/A |
Claims, Registry |
Process |
Patient Safety |
Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)
Percentage of surgical patients aged 18 years and older undergoing procedures for which venous thromboembolism (VTE) prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time |
American Society of Plastic Surgeons |
||
|
0326/ 047 |
N/A |
Claims, Registry |
Process |
Communication and Care Coordination |
Care Plan
Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
|
National Committee for Quality Assurance |
||
! |
N/A/ 109 |
N/A |
Claims, Registry |
Process |
Person and Caregiver-Centered Experience and Outcomes
|
Osteoarthritis (OA): Function and Pain Assessment
Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain |
American Academy of Orthopedic Surgeons
|
||
|
0421/128 |
69v5 |
Claims, Registry, EHR, Web Interface |
Process |
Community/ Population Health |
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter |
Centers for Medicare & Medicaid Services |
||
|
0419/130 |
68v6 |
Claims, Registry, EHR, |
Process |
Patient Safety |
Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration.
|
Centers for Medicare & Medicaid Services |
||
|
N/A/ 178 |
N/A |
Registry |
Process |
Effective Clinical Care
|
Rheumatoid Arthritis (RA): Functional Status Assessment
Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) for whom a functional status assessment was performed at least once within 12 months |
American College of Rheumatology
|
||
* |
N/A/ 179 |
N/A |
Registry |
Process |
Effective Clinical Care
|
Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis
Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease prognosis at least once within 12 months |
American College of Rheumatology
|
||
*
|
N/A/ 180 |
N/A |
Registry |
Process |
Effective Clinical Care |
Rheumatoid Arthritis (RA): Glucocorticoid Management
Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone ≥ 10 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months |
American College of Rheumatology
|
||
|
0028/ 226 |
138v5 |
Claims, Registry, EHR, ,Web Interface |
Process |
Community/Population Health |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.
|
Physician Consortium for Performance Improvement Foundation (PCPI®) |
||
§ !! |
0052/312 |
166v6 |
EHR |
Process |
Efficiency and Cost Reduction |
Use of Imaging Studies for Low Back Pain
Percentage of patients 18-50 years of age with a diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis |
National Committee for Quality Assurance |
||
* |
N/A/317 |
22v5 |
Claims, Registry, EHR |
Process
|
Community/Population Health
|
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.
|
Centers for Medicare & Medicaid Services |
||
* ! |
N/A/ 350 |
N/A |
Registry |
Process |
Communication and Care Coordination
|
Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy
Percentage of patients regardless of age undergoing a total knee replacement with documented shared decision-making with discussion of conservative (non-surgical) therapy (e.g. nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure |
American Association of Hip and Knee Surgeons
|
||
* ! |
N/A/ 351 |
N/A |
Registry |
Process |
Patient Safety
|
Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation
Percentage of patients regardless of age undergoing a total knee replacement who are evaluated for the presence or absence of venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure (e.g. history of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), Myocardial Infarction (MI), Arrhythmia and Stroke) |
American Association of Hip and Knee Surgeons
|
||
* ! |
N/A/ 352 |
N/A |
Registry |
Process |
Patient Safety |
Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet
Percentage of patients regardless of age undergoing a total knee replacement who had the prophylactic antibiotic completely infused prior to the inflation of the proximal tourniquet |
American Association of Hip and Knee Surgeons
|
||
* ! |
N/A/ 353 |
N/A |
Registry |
Process |
Patient Safety |
Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report
Percentage of patients regardless of age undergoing a total knee replacement whose operative report identifies the prosthetic implant specifications including the prosthetic implant manufacturer, the brand name of the prosthetic implant and the size of each prosthetic implant |
American Association of Hip and Knee Surgeons
|
||
! |
N/A/ 358 |
N/A |
Registry |
Process |
Person and Caregiver-Centered Experience and Outcomes
|
Patient-Centered Surgical Risk Assessment and Communication
Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon |
American Association of Hip and Knee Surgeons
|
||
|
NA/ 374 |
50v5 |
EHR |
Process |
Communication and Care Coordination |
Closing the Referral Loop: Receipt of Specialist Report
Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred. |
Centers for Medicare & Medicaid Services |
||
* ! |
N/A/ 375 |
66v 5 |
EHR |
Process |
Person and Caregiver-Centered Experience and Outcomes
|
Functional Status Assessment for Total Knee Replacement
Percentage of patients 18 years of age and older with primary total knee arthroplasty (TKA) who completed baseline and follow-up patient-reported functional status assessments |
Centers for Medicare & Medicaid Services |
||
* ! |
N/A/ 376 |
56v5 |
EHR |
Process |
Person and Caregiver-Centered Experience and Outcomes
|
Functional Status Assessment for Total Hip Replacement
Percentage of patients 18 years of age and older with primary total hip arthroplasty (THA) who completed baseline and follow-up (patient-reported) functional status assessments |
Centers for Medicare & Medicaid Services |
||
|
NA/ 402 |
NA |
Registry |
Process |
Community/ Population Health |
Tobacco Use and Help with Quitting Among Adolescents
The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user |
National Committee for Quality Assurance |
||
CMS did not receive specific comments regarding changes to the measure set.
Response: CMS has added previously identified cross-cutting measures that are relevant for the specialty set (#047, #128, #130, #226, #317, #374, and #402). CMS believes the finalized specialty set reflects the relevant measures appropriate for the Orthopedic Surgery specialty.
Final Decision: CMS is finalizing the Orthopedic Surgery specialty measure set as indicated in the table above.
|
|||||||||
MIPS ID Number |
NQF/ PQRS |
CMS E-Measure ID |
Data Submission Method |
Measure Type |
National Quality Strategy Domain |
Measure Title and Description¥ |
Measure Steward |
|
|||||||
!! |
0268/ 021 |
N/A |
Claims, Registry |
Process |
Patient Safety |
Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin
Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic, who had an order for a first OR second generation cephalosporin for antimicrobial prophylaxis |
American Society of Plastic Surgeons |
! |
0239/023 |
N/A |
Claims, Registry |
Process |
Patient Safety |
Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)
Percentage of surgical patients aged 18 years and older undergoing procedures for which venous thromboembolism (VTE) prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time |
American Society of Plastic Surgeons |
|
0326/ 047 |
N/A |
Claims, Registry |
Process |
Communication and Care Coordination |
Care Plan
Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
|
National Committee for Quality Assurance |
!! |
0653/ 091 |
N/A |
Claims, Registry |
Process |
Effective Clinical Care |
Acute Otitis Externa (AOE): Topical Therapy
Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations |
American Academy of Otolaryngology-Head and Neck Surgery |
!! |
0654/ 093 |
N/A |
Claims, Registry |
Process |
Efficiency and Cost Reduction |
Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use
Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy |
American Academy of Otolaryngology-Head and Neck Surgery |
|
0421/128 |
69v5 |
Claims, Registry, EHR, Web Interface |
Process |
Community/ Population Health |
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter |
Centers for Medicare & Medicaid Services |
|
0419/130 |
68v6 |
Claims, Registry, EHR, |
Process |
Patient Safety |
Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration.
|
Centers for Medicare & Medicaid Services |
|
0028/ 226 |
138v5 |
Claims, Registry, EHR, ,Web Interface |
Process |
Community/Population Health |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.
|
Physician Consortium for Performance Improvement Foundation (PCPI®) |
* |
N/A/317 |
22v5 |
Claims, Registry, EHR |
Process
|
Community/Population Health
|
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.
|
Centers for Medicare & Medicaid Services |
!! |
N/A/ 331 |
N/A |
Registry |
Process |
Efficiency and Cost Reduction |
Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse)
Percentage of patients, aged 18 years and older, with a diagnosis of acute sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms |
American Academy of Otolaryngology-Head and Neck Surgery |
!! |
N/A/ 332 |
N/A |
Registry |
Process |
Efficiency and Cost Reduction |
Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)
Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulante, as a first line antibiotic at the time of diagnosis |
American Academy of Otolaryngology-Head and Neck Surgery |
!! |
N/A/ 333 |
N/A |
Registry |
Efficiency |
Efficiency and Cost Reduction |
Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse)
Percentage of patients aged 18 years and older with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis |
American Academy of Otolaryngology-Head and Neck Surgery |
!! |
N/A/ 334 |
N/A |
Registry |
Efficiency |
Efficiency and Cost Reduction |
Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse)
Percentage of patients aged 18 years and older with a diagnosis of chronic sinusitis who had more than one CT scan of the paranasal sinuses ordered or received within 90 days after the date of diagnosis |
American Academy of Otolaryngology-Head and Neck Surgery |
* ! |
N/A/ 357 |
N/A |
Registry |
Outcome |
Effective Clinical Care |
Surgical Site Infection (SSI)
Percentage of patients aged 18 years and older who had a surgical site infection (SSI) |
American College of Surgeons
|
! |
N/A/ 358 |
N/A
|
Registry |
Process |
Person and Caregiver-Centered Experience and Outcomes |
Patient-Centered Surgical Risk Assessment and Communication
Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon |
American College of Surgeons |
|
NA/ 374 |
50v5 |
EHR |
Process |
Communication and Care Coordination |
Closing the Referral Loop: Receipt of Specialist Report
Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred. |
Centers for Medicare & Medicaid Services |
|
NA/ 402 |
NA |
Registry |
Process |
Community/ Population Health |
Tobacco Use and Help with Quitting Among Adolescents
The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user |
National Committee for Quality Assurance |
|
2152/431 |
NA |
Registry |
Process |
Community/ Population Health |
Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user. |
Physician Consortium for Performance Improvement Foundation (PCPI®)
|
Comments: Although CMS did not receive specific comments regarding changes to the measure set, CMS did receive comments to include measures from the current PQRS measure set.
Response: All measures proposed within the set were previously PQRS measures. CMS has also added previously identified cross-cutting measures that are relevant for the specialty set (#047, #128, #130, #226, #317, #374, #402, and #431). CMS believes the finalized specialty set reflects the relevant measures appropriate for the Otolaryngology specialty.
Final Decision: CMS is finalizing the Otolaryngology specialty measure set as indicated in the table above. |
|||||||
MIPS ID Number |
NQF/ PQRS |
CMS E-Measure ID |
Data Submission Method |
Measure Type |
National Quality Strategy Domain |
Measure Title and Description¥ |
Measure Steward |
|
|||||||
|
0391/099 |
N/A |
Claims, Registry |
Process |
Effective Clinical Care |
Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade
Percentage of breast cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes), and the histologic grade |
College of American Pathologists |
|
0392/100 |
N/A |
Claims, Registry |
Process |
Effective Clinical Care |
Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade
Percentage of colon and rectum cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes) and the histologic grade |
College of American Pathologists |
|
1854/249 |
N/A |
Claims, Registry |
Process |
Effective Clinical Care |
Barrett's Esophagus
Percentage of esophageal biopsy reports that document the presence of Barrett’s mucosa that also include a statement about dysplasia |
College of American Pathologists |
§ |
1853/250 |
N/A |
Claims, Registry |
Process |
Effective Clinical Care |
Radical Prostatectomy Pathology Reporting
Percentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin status |
College of American Pathologists |
|
1855/251 |
N/A |
Claims, Registry |
Structure |
Effective Clinical Care |
Quantitative Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) for Breast Cancer Patients
This is a measure based on whether quantitative evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) by immunohistochemistry (IHC) uses the system recommended in the current ASCO/CAP Guidelines for Human Epidermal Growth Factor Receptor 2 Testing in breast cancer |
College of American Pathologists |
! |
N/A/ 395 |
N/A |
Claims, Registry |
Process |
Communication and Care Coordination |
Lung Cancer Reporting (Biopsy/Cytology Specimens)
Pathology reports based on biopsy and/or cytology specimens with a diagnosis of primary nonsmall cell lung cancer classified into specific histologic type or classified as NSCLC-NOS with an explanation included in the pathology report |
College of American Pathologists |
! |
N/A/ 396 |
N/A |
Claims, Registry |
Process |
Communication and Care Coordination |
Lung Cancer Reporting (Resection Specimens)
Pathology reports based on resection specimens with a diagnosis of primary lung carcinoma that include the pT category, pN category and for non-small cell lung cancer, histologic type |
College of American Pathologists |
! |
N/A/ 397 |
N/A |
Claims, Registry |
Process |
Communication and Care Coordination |
Melanoma Reporting
Pathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness and ulceration and for pT1, mitotic rate |
College of American Pathologists |
Comments: Although CMS received comments regarding changes to the measure set that specified the development of additional Pathology measures, CMS did not receive specific comments on current measures that should be added or removed from the specialty measure set. CMS also received general comments supporting the proposal of the Pathology specialty measure set.
Response: CMS has not changed the specialty measure set from the proposed set and believes the finalized specialty set reflects the relevant measures appropriate for the Pathology specialty.
Final Decision: CMS is finalizing the Pathology specialty measure set as indicated in the table above. |
|||||||
MIPS ID Number |
NQF/ PQRS |
CMS E-Measure ID |
Data Submission Method |
Measure Type |
National Quality Strategy Domain |
Measure Title and Description¥ |
Measure Steward |
|
|||||||
!! |
0069/065 |
154v5 |
Registry, EHR |
Process |
Efficiency and Cost Reduction |
Appropriate Treatment for Children with Upper Respiratory Infection (URI)
Percentage of children 3 months through 18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode. |
National Committee for Quality Assurance |
* !! |
N/A/ 066 |
146v5 |
Registry, EHR |
Process |
Efficiency and Cost Reduction |
Appropriate Testing for Children with Pharyngitis
Percentage of children 3-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode. |
National Committee for Quality Assurance |
!! |
0653/091 |
N/A |
Claims, Registry |
Process |
Effective Clinical Care |
Acute Otitis External (AOE): Topical Therapy
Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations |
American Academy of Otolaryngology-Head and Neck Surgery |
!! |
0654/ 093 |
N/A |
Claims, Registry |
Process |
Efficiency and Cost Reduction |
Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use
Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy |
American Academy of Otolaryngology-Head and Neck Surgery |
|
0041/110 |
147v6 |
Claims, Web Interface, Registry, EHR |
Process |
Community/ Population Health |
Preventive Care and Screening: Influenza Immunization
Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization |
Physician Consortium for Performance Improvement Foundation (PCPI®) |
* |
0418/134 |
2v6
|
Claims, Web Interface, Registry, EHR |
Process |
Community/ Population Health |
Preventive Care and Screening: Screening for Depression and Follow-Up Plan
Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen |
Centers for Medicare & Medicaid Services |
* § |
0405/160 |
52v5 |
EHR |
Process |
Effective Clinical Care |
HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis
Percentage of patients aged 6 weeks and older with a diagnosis of HIV/AIDS who were prescribed Pneumocystis Jiroveci Pneumonia (PCP) prophylaxis |
National Committee for Quality Assurance |
§ |
0409/205 |
N/A |
Registry |
Process |
Effective Clinical Care |
HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis
Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia, gonorrhea and syphilis screenings were performed at least once since the diagnosis of HIV infection |
National Committee for Quality Assurance |
|
0024/239 |
155v5 |
EHR
|
Process |
Community/ Population Health |
Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported. - Percentage of patients with height, weight, and body mass index (BMI) percentile documentation - Percentage of patients with counseling for nutrition - Percentage of patients with counseling for physical activity |
National Committee for Quality Assurance |
|
0038/240 |
117v5
|
EHR |
Process |
Community/Population Health |
Childhood Immunization Status
Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday |
National Committee for Quality Assurance |
|
0033/310 |
153v5 |
EHR |
Process |
Community/Population Health |
Chlamydia Screening for Women:
Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period
|
National Committee for Quality Assurance |
|
0108/366 |
136v6 |
EHR |
Process |
Effective Clinical Care |
ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication:
Percentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported. a. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase. b. Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended
|
National Committee for Quality Assurance |
|
N/A/379 |
74v6 |
EHR |
Process |
Effective Clinical Care |
Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists:
Percentage of children, age 0-20 years, who received a fluoride varnish application during the measurement period
|
Centers for Medicare & Medicaid Services |
! |
1365/382 |
177v5 |
EHR |
Process |
Patient Safety |
Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment:
Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk |
Physician Consortium for Performance Improvement Foundation (PCPI®) |
! |
0576/391
|
N/A |
Registry |
Process |
Communication/ Care Coordination |
Follow-up After Hospitalization for Mental Illness (FUH) The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported: - The percentage of discharges for which the patient received follow-up within 30 days of discharge - The percentage of discharges for which the patient received follow-up within 7 days of discharge |
National Committee for Quality Assurance
|
|
1407/394 |
N/A |
Registry |
Process |
Community/Population Health |
Immunizations for Adolescents: The percentage of adolescents 13 years of age who had the recommended immunizations by their 13th birthday |
National Committee for Quality Assurance |
|
NA/ 402 |
NA |
Registry |
Process |
Community/ Population Health |
Tobacco Use and Help with Quitting Among Adolescents
The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user |
National Committee for Quality Assurance |
+ § ! |
1799/444 |
NA |
Registry |
Process |
Efficiency and Cost Reduction |
Medication Management for People with Asthma (MMA):
The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment period. |
National Committee for Quality Assurance |
Comments: CMS received several comments that suggested the pediatrics measure set align with the Children’s Health Insurance Program Reauthorization Act (CHIPRA) Core Measure Set https://www.medicaid.gov/medicaid-chip-program-information/by-topics/quality-of-care/downloads/2016-child-core-set.pdf.
Response: CMS agrees that pediatrics specialty set should, where practicable, align with the CHIPRA core measures that already exist in the program. As such, CMS added measures #239, #240, #310, #366, #379, #382, #391, #394, #444. Measures not added to the Pediatric specialty measure set for 2017 may be considered for future rulemaking once these measures have been added to the MIPS Quality measure set. Additionally, CMS added measures previously identified as cross-cutting to the measure set that are relevant for pediatrics (, ,, #402,). CMS believes the finalized specialty set reflects the relevant measures appropriate for the pediatrics specialty.
Final Decision: CMS is finalizing the pediatrics specialty measure set as indicated in the table above. |
|||||||
MIPS ID Number |
NQF/ PQRS |
CMS E-Measure ID |
Data Submission Method |
Measure Type |
National Quality Strategy Domain |
Measure Title and Description¥ |
Measure Steward |
|||
|
|
|||||||||
|
0326/ 047 |
N/A |
Claims, Registry |
Process |
Communication and Care Coordination |
Care Plan
Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
|
National Committee for Quality Assurance |
|||
! |
N/A/ 109 |
N/A |
Claims, Registry |
Process |
Person and Caregiver-Centered Experience and Outcomes
|
Osteoarthritis (OA): Function and Pain Assessment
Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain |
American Academy of Orthopedic Surgeons
|
|||
|
0421/128 |
69v5 |
Claims, Registry, EHR, Web Interface |
Process |
Community/ Population Health |
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter |
Centers for Medicare & Medicaid Services |
|||
|
0419/130 |
68v6 |
Claims, Registry, EHR, |
Process |
Patient Safety |
Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration.
|
Centers for Medicare & Medicaid Services |
|||
! |
0420/131 |
N/A |
Claims, Registry
|
Process |
Communication and Care Coordination |
Pain Assessment and Follow-Up
Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present |
Centers for Medicare & Medicaid Services |
|||
! |
2624/182 |
N/A |
Claims, Registry |
Process |
Communication and Care Coordination |
Functional Outcome Assessment
Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies |
Centers for Medicare & Medicaid Services |
|||
|
0028/ 226 |
138v5 |
Claims, Registry, EHR, ,Web Interface |
Process |
Community/Population Health |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.
|
Physician Consortium for Performance Improvement Foundation (PCPI®) |
|||
§ !! |
0052/312 |
166v6 |
EHR |
Process |
Efficiency and Cost Reduction |
Use of Imaging Studies for Low Back Pain
Percentage of patients 18-50 years of age with a diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis |
National Committee for Quality Assurance |
|||
* |
N/A/317 |
22v5 |
Claims, Registry, EHR |
Process
|
Community/Population Health
|
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.
|
Centers for Medicare & Medicaid Services |
|||
|
NA/ 374 |
50v5 |
EHR |
Process |
Communication and Care Coordination |
Closing the Referral Loop: Receipt of Specialist Report
Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred. |
Centers for Medicare & Medicaid Services |
|||
|
NA/ 402 |
NA |
Registry |
Process |
Community/ Population Health |
Tobacco Use and Help with Quitting Among Adolescents
The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user |
National Committee for Quality Assurance |
|||
|
N/A/ 408 |
N/A |
Registry |
Process |
Effective Clinical Care |
Opioid Therapy Follow-up Evaluation
All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record |
American Academy of Neurology |
|||
|
N/A/ 412 |
N/A |
Registry |
Process |
Effective Clinical Care |
Documentation of Signed Opioid Treatment Agreement
All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record |
American Academy of Neurology |
|||
|
N/A/ 414 |
N/A |
Registry |
Process |
Effective Clinical Care |
Evaluation or Interview for Risk of Opioid Misuse
All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAAP-R) or patient interview documented at least once during Opioid Therapy in the medical record |
American Academy of Neurology |
|||
|
2152/431 |
NA |
Registry |
Process |
Community/ Population Health |
Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user. |
Physician Consortium for Performance Improvement Foundation (PCPI®)
|
|||
Comments: CMS received support for development of the physical medicine measure set. CMS also received a specific request to remove the measure set because the commenter believed the measures are irrelevant and not applicable to physical medicine. The commenter also believed that physiatrists would need to find a cross-cutting measure to report in addition to the set.
Response: CMS will continue to work with specialty groups on measures relevant to specialists and would like to reiterate that specialists should work closely with specialty groups to find appropriate measures to report. Additionally, CMS has added previously identified cross-cutting measures that are relevant for the specialty set (#047, #128, #130, #226, #317, #374, #402, and #431). CMS also notes that we will not finalize the cross-cutting measure requirement as detailed in section II.E.5.b of this final rule with comment. CMS believes the finalized specialty set reflects the relevant measures appropriate for the physical medicine specialty.
Final Decision: CMS is finalizing the physical medicine specialty measure set as indicated in the table above.
|
||||||||||
MIPS ID Number |
NQF/ PQRS |
CMS E-Measure ID |
Data Submission Method |
Measure Type |
National Quality Strategy Domain |
Measure Title and Description¥ |
Measure Steward |
|
|||||||
!! |
0268/021 |
N/A |
Claims, Registry |
Process |
Patient Safety |
Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin
Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic, who had an order for a first OR second generation cephalosporin for antimicrobial prophylaxis |
American Society of Plastic Surgeons |
! |
0239/023 |
N/A |
Claims, Registry |
Process |
Patient Safety |
Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)
Percentage of surgical patients aged 18 years and older undergoing procedures for which venous thromboembolism (VTE) prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time |
American Society of Plastic Surgeons |
|
0326/ 047 |
N/A |
Claims, Registry |
Process |
Communication and Care Coordination |
Care Plan
Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
|
National Committee for Quality Assurance |
|
0421/128 |
69v5 |
Claims, Registry, EHR, Web Interface |
Process |
Community/ Population Health |
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter |
Centers for Medicare & Medicaid Services |
|
0419/130 |
68v6 |
Claims, Registry, EHR, |
Process |
Patient Safety |
Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration.
|
Centers for Medicare & Medicaid Services |
|
0028/ 226 |
138v5 |
Claims, Registry, EHR, ,Web Interface |
Process |
Community/Population Health |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.
|
Physician Consortium for Performance Improvement Foundation (PCPI®) |
* |
N/A/317 |
22v5 |
Claims, Registry, EHR |
Process
|
Community/Population Health
|
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.
|
Centers for Medicare & Medicaid Services |
* ! |
N/A/ 357 |
N/A |
Registry |
Outcome |
Effective Clinical Care |
Surgical Site Infection (SSI)
Percentage of patients aged 18 years and older who had a surgical site infection (SSI) |
American College of Surgeons |
! |
N/A/ 358 |
N/A |
Registry |
Process |
Person and Caregiver-Centered Experience and Outcomes |
Patient-Centered Surgical Risk Assessment and Communication
Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon |
American College of Surgeons |
|
NA/ 374 |
50v5 |
EHR |
Process |
Communication and Care Coordination |
Closing the Referral Loop: Receipt of Specialist Report
Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred. |
Centers for Medicare & Medicaid Services |
|
NA/ 402 |
NA |
Registry |
Process |
Community/ Population Health |
Tobacco Use and Help with Quitting Among Adolescents
The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user |
National Committee for Quality Assurance |
Comments: CMS received a specific comment to add measure #357: Surgical Site Infection to the measure set.
Response: CMS agrees that measure #357 is applicable for plastic surgeon specialists. CMS has also added previously identified cross-cutting measures that are relevant for the specialty set (#047, #128, #130, #226, #317, #374, and #402). CMS believes the finalized specialty set reflects the relevant measures appropriate for the plastic surgery specialty.
Final Decision: CMS is finalizing the plastic surgery specialty measure set as indicated in the table above. |
|||||||
MIPS ID Number |
NQF/ PQRS |
CMS E-Measure ID |
Data Submission Method |
Measure Type |
National Quality Strategy Domain |
Measure Title and Description¥ |
Measure Steward |
|
|||||||
* § ! |
0059/001 |
122v5 |
Claims, Web Interface, Registry, EHR |
Intermediate Outcome |
Effective Clinical Care |
Diabetes: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%)
Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period |
National Committee for Quality Assurance |
! |
0045/024 |
N/A |
Claims, Registry |
Process |
Communication and Care Coordination |
Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older
Percentage of patients aged 50 years and older treated for a fracture with documentation of communication, between the physician treating the fracture and the physician or other clinician managing the patient’s on-going care, that a fracture occurred and that the patient was or should be considered for osteoporosis treatment or testing. This measure is reported by the physician who treats the fracture and who therefore is held accountable for the communication |
National Committee for Quality Assurance |
|
0046/039 |
N/A |
Claims, Registry |
Process |
Effective Clinical Care |
Screening for Osteoporosis for Women Aged 65-85 Years of Age
Percentage of female patients aged 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) to check for osteoporosis |
National Committee for Quality Assurance |
|
0326/ 047 |
N/A |
Claims, Registry |
Process |
Communication and Care Coordination |
Care Plan
Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
|
National Committee for Quality Assurance |
|
N/A/ 048 |
N/A |
Claims, Registry |
Process |
Effective Clinical Care |
Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older
Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months |
National Committee for Quality Assurance |
! |
N/A/ 109 |
N/A |
Claims, Registry |
Process |
Person and Caregiver-Centered Experience and Outcomes |
Osteoarthritis (OA): Function and Pain Assessment
Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain |
American Academy of Orthopedic Surgeons |
|
0041/110 |
147v6 |
Claims, Web Interface, Registry, EHR |
Process |
Community/ Population Health |
Preventive Care and Screening: Influenza Immunization
Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization |
Physician Consortium for Performance Improvement Foundation (PCPI®) |
|
0043/111 |
127v5 |
Claims, Web Interface, Registry, EHR |
Process |
Community/ Population Health |
Pneumonia Vaccination Status for Older Adults
Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine |
National Committee for Quality Assurance |
* § |
2372/112 |
125v5 |
Claims, Web Interface, Registry, EHR |
Process |
Effective Clinical Care |
Breast Cancer Screening
Percentage of women 50 - 74 years of age who had a mammogram to screen for breast cancer |
National Committee for Quality Assurance |
|
0421/128 |
69v5 |
Claims, Registry, EHR, Web Interface |
Process |
Community/ Population Health |
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter |
Centers for Medicare & Medicaid Services |
|
0419/130 |
68v6 |
Claims, Registry, EHR, |
Process |
Patient Safety |
Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration.
|
Centers for Medicare & Medicaid Services |
|
0028/ 226 |
138v5 |
Claims, Registry, EHR, ,Web Interface |
Process |
Community/Population Health |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.
|
Physician Consortium for Performance Improvement Foundation (PCPI®) |
|
0018/ 236 |
165v5 |
Claims, Registry, EHR, Web Interface |
Intermediate Outcome |
Effective Clinical Care |
Controlling High Blood Pressure
Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90 mmHg) during the measurement period
|
National Committee for Quality Assurance |
* |
N/A/317 |
22v5 |
Claims, Registry, EHR |
Process
|
Community/Population Health
|
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.
|
Centers for Medicare & Medicaid Services |
|
NA/ 374 |
50v5 |
EHR |
Process |
Communication and Care Coordination |
Closing the Referral Loop: Receipt of Specialist Report
Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred. |
Centers for Medicare & Medicaid Services |
|
NA/ 402 |
NA |
Registry |
Process |
Community/ Population Health |
Tobacco Use and Help with Quitting Among Adolescents
The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user |
National Committee for Quality Assurance |
|
2152/431 |
NA |
Registry |
Process |
Community/ Population Health |
Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user. |
Physician Consortium for Performance Improvement Foundation (PCPI®)
|
Comments: CMS received specific comments to include previously identified cross-cutting measures in the measure set.
Response: CMS has added several previously identified cross-cutting measures that are relevant for the preventive medicine specialty set (#047, #128, #130, #226, #236, #317, #374, #402, and #431). CMS believes the finalized specialty set reflects the relevant measures appropriate for the preventive medicine specialty.
Final Decision: CMS is finalizing the preventive medicine specialty measure set as indicated in the table above. |
|||||||
MIPS ID Number |
NQF/ PQRS |
CMS E-Measure ID |
Data Submission Method |
Measure Type |
National Quality Strategy Domain |
Measure Title and Description¥ |
Measure Steward |
|
|||||||
|
0325/032 |
N/A |
Claims, Registry |
Process |
Effective Clinical Care |
Stroke and Stroke Rehabilitation: Discharged on Antithrombotic Therapy
Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or transient ischemic attack (TIA) who were prescribed an antithrombotic therapy at discharge. |
American Academy of Neurology |
|
0326/ 047 |
N/A |
Claims, Registry |
Process |
Communication and Care Coordination |
Care Plan
Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
|
National Committee for Quality Assurance |
|
0421/128 |
69v5 |
Claims, Registry, EHR, Web Interface |
Process |
Community/ Population Health |
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter |
Centers for Medicare & Medicaid Services |
|
0419/130 |
68v6 |
Claims, Registry, EHR, |
Process |
Patient Safety |
Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration.
|
Centers for Medicare & Medicaid Services |
|
0028/ 226 |
138v5 |
Claims, Registry, EHR, ,Web Interface |
Process |
Community/Population Health |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.
|
Physician Consortium for Performance Improvement Foundation (PCPI®) |
* |
1814/268 |
N/A |
Claims, Registry |
Process |
Effective Clinical Care |
Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy
All female patients of childbearing potential (12 - 44 years old) diagnosed with epilepsy who were counseled or referred for counseling for how epilepsy and its treatment may affect contraception OR pregnancy at least once a year |
American Academy of Neurology |
|
N/A/ 281 |
149v5 |
EHR |
Process |
Effective Clinical Care |
Dementia: Cognitive Assessment
Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12 month period |
Physician Consortium for Performance Improvement Foundation (PCPI®) |
* |
N/A/ 282 |
N/A |
Registry |
Process |
Effective Clinical Care |
Dementia: Functional Status Assessment
Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of functional status is performed and the results reviewed at least once within a 12 month period |
American Academy of Neurology |
* |
N/A/ 283 |
N/A |
Registry |
Process |
Effective Clinical Care |
Dementia: Neuropsychiatric Symptom Assessment
Percentage of patients, regardless of age, with a diagnosis of dementia and for whom an assessment of neuropsychiatric symptoms is performed and results reviewed at least once in a 12 month period |
American Academy of Neurology |
* |
N/A/ 284 |
N/A |
Registry |
Process |
Effective Clinical Care |
Dementia: Management of Neuropsychiatric Symptoms
Percentage of patients, regardless of age, with a diagnosis of dementia who have one or more neuropsychiatric symptoms who received or were recommended to receive an intervention for neuropsychiatric symptoms within a 12 month period |
American Academy of Neurology |
* ! |
N/A/ 286 |
N/A |
Registry |
Process |
Patient Safety |
Dementia: Counseling Regarding Safety Concerns
Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled or referred for counseling regarding safety concerns within a 12 month period |
American Academy of Neurology |
* ! |
N/A/ 288 |
N/A |
Registry |
Process |
Communication and Care Coordination |
Dementia: Caregiver Education and Support
Percentage of patients, regardless of age, with a diagnosis of dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND referred to additional sources for support within a 12 month period |
American Academy of Neurology |
* |
N/A/ 290 |
N/A |
Registry |
Process |
Effective Clinical Care |
Parkinson’s Disease: Psychiatric Symptoms Assessment for Patients with Parkinson’s Disease: All patients with a diagnosis of Parkinson’s disease who were assessed for psychiatric symptoms (e.g., psychosis, depression, anxiety disorder, apathy, or impulse control disorder) in the last 12 months |
American Academy of Neurology |
* |
N/A/ 291 |
N/A |
Registry |
Process |
Effective Clinical Care |
Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment
All patients with a diagnosis of Parkinson’s disease who were assessed for cognitive impairment or dysfunction in the last 12 months |
American Academy of Neurology |
* ! |
N/A/ 293 |
N/A |
Registry |
Process |
Communication and Care Coordination |
Parkinson’s Disease: Rehabilitative Therapy Options
All patients with a diagnosis of Parkinson’s disease (or caregiver(s), as appropriate) who had rehabilitative therapy options (e.g., physical, occupational, or speech therapy) discussed in the last 12 months |
American Academy of Neurology |
* ! |
N/A/ 294 |
N/A |
Registry |
Process |
Communication and Care Coordination |
Parkinson’s Disease: Parkinson’s Disease Medical and Surgical Treatment Options Reviewed
All patients with a diagnosis of Parkinson’s disease (or caregiver(s), as appropriate) who had the Parkinson’s disease treatment options (e.g., non-pharmacological treatment, pharmacological treatment, or surgical treatment) reviewed at least once annually |
American Academy of Neurology |
* |
N/A/317 |
22v5 |
Claims, Registry, EHR |
Process
|
Community/Population Health
|
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.
|
Centers for Medicare & Medicaid Services |
|
NA/ 374 |
50v5 |
EHR |
Process |
Communication and Care Coordination |
Closing the Referral Loop: Receipt of Specialist Report
Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred. |
Centers for Medicare & Medicaid Services |
! |
N/A/ 386 |
N/A |
Registry |
Process |
Person and Caregiver-Centered Experience and Outcomes |
Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences
Percentage of patients diagnosed with Amyotrophic Lateral Sclerosis (ALS) who were offered assistance in planning for end of life issues (e.g. advance directives, invasive ventilation, hospice) at least once annually |
American Academy of Neurology |
|
NA/ 402 |
NA |
Registry |
Process |
Community/ Population Health |
Tobacco Use and Help with Quitting Among Adolescents
The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user |
National Committee for Quality Assurance |
|
N/A/ 408 |
N/A |
Registry |
Process |
Effective Clinical Care |
Opioid Therapy Follow-up Evaluation
All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record |
American Academy of Neurology |
|
N/A/ 412 |
N/A |
Registry |
Process |
Effective Clinical Care |
Documentation of Signed Opioid Treatment Agreement
All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record |
American Academy of Neurology |
|
N/A/ 414 |
N/A |
Registry |
Process |
Effective Clinical Care |
Evaluation or Interview for Risk of Opioid Misuse
All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAAP-R) or patient interview documented at least once during Opioid Therapy in the medical record |
American Academy of Neurology |
!! |
N/A/ 419 |
N/A |
Claims, Registry |
Efficiency |
Efficiency and Cost Reduction |
Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination
Percentage of patients with a diagnosis of primary headache disorder whom advanced brain imaging was not ordered |
American Academy of Neurology |
|
2152/431 |
NA |
Registry |
Process |
Community/ Population Health |
Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user. |
Physician Consortium for Performance Improvement Foundation (PCPI®)
|
! |
N/A/ 435 |
N/A |
Claims, Registry |
Outcome |
Effective Clinical Care |
Quality Of Life Assessment For Patients With Primary Headache Disorders
Percentage of patients with a diagnosis of primary headache disorder whose health related quality of life (HRQoL) was assessed with a tool(s) during at least two visits during the 12 month measurement period AND whose health related quality of life score stayed the same or improved |
American Academy of Neurology |
Comments: CMS received several comments supporting the inclusion of neurology as a specialty measure set. Additionally, one commenter asked that #32 be removed because it does not apply to general neurology clinicians.
Response: CMS does not agree and believes that #32 is reasonable to include in the measure set as it is applicable to some specialists. Finally, CMS has added previously identified cross-cutting measures that are relevant for the specialty set (#047, #128, #130, #226, #317, #374, #402, and #431). CMS believes the finalized specialty set reflects the relevant measures appropriate for the neurology specialty.
Final Decision: CMS is finalizing the neurology specialty measure set as indicated in the table above. |
|||||||
MIPS ID Number |
NQF/ PQRS |
CMS E-Measure ID |
Data Submission Method |
Measure Type |
National Quality Strategy Domain |
Measure Title and Description¥ |
Measure Steward |
||
|
|||||||||
|
105/ 009 |
128v5 |
EHR |
Process |
Effective Clinical Care |
Anti-Depressant Medication Management Percentage of patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on antidepressant medication treatment. Two rates are reported a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks) b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months) |
National Committee for Quality Assurance |
||
|
0326/ 047 |
N/A |
Claims, Registry |
Process |
Communication and Care Coordination |
Care Plan
Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
|
National Committee for Quality Assurance |
||
|
0421/128 |
69v5 |
Claims, Registry, EHR, Web Interface |
Process |
Community/ Population Health |
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter |
Centers for Medicare & Medicaid Services |
||
|
0419/130 |
68v6 |
Claims, Registry, EHR, |
Process |
Patient Safety |
Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration.
|
Centers for Medicare & Medicaid Services |
||
*
|
0418/134 |
2v6 |
Claims, Web Interface, Registry, EHR |
Process |
Community/Population Health |
Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan
Percentage of patients aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen |
Centers for Medicare & Medicaid Services |
||
! |
N/A/ 181
|
N/A |
Claims, Registry |
Process |
Patient Safety |
Elder Maltreatment Screen and Follow-Up Plan
Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening Tool on the date of encounter AND a documented follow-up plan on the date of the positive screen
|
Centers for Medicare & Medicaid Services |
||
|
0028/ 226 |
138v5 |
Claims, Registry, EHR, ,Web Interface |
Process |
Community/Population Health |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.
|
Physician Consortium for Performance Improvement Foundation (PCPI®) |
||
|
N/A/ 281 |
149v5 |
EHR |
Process |
Effective Clinical Care |
Dementia: Cognitive Assessment
Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12 month period |
-Physician Consortium for Performance Improvement Foundation (PCPI®) |
||
* |
N/A/ 282 |
N/A |
Registry |
Process |
Effective Clinical Care |
Dementia: Functional Status Assessment
Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of functional status is performed and the results reviewed at least once within a 12 month period |
American Academy of Neurology |
||
* |
N/A/ 283 |
N/A |
Registry |
Process |
Effective Clinical Care |
Dementia: Neuropsychiatric Symptom Assessment
Percentage of patients, regardless of age, with a diagnosis of dementia and for whom an assessment of neuropsychiatric symptoms is performed and results reviewed at least once in a 12 month period |
American Academy of Neurology |
||
* |
N/A/ 284 |
N/A |
Registry |
Process |
Effective Clinical Care |
Dementia: Management of Neuropsychiatric Symptoms
Percentage of patients, regardless of age, with a diagnosis of dementia who have one or more neuropsychiatric symptoms who received or were recommended to receive an intervention for neuropsychiatric symptoms within a 12 month period |
American Academy of Neurology |
||
* ! |
N/A/ 286 |
N/A |
Registry |
Process |
Patient Safety |
Dementia: Counseling Regarding Safety Concerns
Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled or referred for counseling regarding safety concerns within a 12 month period |
American Academy of Neurology |
||
* ! |
N/A/ 288 |
N/A |
Registry |
Process |
Communication and Care Coordination |
Dementia: Caregiver Education and Support
Percentage of patients, regardless of age, with a diagnosis of dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND referred to additional sources for support within a 12 month period |
American Academy of Neurology |
||
* |
N/A/317 |
22v5 |
Claims, Registry, EHR |
Process
|
Community/Population Health
|
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.
|
Centers for Medicare & Medicaid Services |
||
! |
N/A/ 325 |
N/A |
Registry |
Process |
Communication/ Care Coordination |
Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions
Percentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Renal Disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition
|
American Psychiatric Association |
||
|
0108/366 |
136v6 |
EHR |
Process
|
Effective Clinical Care |
ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication:
Percentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported. a. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase. b. Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.
|
National Committee for Quality Assurance |
||
* § ! |
0710/370 |
159v5 |
Web Interface, Registry, EHR |
Outcome
|
Effective Clinical Care |
Depression Remission at Twelve Months:
Patients age 18 and older with major depression or dysthymia and an initial Patient Health Questionnaire (PHQ-9) score greater than nine who demonstrate remission at twelve months (+/- 30 days after an index visit) defined as a PHQ-9 score less than five. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment.
|
Minnesota Community Measurement |
||
|
0712/371 |
160v5 |
EHR |
Process
|
Effective Clinical Care |
Depression Utilization of the PHQ-9 Tool:
Patients age 18 and older with the diagnosis of major depression or dysthymia who have a Patient Health Questionnaire (PHQ-9) tool administered at least once during a 4 month period in which there was a qualifying visit
|
Minnesota Community Measurement |
||
|
NA/ 374 |
50v5 |
EHR |
Process |
Communication and Care Coordination |
Closing the Referral Loop: Receipt of Specialist Report
Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred.
|
Centers for Medicare & Medicaid Services |
||
! |
1365/382 |
177v5 |
EHR |
Process |
Patient Safety |
Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment:
Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk.
|
Physician Consortium for Performance Improvement Foundation (PCPI®) |
||
! |
1879/383
|
N/A |
Registry |
Intermediate Outcome |
Patient Safety |
Adherence to Antipsychotic Medications for Individuals with Schizophrenia
Percentage of individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months)
|
National Committee for Quality Assurance
|
||
! |
0576/391
|
N/A |
Registry |
Process |
Communication/ Care Coordination |
Follow-up After Hospitalization for Mental Illness (FUH)
The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported: - The percentage of discharges for which the patient received follow-up within 30 days of discharge - The percentage of discharges for which the patient received follow-up within 7 days of discharge
|
National Committee for Quality Assurance
|
||
|
NA/ 402 |
NA |
Registry |
Process |
Community/ Population Health |
Tobacco Use and Help with Quitting Among Adolescents
The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user |
National Committee for Quality Assurance |
||
! |
0711/411‡ |
N/A |
Registry
|
Outcome
|
Effective Clinical Care |
Depression Remission at Six Months:
Adult patients age 18 years and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at six months defined as a PHQ-9 score less than 5. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment. This measure additionally promotes ongoing contact between the patient and provider as patients who do not have a follow-up PHQ-9 score at six months (+/- 30 days) are also included in the denominator
|
Minnesota Community Measurement |
||
|
2152/431 |
NA |
Registry |
Process |
Community/ Population Health |
Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user. |
Physician Consortium for Performance Improvement Foundation (PCPI®)
|
||
Comments: CMS received several specific comments regarding changes to the measure set, such as the addition of measures #366, #370, #371, #382, #411.
Response: After further review, CMS agrees with commenters that the measures recommended are applicable to the specialty measure set. As such, CMS has added the aforementioned measures to the mental and behavioral measure set. CMS has also added previously identified cross-cutting measures that are relevant for the specialty set (#047, #128, #130, #226, #317, #374, #402, and #431). CMS believes the finalized specialty set reflects the relevant measures appropriate for the mental and behavioral specialty.
Final Decision: CMS is finalizing the mental and behavioral health specialty measure set as indicated in the table above. |
|||||||||
MIPS ID Number |
NQF/ PQRS |
CMS E-Measure ID |
Data Submission Method |
Measure Type |
National Quality Strategy Domain |
Measure Title and Description¥ |
Measure Steward |
|
|||||||
20a. Diagnostic Radiology |
|||||||
!! |
N/A/ 145 |
N/A |
Registry |
Process |
Patient Safety |
Radiology: Exposure Dose or Time Reported for Procedures Using Fluoroscopy
Final reports for procedures using fluoroscopy that document radiation exposure indices, or exposure time and number of fluorographic images (if radiation exposure indices are not available) |
American College of Radiology |
! |
0508/ 146 |
N/A |
Claims, Registry |
Process |
Efficiency and Cost Reduction |
Radiology: Inappropriate Use of “Probably Benign” Assessment Category in Mammography Screening
Percentage of final reports for screening mammograms that are classified as “probably benign” |
American College of Radiology |
! |
N/A/ 147 |
N/A |
Claims, Registry |
Process |
Communication and Care Coordination |
Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy
Percentage of final reports for all patients, regardless of age, undergoing bone scintigraphy that include physician documentation of correlation with existing relevant imaging studies (e.g., x-ray, MRI, CT, etc.) that were performed |
Society of Nuclear Medicine and Molecular Imaging |
|
0507/ 195 |
N/A |
Claims, Registry |
Process |
Effective Clinical Care |
Radiology: Stenosis Measurement in Carotid Imaging Reports
Percentage of final reports for carotid imaging studies (neck magnetic resonance angiography [MRA], neck computed tomography angiography [CTA], neck duplex ultrasound, carotid angiogram) performed that include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement |
American College of Radiology |
! |
0509/225 |
N/A |
Claims, Registry |
Structure |
Communication and Care Coordination |
Radiology: Reminder System for Screening Mammograms
Percentage of patients undergoing a screening mammogram whose information is entered into a reminder system with a target due date for the next mammogram |
American College of Radiology |
* ! |
N/A/ 359 |
N/A |
Registry |
Process |
Communication and Care Coordination |
Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging
Percentage of computed tomography (CT) imaging reports for all patients, regardless of age, with the imaging study named according to a standardized nomenclature and the standardized nomenclature is used in institution’s computer systems |
American College of Radiology |
* !! |
N/A/ 360
|
N/A |
Registry |
Process |
Patient Safety |
Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies
Percentage of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion studies) imaging reports for all patients, regardless of age, that document a count of known previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion) studies that the patient has received in the 12-month period prior to the current study. |
American College of Radiology |
* ! |
N/A/ 361 |
N/A |
Registry |
Structure |
Patient Safety |
Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry
Percentage of total computed tomography (CT) studies performed for all patients, regardless of age, that are reported to a radiation dose index registry that is capable of collecting at a minimum selected data elements |
American College of Radiology |
* ! |
N/A/ 362
|
N/A |
Registry |
Structure |
Communication and Care Coordination |
Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison Purposes
Percentage of final reports for computed tomography (CT) studies performed for all patients, regardless of age, which document that Digital Imaging and Communications in Medicine (DICOM) format image data are available to non-affiliated external healthcare facilities or entities on a secure, media free, reciprocally searchable basis with patient authorization for at least a 12-month period after the study
This measure was finalized for inclusion in 2014 PQRS in the CY 2013 PFS Final Rule (see Table 52 at 78 FR 74667)
|
American College of Radiology |
* ! |
N/A/ 363 |
N/A |
Registry |
Structure |
Communication and Care Coordination |
Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Studies Through a Secure, Authorized, Media-Free, Shared Archive
Percentage of final reports of computed tomography (CT) studies performed for all patients, regardless of age, which document that a search for Digital Imaging and Communications in Medicine (DICOM) format images was conducted for prior patient CT imaging studies completed at non-affiliated external healthcare facilities or entities within the past 12-months and are available through a secure, authorized, media free, shared archive prior to an imaging study being performed
|
American College of Radiology |
* !! |
N/A/ 364 |
N/A |
Registry |
Process |
Communication and Care Coordination |
Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines
Percentage of final reports for computed tomography (CT) imaging studies of the thorax for patients aged 18 years and older with documented follow-up recommendations for incidentally detected pulmonary nodules (e.g., follow-up CT imaging studies needed or that no follow-up is needed) based at a minimum on nodule size AND patient risk factors
|
American College of Radiology |
|
N/A/ 405 |
N/A |
Claims, Registry |
Process |
Effective Clinical Care |
Appropriate Follow-up Imaging for Incidental Abdominal Lesions
Percentage of final reports for abdominal imaging studies for asymptomatic patients aged 18 years and older with one or more of the following noted incidentally with follow‐up imaging recommended: • Liver lesion ≤ 0.5 cm • Cystic kidney lesion < 1.0 cm • Adrenal lesion ≤ 1.0 cm
|
American College of Radiology |
!! |
N/A/ 406 |
N/A |
Claims, Registry |
Process |
Effective Clinical Care |
Appropriate Follow-Up Imaging for Incidental Thyroid Nodules in Patients
Percentage of final reports for computed tomography (CT), magnetic resonance imaging (MRI) or magnetic resonance angiogram (MRA) studies of the chest or neck or ultrasound of the neck for patients aged 18 years and older with no known thyroid disease with a thyroid nodule < 1.0 cm noted incidentally with follow-up imaging recommended |
American College of Radiology |
|
N/A/ 436 |
N/A |
Claims, Registry |
Process |
Effective Clinical Care |
Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques
Percentage of final reports for patients aged 18 years and older undergoing CT with documentation that one or more of the following dose reduction techniques were used: • Automated exposure control • Adjustment of the mA and/or kV according to patient size • Use of iterative reconstruction technique |
American College of Radiology/ American Medical Association-Physician Consortium for Performance Improvement/ National Committee for Quality Assurance |
20b. Interventional Radiology |
|||||||
! |
N/A/ 259 |
N/A |
Registry |
Outcome |
Patient Safety |
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)
Percent of patients undergoing endovascular repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) that do not experience a major complication (discharged to home no later than post-operative day #2) |
Society for Vascular Surgeons |
! |
N/A/ 265 |
N/A |
Registry |
Process |
Communication and Care Coordination |
Biopsy Follow-Up
Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient by the performing physician |
American Academy of Dermatology |
! |
N/A/ 344 |
N/A |
Registry |
Outcome |
Effective Clinical Care |
Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)
Percent of asymptomatic patients undergoing CAS who are discharged to home no later than post-operative day #2 |
Society for Vascular Surgeons |
! |
N/A/ 345 |
N/A |
Registry |
Outcome |
Effective Clinical Care |
Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS)
Percent of asymptomatic patients undergoing CAS who experience stroke or death following surgery while in the hospital |
Society for Vascular Surgeons |
Comments: CMS received several comments that recommended CMS remove the radiation oncology sub-specialty from the radiology specialty measure set. Commenters cited that the sub-specialty should be in a specialty set of its own or within an oncology specialty set. CMS also received specific comments to remove #360 from the specialty set.
Response: Under further review, CMS agrees with commenters that the radiation oncology specialty set should be removed from the radiology specialty set and moved to the oncology specialty set. CMS believes that measure #360 is relevant to most radiologists and that if it is not, radiologists have the opportunity to choose other measures to report if #360 is not applicable. Therefore, we will continue to include #360 in measure set. CMS believes the finalized specialty set reflects the relevant measures appropriate for the radiology specialty.
Final Decision: CMS is finalizing the radiology specialty measure set as indicated in the table above. |
|||||||
MIPS ID Number |
NQF/ PQRS |
CMS E-Measure ID |
Data Submission Method |
Measure Type |
National Quality Strategy Domain |
Measure Title and Description¥ |
Measure Steward |
|||||||
|
||||||||||||||
21a. Vascular Surgery |
||||||||||||||
|
0326/ 047 |
N/A |
Claims, Registry |
Process |
Communication and Care Coordination |
Care Plan
Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
|
National Committee for Quality Assurance |
|||||||
|
0421/128 |
69v5 |
Claims, Registry, EHR, Web Interface |
Process |
Community/ Population Health |
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter |
Centers for Medicare & Medicaid Services |
|||||||
|
0419/130 |
68v6 |
Claims, Registry, EHR, |
Process |
Patient Safety |
Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration.
|
Centers for Medicare & Medicaid Services |
|||||||
|
0028/ 226 |
138v5 |
Claims, Registry, EHR, ,Web Interface |
Process |
Community/Population Health |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.
|
Physician Consortium for Performance Improvement Foundation (PCPI®) |
|||||||
|
0018/ 236 |
165v5 |
Claims, Registry, EHR, Web Interface |
Intermediate Outcome |
Effective Clinical Care |
Controlling High Blood Pressure
Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90 mmHg) during the measurement period
|
National Committee for Quality Assurance |
|||||||
! |
N/A/ 258 |
N/A |
Registry |
Outcome |
Patient Safety |
Rate of Open Elective Repair of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7)
Percent of patients undergoing open repair of small or moderate sized non-ruptured infrarenal abdominal aortic aneurysms who do not experience a major complication (discharge to home no later than post-operative day #7) |
Society for Vascular Surgeons |
|||||||
! |
N/A/ 259 |
N/A |
Registry |
Outcome |
Patient Safety |
Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged at Home by Post-Operative Day #2)
Percent of patients undergoing endovascular repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) that do not experience a major complication (discharged to home no later than post-operative day #2) |
Society for Vascular Surgeons |
|||||||
! |
N/A/ 260 |
N/A |
Registry |
Outcome |
Patient Safety |
Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2)
Percent of asymptomatic patients undergoing CEA who are discharged to home no later than post-operative day #2) |
Society for Vascular Surgeons |
|||||||
* |
N/A/317 |
22v5 |
Claims, Registry, EHR |
Process
|
Community/Population Health
|
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.
|
Centers for Medicare & Medicaid Services |
|||||||
! |
N/A/ 344 |
N/A |
Registry |
Outcome |
Effective Clinical Care |
Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)
Percent of asymptomatic patients undergoing CAS who are discharged to home no later than post-operative day #2 |
Society for Vascular Surgeons |
|||||||
! |
N/A/ 345 |
N/A |
Registry |
Outcome |
Effective Clinical Care |
Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS)
Percent of asymptomatic patients undergoing CAS who experience stroke or death following surgery while in the hospital |
Society for Vascular Surgeons |
|||||||
! |
1534/347 |
N/A |
Registry |
Outcome |
Patient Safety |
Rate of Endovascular Aneurysm Repair (EVAR of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) Who Die While in Hospital
Percent of patients undergoing endovascular repair of small or moderate infrarenal abdominal aortic aneurysms (AAA) who die while in the hospital |
Society for Vascular Surgeons |
|||||||
* ! |
N/A/ 357 |
N/A |
Registry |
Outcome |
Effective Clinical Care |
Surgical Site Infection (SSI)
Percentage of patients aged 18 years and older who had a surgical site infection (SSI) |
American College of Surgeons |
|||||||
|
NA/ 374 |
50v5 |
EHR |
Process |
Communication and Care Coordination |
Closing the Referral Loop: Receipt of Specialist Report
Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred.
|
Centers for Medicare & Medicaid Services |
|||||||
|
NA/ 402 |
NA |
Registry |
Process |
Community/ Population Health |
Tobacco Use and Help with Quitting Among Adolescents
The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user |
National Committee for Quality Assurance |
|||||||
21b. General Surgery |
||||||||||||||
!! |
0268/021 |
N/A |
Claims, Registry |
Process |
Patient Safety |
Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalasporin
Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic, which had an order for a first OR second generation cephalosporin for antimicrobial prophylaxis |
American Society of Plastic Surgeons |
|||||||
! |
0239/023 |
N/A |
Claims, Registry |
Process |
Patient Safety |
Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)
Percentage of surgical patients aged 18 years and older undergoing procedures for which venous thromboembolism (VTE) prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low-Dose Unfractionated heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time |
American Society of Plastic Surgeons |
|||||||
|
0326/ 047 |
N/A |
Claims, Registry |
Process |
Communication and Care Coordination |
Care Plan
Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
|
National Committee for Quality Assurance |
|||||||
|
0421/128 |
69v5 |
Claims, Registry, EHR, Web Interface |
Process |
Community/ Population Health |
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter |
Centers for Medicare & Medicaid Services |
|||||||
|
0419/130 |
68v5 |
Claims, Registry, EHR, Web Interface |
Process |
Patient Safety |
Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration.
|
Centers for Medicare & Medicaid Services |
|||||||
|
0028/ 226 |
138v5 |
Claims, Registry, EHR, ,Web Interface |
Process |
Community/Population Health |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.
|
Physician Consortium for Performance Improvement Foundation (PCPI®) |
|||||||
* |
N/A/317 |
22v5 |
Claims, Registry, EHR |
Process
|
Community/Population Health
|
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.
|
Centers for Medicare & Medicaid Services |
|||||||
* ! |
N/A/ 354 |
N/A
|
Registry |
Outcome |
Patient Safety |
Anastomotic Leak Intervention
Percentage patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery |
American College of Surgeons |
|||||||
* ! |
N/A/ 355 |
N/A |
Registry |
Outcome |
Patient Safety |
Unplanned Reoperation within the 30 Day Postoperative Period
Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period |
American College of Surgeons |
|||||||
* ! |
N/A/ 356 |
N/A |
Registry |
Outcome |
Effective Clinical Care |
Unplanned Hospital Readmission within 30 Days of Principal Procedure
Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure |
American College of Surgeons |
|||||||
* ! |
N/A/ 357 |
N/A |
Registry |
Outcome |
Effective Clinical Care |
Surgical Site Infection (SSI)
Percentage of patients aged 18 years and older who had a surgical site infection (SSI) |
American College of Surgeons |
|||||||
! |
N/A/ 358 |
N/A |
Registry |
Process |
Person and Caregiver-Centered Experience and Outcomes |
Patient-Centered Surgical Risk Assessment and Communication
Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon |
American College of Surgeons |
|||||||
|
NA/ 374 |
50v5 |
EHR |
Process |
Communication and Care Coordination |
Closing the Referral Loop: Receipt of Specialist Report
Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred.
|
Centers for Medicare & Medicaid Services |
|||||||
|
NA/ 402 |
NA |
Registry |
Process |
Community/ Population Health |
Tobacco Use and Help with Quitting Among Adolescents
The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user |
National Committee for Quality Assurance |
|||||||
Comments: CMS received specific comments to add #357 to the measure set.
Response: CMS agrees that measure #357 is applicable to the surgery specialty and will, therefore add the measure to the set. CMS has also added previously identified cross-cutting measures that are relevant for the specialty set (#047, #128, #130, #226, #317, #374, and #402). CMS believes the finalized specialty set reflects the relevant measures appropriate for the surgery specialty and sub-specialties.
Final Decision: CMS is finalizing the surgery specialty measure set as indicated in the table above. |
||||||||||||||
MIPS ID Number |
NQF/ PQRS |
CMS E-Measure ID |
Data Submission Method |
Measure Type |
National Quality Strategy Domain |
Measure Title and Description¥ |
Measure Steward |
|
|||||||
!! |
0268/021 |
N/A |
Claims, Registry |
Process |
Patient Safety |
Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin
Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic, who had an order for a first OR second generation cephalosporin for antimicrobial prophylaxis |
American Society of Plastic Surgeons |
! |
0239/023 |
N/A |
Claims, Registry |
Process |
Patient Safety |
Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)
Percentage of surgical patients aged 18 years and older undergoing procedures for which venous thromboembolism (VTE) prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time |
American Society of Plastic Surgeons |
|
0326/ 047 |
N/A |
Claims, Registry |
Process |
Communication and Care Coordination |
Care Plan
Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
|
National Committee for Quality Assurance |
|
0419/130 |
68v6 |
Claims, Registry, EHR, |
Process |
Patient Safety |
Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration.
|
Centers for Medicare & Medicaid Services |
! |
0129/164 |
N/A
|
Registry |
Outcome |
Effective Clinical Care |
Coronary Artery Bypass Graft (CABG): Prolonged Intubation
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation > 24 hours |
American Thoracic Society |
* ! |
0130/165 |
N/A
|
Registry |
Outcome |
Effective Clinical Care |
Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who, within 30 days postoperatively, develop deep sternal wound infection involving muscle, bone, and/or mediastinum requiring operative intervention |
American Thoracic Society |
* ! |
0131/166 |
N/A
|
Registry |
Outcome |
Effective Clinical Care |
Coronary Artery Bypass Graft (CABG): Stroke
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who have a postoperative stroke (i.e., any confirmed neurological deficit of abrupt onset caused by a disturbance in blood supply to the brain) that did not resolve within 24 hours |
American Thoracic Society |
* ! |
0114/167 |
N/A
|
Registry |
Outcome |
Effective Clinical Care |
Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure
Percentage of patients aged 18 years and older undergoing isolated CABG surgery (without pre-existing renal failure) who develop postoperative renal failure or require dialysis |
American Thoracic Society |
* ! |
0115/168 |
N/A |
Registry |
Outcome |
Effective Clinical Care
|
Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require a return to the operating room (OR) during the current hospitalization for mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction, or other cardiac reason |
Society of Thoracic Surgeons |
|
0028/ 226 |
138v5 |
Claims, Registry, EHR, ,Web Interface |
Process |
Community/Population Health |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.
|
Physician Consortium for Performance Improvement Foundation (PCPI®) |
|
0018/ 236 |
165v5 |
Claims, Registry, EHR, Web Interface |
Intermediate Outcome |
Effective Clinical Care |
Controlling High Blood Pressure
Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90 mmHg) during the measurement period
|
National Committee for Quality Assurance |
* |
N/A/317 |
22v5 |
Claims, Registry, EHR |
Process
|
Community/Population Health
|
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.
|
Centers for Medicare & Medicaid Services |
! |
N/A/ 358 |
N/A |
Registry |
Process |
Person and Caregiver-Centered Experience and Outcomes |
Patient-Centered Surgical Risk Assessment and Communication
Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon |
American College of Surgeons |
|
NA/ 374 |
50v5 |
EHR |
Process |
Communication and Care Coordination |
Closing the Referral Loop: Receipt of Specialist Report
Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred.
|
Centers for Medicare & Medicaid Services |
|
NA/ 402 |
NA |
Registry |
Process |
Community/ Population Health |
Tobacco Use and Help with Quitting Among Adolescents
The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user |
National Committee for Quality Assurance |
CMS did not receive specific comments regarding changes to the measure set.
Response: CMS has added previously identified cross-cutting measures that are relevant for the specialty set (#047, #128, #130, #226, #236, #317, #374, and #402). CMS believes the finalized specialty set reflects the relevant measures appropriate for the thoracic surgery specialty.
Final Decision: CMS is finalizing the thoracic surgery specialty measure set as indicated in the table above. |
|||||||
MIPS ID Number |
NQF/ PQRS |
CMS E-Measure ID |
Data Submission Method |
Measure Type |
National Quality Strategy Domain |
Measure Title and Description¥ |
Measure Steward |
|
|||||||
|
0326/ 047 |
N/A |
Claims, Registry |
Process |
Communication and Care Coordination |
Care Plan
Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
|
National Committee for Quality Assurance |
|
N/A/ 048 |
N/A |
Claims, Registry |
Process |
Effective Clinical Care |
Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older
Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months |
National Committee for Quality Assurance |
! |
N/A/ 050 |
N/A |
Claims, Registry |
Process |
Person and Caregiver-Centered Experience and Outcomes |
Urinary Incontinence: Assessment of Presence or Absence Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older
Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months |
National Committee for Quality Assurance |
* § !! |
0389/ 102 |
129v6 |
Registry, EHR |
Process |
Efficiency and Cost Reduction |
Prostate Cancer: Avoidance of Overuse of Bone Scan for staging Low Risk Prostate Cancer Patients
Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer
|
Physician Consortium for Performance Improvement Foundation (PCPI®) |
|
0390/ 104 |
N/A |
Registry |
Process |
Effective Clinical Care |
Prostate Cancer: Adjuvant Hormonal Therapy for High Risk or very High Risk Prostate Cancer
Percentage of patients, regardless of age, with a diagnosis of prostate cancer at high or very high risk of recurrence receiving external beam radiotherapy to the prostate who were prescribed adjuvant hormonal therapy (GnRH [gonadotropin-releasing hormone] agonist or antagonist |
American Urological Association Education and Research |
|
0419/130 |
68v6 |
Claims, Registry, EHR, |
Process |
Patient Safety |
Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration.
|
Centers for Medicare & Medicaid Services |
|
0028/ 226 |
138v5 |
Claims, Registry, EHR, ,Web Interface |
Process |
Community/Population Health |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.
|
Physician Consortium for Performance Improvement Foundation (PCPI®) |
! |
N/A/ 265 |
N/A |
Registry |
Process |
Communication and Care Coordination |
Biopsy Follow-Up
Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient by the performing physician |
American Academy of Dermatology |
* |
N/A/317 |
22v5 |
Claims, Registry, EHR |
Process
|
Community/Population Health
|
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.
|
Centers for Medicare & Medicaid Services |
! |
N/A/ 358 |
N/A |
Registry |
Process |
Person and Caregiver-Centered Experience and Outcomes |
Patient-Centered Surgical Risk Assessment and Communication
Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon |
American College of Surgeons |
|
NA/ 374 |
50v5 |
EHR |
Process |
Communication and Care Coordination |
Closing the Referral Loop: Receipt of Specialist Report
Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred.
|
Centers for Medicare & Medicaid Services |
|
NA/ 402 |
NA |
Registry |
Process |
Community/ Population Health |
Tobacco Use and Help with Quitting Among Adolescents
The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user |
National Committee for Quality Assurance |
CMS did not receive specific comments regarding changes to the measure set.
Response: CMS removed #357 Surgical Site Infection because the measure is not applicable to Urology specialty. CMS also has added previously identified cross-cutting measures that are relevant for the specialty set (#047, #128, #130, #226, #317, #374, and #402). CMS believes the finalized specialty set reflects the relevant measures appropriate for the urology specialty.
Final Decision: CMS is finalizing the urology specialty measure set as indicated in the table above. |
|||||||
MIPS ID Number |
NQF/ PQRS |
CMS E-Measure ID |
Data Submission Method |
Measure Type |
National Quality Strategy Domain |
Measure Title and Description¥ |
Measure Steward |
|
|||||||
24a. General Oncology |
|||||||
|
0326/ 047 |
N/A |
Claims, Registry |
Process |
Communication and Care Coordination |
Care Plan
Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
|
National Committee for Quality Assurance |
* § !! |
0389/102 |
129v6 |
Registry, EHR |
Process |
Efficiency and Cost Reduction |
Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients
Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer |
Physician Consortium for Performance Improvement Foundation (PCPI®) |
|
0419/130 |
68v6 |
Claims, Registry, EHR, |
Process |
Patient Safety |
Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration.
|
Centers for Medicare & Medicaid Services |
§ !
|
0384/143 |
157v5 |
Registry, EHR |
Process |
Person and Caregiver Centered Experience and Outcome |
Oncology: Medical and Radiation – Pain Intensity Quantified
Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified |
Physician Consortium for Performance Improvement Foundation (PCPI® |
|
0028/ 226 |
138v5 |
Claims, Registry, EHR, ,Web Interface |
Process |
Community/Population Health |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.
|
Physician Consortium for Performance Improvement Foundation (PCPI®) |
§ |
1853/250 |
N/A |
Claims, Registry |
Process |
Effective Clinical Care |
Radical Prostatectomy Pathology Reporting: Percentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin status.
|
College of American Pathologists |
* |
N/A/317 |
22v5 |
Claims, Registry, EHR |
Process
|
Community/Population Health
|
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.
|
Centers for Medicare & Medicaid Services |
|
NA/ 374 |
50v5 |
EHR |
Process |
Communication and Care Coordination |
Closing the Referral Loop: Receipt of Specialist Report
Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred.
|
Centers for Medicare & Medicaid Services |
|
NA/ 402 |
NA |
Registry |
Process |
Community/ Population Health |
Tobacco Use and Help with Quitting Among Adolescents
The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user |
National Committee for Quality Assurance |
|
2152/431 |
NA |
Registry |
Process |
Community/ Population Health |
Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user. |
Physician Consortium for Performance Improvement Foundation (PCPI®)
|
+ § !! |
1857/449 |
NA |
Registry |
Process |
Efficiency and Cost Reduction |
HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment with HER2-Targeted Therapies:
Proportion of female patients (aged 18 years and older) with breast cancer who are human epidermal growth factor receptor 2 (HER2)/neu negative who are not administered HER2-targeted therapies |
American Society of Clinical Oncology |
+ § !! |
1858/450 |
NA |
Registry |
Process |
Efficiency and Cost Reduction |
Trastuzumab Received By Patients With AJCC Stage I (T1c) – III And HER2 Positive Breast Cancer Receiving Adjuvant Chemotherapy: Proportion of female patients (aged 18 years and older) with AJCC stage I (T1c) – III, human epidermal growth factor receptor 2 (HER2) positive breast cancer receiving adjuvant chemotherapy who are also receiving trastuzumab |
American Society of Clinical Oncology |
+ § |
1859/451 |
NA |
Registry |
Process |
Effective Clinical Care |
KRAS Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy::
Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy for whom KRAS gene mutation testing was performed.
|
American Society of Clinical Oncology |
+ § !! |
1860/452 |
NA |
Registry |
Process |
Patient Safety |
Patients with Metastatic Colorectal Cancer and KRAS Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal: Antibodies: Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer and KRAS gene mutation spared treatment with anti-EGFR monoclonal antibodies.
|
American Society of Clinical Oncology |
+ § !! |
0210/453 |
NA |
Registry |
Process |
Effective Clinical Care |
Proportion Receiving Chemotherapy in the Last 14 Days of life::
Proportion of patients who died from cancer receiving chemotherapy in the last 14 days of life.
|
American Society of Clinical Oncology |
+ § !! |
0211/454 |
|
Registry |
Outcome |
Effective Clinical Care |
Proportion of Patients who Died from Cancer with more than One Emergency Department Visit in the Last 30 Days of Life: Proportion of patients who died from cancer with more than one emergency room visit in the last 30 days of life.
|
American Society of Clinical Oncology |
+ § !! |
0213/455 |
|
Registry |
Outcome |
Effective Clinical Care |
Proportion Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life:
Proportion of patients who died from cancer admitted to the ICU in the last 30 days of life.
|
American Society of Clinical Oncology |
+ § !! |
0215/456 |
|
Registry |
Process |
Effective Clinical Care |
Proportion Not Admitted to Hospice:
Proportion of patients who died from cancer not admitted to hospice.
|
American Society of Clinical Oncology |
+ § !! |
0216/457 |
|
Registry |
Outcome |
Effective Clinical Care |
Proportion Admitted to Hospice for less than 3 days:
Proportion of patients who died from cancer, and admitted to hospice and spent less than 3 days there.
|
American Society of Clinical Oncology |
24b. Radiation Oncology |
|||||||
* § !! |
0389/102 |
129v6 |
Registry, EHR |
Process |
Efficiency and Cost Reduction |
Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients
Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer |
Physician Consortium for Performance Improvement Foundation (PCPI®) |
§ !
|
0384/143 |
157v5 |
Registry, EHR |
Process |
Person and Caregiver Centered Experience and Outcome |
Oncology: Medical and Radiation – Pain Intensity Quantified
Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified |
Physician Consortium for Performance Improvement Foundation (PCPI®) |
! |
0383/144 |
N/A |
Registry |
Process |
Person and Caregiver Centered Experience and Outcome |
Oncology: Medical and Radiation – Plan of Care for Pain
Percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain |
American Society of Clinical Oncology |
!! |
0382/156 |
N/A |
Claims, Registry |
Process |
Patient Safety |
Oncology: Radiation Dose Limits to Normal Tissues
Percentage of patients, regardless of age, with a diagnosis of breast, rectal, pancreatic or lung cancer receiving 3D conformal radiation therapy who had documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues |
American Society for Radiation Oncology |
Comments: CMS received several comments that oncology should be a specialty measure set. Several commenters recommended that CMS remove the Radiation oncology sub-specialty from the radiology specialty set and include it within the oncology measure set. Most comments were very specific about which measures should be included in the specialty measure sets. Particularly, commenters requested CMS align the oncology specialty set with the CQMC oncology core set by including #102, #143, #250, #431, #449, #450, #451, #452, #453, #454, #455, #456, and #457.
Response: CMS also included previously identified cross-cutting measures that are relevant for the specialty set (#047, #128, #130, #226, #317, #374, #402, and #431). Additionally, CMS removed the Radiation oncology sub-specialty from the radiology specialty set and included it within the oncology measure set. CMS believes the finalized specialty set reflects the relevant measures appropriate for the oncology specialty.
Final Decision: CMS is finalizing the oncology specialty measure set as indicated in the table above. |
|||||||
MIPS ID Number |
NQF/ PQRS |
CMS E-Measure ID |
Data Submission Method |
Measure Type |
National Quality Strategy Domain |
Measure Title and Description¥ |
Measure Steward |
|
|||||||
§ |
0081/005 |
135v5 |
Registry, EHR |
Process |
Effective Clinical Care |
Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge |
Physician Consortium for Performance Improvement (PCPI®) Foundation |
* § |
0083/008 |
144v5 |
Registry, EHR |
Process |
Effective Clinical Care |
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge |
Physician Consortium for Performance Improvement Foundation(PCPI®) |
|
0325/032 |
N/A |
Claims, Registry |
Process |
Effective Clinical Care |
Stroke and Stroke Rehabilitation: Discharged on Antithrombotic Therapy
Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or transient ischemic attack (TIA) who were prescribed an antithrombotic therapy at discharge. |
American Academy of Neurology |
|
0326/ 047 |
N/A |
Claims, Registry |
Process |
Communication and Care Coordination |
Care Plan
Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
|
National Committee for Quality Assurance |
! |
N/A/ 076 |
N/A |
Claims, Registry |
Process |
Patient Safety |
Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections
Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed |
American Society of Anesthesiologists |
|
0421/128 |
69v5 |
Claims, Registry, EHR, Web Interface |
Process |
Community/ Population Health |
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter |
Centers for Medicare & Medicaid Services |
|
0419/130 |
68v6 |
Claims, Registry, EHR, |
Process |
Patient Safety |
Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration.
|
Centers for Medicare & Medicaid Services |
|
0028/ 226 |
138v5 |
Claims, Registry, EHR, ,Web Interface |
Process |
Community/Population Health |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.
|
Physician Consortium for Performance Improvement Foundation (PCPI®) |
* |
N/A/317 |
22v5 |
Claims, Registry, EHR |
Process
|
Community/Population Health
|
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.
|
Centers for Medicare & Medicaid Services |
|
NA/ 374 |
50v5 |
EHR |
Process |
Communication and Care Coordination |
Closing the Referral Loop: Receipt of Specialist Report
Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred.
|
Centers for Medicare & Medicaid Services |
|
NA/ 402 |
NA |
Registry |
Process |
Community/ Population Health |
Tobacco Use and Help with Quitting Among Adolescents
The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user |
National Committee for Quality Assurance |
!! |
N/A/407‡ |
N/A |
Claims, Registry |
Process
|
Effective Clinical Care |
Appropriate Treatment of MSSA Bacteremia:
Percentage of patients with sepsis due to MSSA bacteremia who received beta-lactam antibiotic (e.g. nafcillin, oxacillin or cefazolin) as definitive therapy.
|
Infectious Disease Society of America |
|
2152/431 |
NA |
Registry |
Process |
Community/ Population Health |
Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user. |
Physician Consortium for Performance Improvement Foundation (PCPI®)
|
Comments: CMS received several comments that hospitalist should be a specialty measure set. Commenters included specific measure recommendations within their comment. Specifically, commenters asked that the specialty measure set align with the preferred specialty set in PQRS which includes measures #5, #8, #32, #47, #76, #130, #187, #407.
Response: Upon further review of the recommendations provided by the commenters, CMS agreed and added the hospitalist measure set to the specialty measure set list. This set included the measures recommended by the commenters as indicated above, in addition to relevant measures that were previously identified as cross-cutting (#128, #226, #317, #374, #402, #431). CMS believes this new specialty measure set is relevant for hospitalists.
Final Decision: CMS is finalizing the hospitalist specialty measure set as indicated in the table above. |
|||||||
MIPS ID Number |
NQF/ PQRS |
CMS E-Measure ID |
Data Submission Method |
Measure Type |
National Quality Strategy Domain |
Measure Title and Description¥ |
Measure Steward |
|
|||||||
|
0326/ 047 |
N/A |
Claims, Registry |
Process |
Communication and Care Coordination |
Care Plan
Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
|
National Committee for Quality Assurance |
|
0421/128 |
69v5 |
Claims, Registry, EHR, Web Interface |
Process |
Community/ Population Health |
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter |
Centers for Medicare & Medicaid Services |
|
0419/130 |
68v6 |
Claims, Registry, EHR, |
Process |
Patient Safety |
Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration.
|
Centers for Medicare & Medicaid Services |
* |
N/A/176 |
N/A |
Registry |
Process
|
Effective Clinical Care |
Rheumatoid Arthritis (RA): Tuberculosis Screening:
Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have documentation of a tuberculosis (TB) screening performed and results interpreted within 6 months prior to receiving a first course of therapy using a biologic disease-modifying anti-rheumatic drug (DMARD).
|
American College of Rheumatology |
* |
N/A/ 177 |
N/A |
Registry |
Process
|
Effective Clinical Care |
Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity:
Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease activity within 12 months.
|
American College of Rheumatology |
|
N/A/ 178 |
N/A |
Registry |
Process |
Effective Clinical Care
|
Rheumatoid Arthritis (RA): Functional Status Assessment
Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) for whom a functional status assessment was performed at least once within 12 months |
American College of Rheumatology
|
* |
N/A/ 179 |
N/A |
Registry |
Process |
Effective Clinical Care
|
Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis
Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease prognosis at least once within 12 months |
American College of Rheumatology
|
*
|
N/A/ 180 |
N/A |
Registry |
Process |
Effective Clinical Care |
Rheumatoid Arthritis (RA): Glucocorticoid Management
Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone ≥ 10 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months |
American College of Rheumatology
|
|
0028/ 226 |
138v5 |
Claims, Registry, EHR, ,Web Interface |
Process |
Community/Population Health |
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.
|
Physician Consortium for Performance Improvement Foundation (PCPI®) |
* |
N/A/317 |
22v5 |
Claims, Registry, EHR |
Process
|
Community/Population Health
|
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.
|
Centers for Medicare & Medicaid Services |
|
N/A/ 337 |
N/A |
Registry |
Process |
Effective Clinical Care |
Tuberculosis (TB) Prevention for Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier
Percentage of patients whose providers are ensuring active tuberculosis prevention either through yearly negative standard tuberculosis screening tests or are reviewing the patient’s history to determine if they have had appropriate management for a recent or prior positive test |
American Academy of Dermatology |
|
NA/ 374 |
50v5 |
EHR |
Process |
Communication and Care Coordination |
Closing the Referral Loop: Receipt of Specialist Report
Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred.
|
Centers for Medicare & Medicaid Services |
|
NA/ 402 |
NA |
Registry |
Process |
Community/ Population Health |
Tobacco Use and Help with Quitting Among Adolescents
The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user |
National Committee for Quality Assurance |
Comments: CMS received multiple comments requesting CMS separate Rheumatology into a different specialty measure set from Allergy/Immunology. Commenters cited that Allergy, Immunology and Rheumatology specialties are not similar and measures for these specialties do not align.
Response: Based on the comments, CMS agrees that these specialties should not share a specialty measure set. Therefore, CMS is finalizing Rheumatology as a separate specialty measure set. Additionally, CMS added previously identified cross-cutting measures that are relevant for the specialty set (# 047, #128, #130, #226, #317, #374, and #402). CMS believes the finalized specialty set reflects the relevant measures appropriate for Rheumatology specialty.
Final Decision: CMS is finalizing the rheumatology specialty measure set as indicated in the table above. |
|||||||
TABLE F: 2016 PQRS Measures Finalized for Removal for MIPS Reporting in 2017
Indicator |
NQF/ Quality # |
CMS E-Measure ID |
Data Submission Method |
National Quality Strategy Domain |
Measure Title and Description¥ |
Measure Steward |
|
N/A/ 002 |
163v4 |
EHR |
Effective Clinical Care |
Diabetes: Low Density Lipoprotein (LDL-C) Control (<100 mg/dL)
Percentage of patients 18–75 years of age with diabetes whose LDL-C was adequately controlled (< 100 mg/dL) during the measurement period
CMS did not receive specific comments regarding this measure.
Final Decision: This measure no longer reflects evidence. CMS is finalizing its proposal for the removal of this measure because it no longer reflects clinical guidelines and evidence. Clinical guidelines are better represented by PQRS # 438: Statin Therapy for the Prevention and Treatment of Cardiovascular Disease.
|
National Committee for Quality Assurance |
! |
0271/ 022 |
N/A |
Claims, Registry |
Patient Safety |
Perioperative Care: Discontinuation of Prophylactic Parenteral Antibiotics (Non-Cardiac Procedures)
Percentage of non-cardiac surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic parenteral antibiotics AND who received a prophylactic parenteral antibiotic, who have an order for discontinuation of prophylactic parenteral antibiotics within 24 hours of surgical end time
Comments: CMS received several comments to include this measure in the 2017 measure set. Commenter believes this measures is still relevant for certain clinicians and support inclusion in the program if it were modified to be an outcome measure.
Response: CMS is finalizing its proposal to remove this measure. This measure is considered low bar and is part of standard clinical practice. There is no significant performance gap for this measure as indicated by its high performance rate above 95%. Removing this measure will not significantly impact surgeons’ ability to report.
Final Decision: CMS is finalizing its proposal to remove this measure. |
American Medical Association-Physician Consortium for Performance Improvement/ National Committee for Quality Assurance |
|
NA/ 041 |
NA |
Claims, Registry |
Effective Clinical Care |
Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years and Older
Percentage of patients aged 50 years and older with a diagnosis of osteoporosis who were prescribed pharmacologic therapy within 12 months
Comments: CMS received several comments to include this measure in the 2017 measure set. One commenter stated this measure should continue in the program because they do not consider the measure low-bar.
Response: CMS is finalizing its proposal to remove this measure. The measure steward will no longer support stewardship of this measure. Measures implemented in the quality payment program are required to be updated annually by the measure steward. Since the measure steward has removed its support to update this measure in 2017, CMS is finalizing the removal of the measure.
Final Decision: CMS is finalizing its proposal to remove this measure. |
National Committee for Quality Assurance/ American Medical Association-Physician Consortium for Performance Improvement |
|
0047/ 053 |
N/A |
Registry, Measures Group |
Effective Clinical Care |
Asthma: Pharmacologic Therapy for Persistent Asthma - Ambulatory Care Setting
Percentage of patients aged 5 years and older with a diagnosis of persistent asthma who were prescribed long-term control medication
Comments: CMS received several comments to include this measure in the 2017 measure set. Commenters urged CMS not to remove measure because it remained relevant for immunologists.
Response: CMS is finalizing its proposal for the removal of this measure. This measure is being replaced by NQF 1799: Medication Management for People with Asthma. NQF #1799 is a measure included in a CQMC core measure set. Additionally, this measure has a performance rate of above 97%.
Final Decision: CMS is finalizing its proposal to remove this measure. |
American Academy of Allergy, Asthma, and Immunology/ American Medical Association-Physician Consortium for Performance Improvement/ National Committee for Quality Assurance |
|
0090/ 054 |
N/A |
Claims, Registry |
Effective Clinical Care |
Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for Non-Traumatic Chest Pain
Percentage of patients aged 40 years and older with an emergency department discharge diagnosis of non-traumatic chest pain who had a 12-lead electrocardiogram (ECG) performed
Comments: CMS received several comments to include this measure in the 2017 measure set. Commenters cited that removal of this measure would inhibit the number of claims-based measures emergency medicine physicians can report.
Response: CMS is finalizing its proposal for the removal of this measure. This measure is considered low bar and is part of standard clinical practice. There is no significant performance gap for this measure as indicated by the high performance rate of 94%. Removal of this measure does not impact the number of adequate measures for Emergency Department Physicians. CMS estimates that emergency medicine physicians can report more than 10 measures that are claims based if this measure is removed.
Final Decision: CMS is finalizing its proposal to remove this measure. |
American Medical Association-Physician Consortium for Performance Improvement/ National Committee for Quality Assurance |
|
0387/ 071 |
CMS140v4 |
Claims, Registry, EHR, Measures Group |
Effective Clinical Care |
Breast Cancer: Hormonal Therapy for Stage IC -IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer
Percentage of female patients aged 18 years and older with Stage IC through IIIC, ER or PR positive breast cancer who were prescribed tamoxifen or aromatase inhibitor (AI) during the 12-month reporting period
Comments: CMS received comments requesting that CMS not remove this measure from the 2017 measure set. The commenter believed that this measure was easy to report and should not be replaced with more complicated measures.
Response: CMS is finalizing its proposal to remove this measure. CMS is finalizing its proposal to remove this measure as it is similar to a core measure established by the CQMC. Additionally, this measure is topped out with a performance rate above 96%. The CQMC measure is reportable via registry but not EHR. If the clinician was submitting this measure via EHR, the clinician will need to work with a registry to report the new measure. However, the new measure is not more complicated clinically. Additionally, the clinical performance identified with this measure can be addressed by the measures within the core measure set.
Final Decision: CMS is finalizing its proposal to remove this measure. |
American Medical Association-Physician Consortium for Performance Improvement/American Society of Clinical Oncology/ National Comprehensive Cancer Network |
|
0385 /072 |
CMS141v5 |
Claims, Registry, EHR, Measures Group |
Effective Clinical Care |
Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients
Percentage of patients aged 18 through 80 years with AJCC Stage III colon cancer who are referred for adjuvant chemotherapy, prescribed adjuvant chemotherapy, or have previously received adjuvant chemotherapy within the 12-month reporting period
Comments: CMS received comments requesting that CMS not remove this measure from the 2017 measure set. One commenter believed that this measure was easy to report and should not be replaced with more complicated measures.
Response: CMS is finalizing its proposal for the removal of this measure. CMS is finalizing its proposal to remove this measure as it is similar to a core measure. Additionally, this measure is topped out with a performance rate above 98%. This measure is closely related to one of the core measures covered under the Core Measure Collaborative and is not included in the core measure set. The Core Measure Collaborative measure is reportable via registry but not EHR. If the clinician was submitting this measure via EHR, the clinician will need to work with a registry to report the new measure. However, the new measure is not more complicated clinically. Additionally, the clinical performance identified with this measure can be addressed by the measures within the core measure set.
Final Decision: CMS is finalizing its proposal to remove this measure. |
American Medical Association-Physician Consortium for Performance Improvement/American Society of Clinical Oncology/ National Comprehensive Cancer Network |
|
0395/ 084 |
N/A |
Measures Group |
Effective Clinical Care
|
Hepatitis C: Ribonucleic Acid (RNA) Testing Before Initiating Treatment
Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who started antiviral treatment within the 12 month reporting period for whom quantitative hepatitis C virus (HCV) ribonucleic acid (RNA) testing was performed within 12 months prior to initiation of antiviral treatment
Comments: CMS received a comment requesting that this measure continue to be included in the 2017 measure set as an individual measure. Commenter noted that there were not a lot of measures that hepatologists can report and should, therefore, not remove this measure.
Response: This measure was previously a part of a Measures Group and was reportable as a measures group only. To align with the finalized MIPS policy of removing Measures Group as a reporting option, this measure will no longer be reportable as part of a measure group. As an individual measure this measure is considered low-bar and not robust enough to stand alone. CMS is finalizing its proposal to remove this measure because it is considered low-bar as an individual measure and is standard clinical practice.
Final Decision: CMS is finalizing its proposal to remove this measure. |
American Medical Association-Physician Consortium for Performance Improvement /American Gastroenterological Association |
|
0396/ 085 |
N/A |
Measures Group |
Effective Clinical Care
|
Hepatitis C: Hepatitis C Virus (HCV) Genotype Testing Prior to Treatment
Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who started antiviral treatment within the 12 month reporting period for whom hepatitis C virus (HCV) genotype testing was performed within 12 months prior to initiation of antiviral treatment
Comments: CMS received a comment requesting that this measure continue to be included in the 2017 measure set as an individual measure. Commenter noted that there were not a lot of measures that hepatologists can report and should, therefore, not remove this measure.
Response: This measure was previously a part of a Measures Group and was reportable as a measures group only. To align with the finalized MIPS policy of removing Measures Group as a reporting option, this measure will no longer be reportable as part of a measure group. As an individual measure this measure is considered low-bar and not robust enough to stand alone. CMS is finalizing its proposal to remove this measure because it is considered low-bar as an individual measure and is standard clinical practice.
Final Decision: CMS is finalizing its proposal to remove this measure. |
American Medical Association-Physician Consortium for Performance Improvement /American Gastroenterological Association |
|
0398/ 087 |
N/A
|
Measures Group |
Effective Clinical Care
|
Hepatitis C: Hepatitis C Virus (HCV) Ribonucleic Acid (RNA) Testing Between 4-12 Weeks After Initiation of Treatment
Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment for whom quantitative hepatitis C virus (HCV) ribonucleic acid (RNA) testing was performed between 4-12 weeks after the initiation of antiviral treatment
Comments: CMS received a comment requesting that this measure continue to be included in the 2017 measure set as an individual measure. Commenter noted that there were not a lot of measures that hepatologists can report and should, therefore, not remove this measure.
Response: This measure was previously a part of a Measures Group and was reportable as a measures group only. To align with the finalized MIPS policy of removing Measures Group as a reporting option, this measure will no longer be reportable as part of a measure group. As an individual measure this measure is considered low-bar and not robust enough to stand alone. CMS is finalizing its proposal to remove this measure because it is considered low-bar as an individual measure and is standard clinical practice.
Final Decision: CMS is finalizing its proposal to remove this measure. |
American Gastroenterological Association |
|
0054/ 108 |
N/A |
Measures Group |
Effective Clinical Care
|
Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug (DMARD) Therapy
Percentage of patients aged 18 years and older who were diagnosed with rheumatoid arthritis and were prescribed, dispensed, or administered at least one ambulatory prescription for a disease-modifying anti-rheumatic drug (DMARD)
Comments: CMS received comments that both supported and did not support the removal of this measure. Commenter asked that this measure be included in a Rheumatology measure set instead of being removed.
Response: This measure was previously a part of a Measures Group and was reportable as a measures group only. To align with the finalized MIPS policy of removing Measures Group as a reporting option, this measure will no longer be reportable as part of a measure group. As an individual measure this measure is considered low-bar and not robust enough to stand alone. CMS is finalizing its proposal to remove this measure because it is considered low-bar as an individual measure and is standard clinical practice.
Final Decision: CMS is finalizing its proposal to remove this measure. |
National Committee for Quality Assurance |
|
N/A/ 121 |
N/A |
Registry, Measures Group |
Effective Clinical Care |
Adult Kidney Disease: Laboratory Testing (Lipid Profile)
Percentage of patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (stage 3, 4, or 5, not receiving Renal Replacement Therapy [RRT]) who had a fasting lipid profile performed at least once within a 12-month period
Comments: CMS received a comment supporting its proposal to remove the measure.
Response: We thank the commenter for their support. CMS is finalizing its proposal to remove this measure because it is considered a low bar measure and is part of standard clinical practice. There is no significant performance gap for this measure.
Final Decision: CMS is finalizing its proposal to remove this measure. |
Renal Physicians Association |
|
0399/ 183 |
N/A |
Measures Group |
Community/ Population Health |
Hepatitis C: Hepatitis A Vaccination
Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who have received at least one injection of hepatitis A vaccine, or who have documented immunity to hepatitis A
Comments: CMS received a comment requesting that this measure not be removed from the measure set. Commenter noted that there were not a lot of measures that hepatologists can report and should, therefore, not remove this measure.
Response: This measure was previously a part of a Measures Group and was reportable as a measures group only. To align with the finalized MIPS policy of removing Measures Group as a reporting option, this measure will no longer be reportable as part of a measure group. As an individual measure, this measure is considered low-bar and not robust enough to stand alone. CMS will finalize its proposal to remove this measure because it is considered low-bar as an individual measure and is standard clinical practice.
Final Decision: CMS is finalizing its proposal to remove this measure. |
American Medical Association-Physician Consortium for Performance Improvement/ American Gastroenterological Association |
|
N/A/ 241 |
182v5 |
EHR |
Effective Clinical Care |
Ischemic Vascular Disease (IVD): Complete Lipid Profile and LDL-C Control (< 100 mg/dL)
Percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had each of the following during the measurement period: a complete lipid profile and LDL-C was adequately controlled (< 100 mg/dL)
Comments: CMS received one comment that supported the removal of this measure.
Response: We thank the commenter for their support. This measure no longer reflects evidence. CMS is finalizing its proposal to remove this measure because it no longer reflects clinical guidelines and evidence. Clinical guidelines are better represented by PQRS # 438: Statin Therapy for the Prevention and Treatment of Cardiovascular Disease.
Final Decision: CMS is finalizing its proposal to remove this measure. |
National Committee for Quality Assurance |
|
N/A/ 242 |
N/A |
Measures Group |
Effective Clinical Care |
Coronary Artery Disease (CAD): Symptom Management
Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12 month period with results of an evaluation of level of activity and an assessment of whether anginal symptoms are present or absent with appropriate management of anginal symptoms within a 12 month period
CMS did not receive any comments regarding the removal of this measure.
Final Decision: This measure was previously a part of a Measures Group and was reportable as a measures group only. To align with the finalized MIPS policy of removing Measures Group as a reporting option, this measure will no longer be reportable as part of a measure group. As an individual measure this measure is considered low-bar and not robust enough to stand alone. CMS is finalizing its proposal to remove this measure because it is considered low-bar as an individual measure and is standard clinical practice. |
American College of Cardiology/ American Heart Association/ American Medical Association-Physician Consortium for Performance Improvement |
|
N/A/ 270 |
N/A |
Registry, Measures Group |
Effective Clinical Care |
Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Sparing Therapy
Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease who have been managed by corticosteroids greater than or equal to 10 mg/day of prednisone equivalents for 60 or greater consecutive days or a single prescription equating to 600 mg prednisone or greater for all fills that have been prescribed corticosteroid sparing therapy within the last twelve months
Comments: CMS received a comment to not remove the measure from the 2017 measure set. But no specific reason was given to justify continued inclusion.
Response: CMS is finalizing its proposal to remove this measure. This measure is related to one of the conditions covered under the Core Measure Collaborative but is not included in the core measure set. The clinical performance identified with this measure can be addressed by the measures within the core measure set.
Final Decision: CMS is finalizing its proposal to remove this measure. |
American Gastroenterological Association |
|
N/A/ 274 |
N/A |
Registry, Measures Group |
Effective Clinical Care |
Inflammatory Bowel Disease (IBD): Testing for Latent Tuberculosis (TB) Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy
Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease (IBD) for whom a tuberculosis (TB) screening was performed and results interpreted within six months prior to receiving a first course of anti-TNF (tumor necrosis factor) therapy
Comments: CMS received a comment to not remove the measure from the 2017 measure set. But no specific reason was given to justify continued inclusion.
Response: CMS is finalizing its proposal to remove this measure. This measure is related to one of the conditions covered under the Core Measure Collaborative but is not included in the core measure set. The clinical performance identified with this measure can be addressed by the measures within the core measure set.
Final Decision: CMS is finalizing its proposal to remove this measure. |
American Gastroenterological Association |
|
N/A/ 280 |
N/A
|
Measures Group |
Effective Clinical Care |
Dementia: Staging of Dementia
Percentage of patients, regardless of age, with a diagnosis of dementia whose severity of dementia was classified as mild, moderate or severe at least once within a 12 month period
Comments: CMS received a comment to not remove the measure from the 2017 measure set. But no specific reason was given to justify continued inclusion.
Response: This measure was previously a part of a Measures Group and was reportable as a measures group only. To align with the finalized MIPS policy of removing Measures Group as a reporting option, this measure will no longer be reportable as part of a measure group. As an individual measure this measure is considered low-bar and not robust enough to stand alone. CMS is finalizing its proposal to remove this measure because it is considered low-bar as an individual measure and is standard clinical practice.
Final Decision: CMS is finalizing its proposal to remove this measure. |
American Academy of Neurology/ American Psychiatric Association |
|
N/A/ 287 |
N/A |
Measures Group |
Effective Clinical Care
|
Dementia: Counseling Regarding Risks of Driving
Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled regarding the risks of driving and the alternatives to driving at least once within a 12 month period
Comments: CMS received a comment to not remove the measure from the 2017 measure set. But no specific reason was given to justify continued inclusion.
Response: This measure was previously a part of a Measures Group and was reportable as a measures group only. As an individual measure this measure is considered low-bar and not robust enough to stand alone. CMS is finalizing its proposal to remove this measure because it is considered low-bar as an individual measure and is standard clinical practice.
Final Decision: CMS is finalizing its proposal to remove this measure. |
American Medical Association-Physician Consortium for Performance Improvement/ American Gastroenterological Association |
|
N/A/ 289 |
N/A
|
Measures Group |
Effective Clinical Care |
Parkinson’s Disease: Annual Parkinson’s Disease Diagnosis Review
All patients with a diagnosis of Parkinson’s disease who had an annual assessment including a review of current medications (e.g., medications that can produce Parkinson-like signs or symptoms) and a review for the presence of atypical features (e.g., falls at presentation and early in the disease course, poor response to levodopa, symmetry at onset, rapid progression [to Hoehn and Yahr stage 3 in 3 years], lack of tremor or dysautonomia) at least annually
Comments: CMS received a comment to not remove the measure from the 2017 measure set. But no specific reason was given to justify continued inclusion.
Response: This measure was previously a part of a Measures Group and was reportable as a measures group only. To align with the finalized MIPS policy of removing Measures Group as a reporting option, this measure will no longer be reportable as part of a measure group. As an individual measure this measure is considered low-bar and not robust enough to stand alone. CMS is finalizing its proposal to remove this measure because it is considered low-bar as an individual measure and is standard clinical practice.
Final Decision: CMS is finalizing its proposal to remove this measure. |
American Academy of Neurology |
|
N/A/ 292 |
N/A |
Measures Group |
Effective Clinical Care |
Parkinson’s Disease: Querying about Sleep Disturbances
All patients with a diagnosis of Parkinson’s disease (or caregivers, as appropriate) who were queried about sleep disturbances at least annually
Comments: CMS received a comment to not remove the measure from the 2017 measure set. But no specific reason was given to justify continued inclusion.
Response: This measure was previously a part of a Measures Group and was reportable as a measures group only. To align with the finalized MIPS policy of removing Measures Group as a reporting option, this measure will no longer be reportable as part of a measure group. As an individual measure this measure is considered low-bar and not robust enough to stand alone. CMS is finalizing its proposal to remove this measure because it is considered low-bar as an individual measure and is standard clinical practice.
Final Decision: CMS is finalizing its proposal to remove this measure. |
American Academy of Neurology |
|
0036/ 311 |
126v4 |
EHR |
Effective Clinical Care |
Use of Appropriate Medications for Asthma
Percentage of patients 5-64 years of age who were identified as having persistent asthma and were appropriately prescribed medication during the measurement period
Comments: CMS received a comment asking the CMS reconsider removal of this measure and instead remove NQF #1799 because eligible clinicians can report pharmacy refills with Q #311. Additionally, CMS received comments to include this measure because it aligns with the CHIPRA core measure set.
Response: This measure has a high performance rate and shows little variation in care. CMS is finalizing its proposal to remove this measure because it has a high performance rate and is clinically close to another measure that is being finalized, NQF 1799: Medication Management for people with Asthma.
Final Decision: CMS is finalizing its proposal to remove this measure. |
National Committee for Quality Assurance |
|
NA/316 |
61v5 & 64v4 |
EHR |
Effective Clinical Care |
Preventive Care and Screening: Cholesterol – Fasting Low Density Lipoprotein (LDL-C) Test Performed AND Risk-Stratified Fasting LDL-C
Percentage of patients aged 20 through 79 years whose risk factors* have been assessed and a fasting LDL test has been performed AND percentage of patients aged 20 through 79 years who had a fasting LDL-C test performed and whose risk-stratified fasting LDL-C is at or below the recommended LDL-C goal. *There are three criteria for this measure based on the patient’s risk category. 1. Highest Level of Risk: Coronary Heart Disease (CHD) or CHD Risk Equivalent OR 10-Year Framingham Risk >20% 2. Moderate Level of Risk: Multiple (2+) Risk Factors OR 10-Year Framingham Risk 10-20% 3. Lowest Level of Risk: 0 or 1 Risk Factor OR 10-Year Framingham Risk <10%
Comments: CMS received a comment asking that CMS remove the measure because it does not align with AHA/ACC recommendation. CMS also received a comment supporting the inclusion of the measure but would like the measure to be modified to align with recommendations. CMS also received a comment requesting the measure be reportable via registry.
Response: Although this measure was not originally proposed for removal from MIPS, CMS would like to finalize its removal. CMS received comments that recommended this measure be removed because it does not align with current clinical recommendations. This measure is currently only reportable via EHR data submission method.
Final Decision: CMS agrees this measures is not aligned with current clinical guidelines and is finalizing its removal. Measure #438 is a measure representative of the current guidelines.
|
Centers for Medicare & Medicaid Services/ Quality Insights of Pennsylvania |
|
2083/ 339 |
N/A |
Measures Group |
Effective Clinical Care |
Prescription of HIV Antiretroviral Therapy
Percentage of patients, regardless of age, with a diagnosis of HIV prescribed antiretroviral therapy for the treatment of HIV infection during the measurement year
CMS did not receive any comments on this proposal.
Final Decision: CMS is finalizing its proposal to remove this measure. This measure is related to one of the conditions covered under the Core Measure Collaborative but is not included in the core measure set. The clinical performance identified with this measure can be addressed by the measures within the core measure set.
|
Health Resources and Services Administration |
|
N/A/ 365 |
148v4 |
EHR |
Effective Clinical Care |
Hemoglobin A1c Test for Pediatric Patients
Percentage of patients 5-17 years of age with diabetes with a HbA1c test during the measurement period
CMS did not receive any comments on this proposal.
Response: CMS is finalizing its proposal to remove this measure because the measure owner is no longer supporting implementation. Additionally, the evidence for this measure is no longer supported by clinical experts and guidance.
|
National Committee for Quality Assurance |
|
N/A/ 368 |
62v4 |
EHR |
Effective Clinical Care |
HIV/AIDS: Medical Visit
Percentage of patients, regardless of age, with a diagnosis of HIV/AIDS with at least two medical visits during the measurement year with a minimum of 90 days between each visit
CMS did not receive any comments on this proposal.
Response: According to clinical experts, this measure no longer reflects the evidence. CMS is finalizing its proposal to remove this measure because it no longer reflects clinical guidelines and evidence.
|
National Committee for Quality Assurance |
! |
N/A/ 380 |
CMS179v4 |
EHR |
Patient Safety |
ADE Prevention and Monitoring: Warfarin Time in Therapeutic Range
Average percentage of time in which patients aged 18 and older with atrial fibrillation who are on chronic warfarin therapy have International Normalized Ratio (INR) test results within the therapeutic range (i.e., TTR) during the measurement period
Comments: CMS received comments to support the removal of this measure. Commenters agreed with CMS assessment that the measure was difficult to report.
Response: Since its implementation, this measure has had difficulty with feasibility. CMS is finalizing its proposal to remove this measure because it is not technically feasible to implement.
Final Decision: CMS is finalizing its proposal to remove this measure. |
Centers for Medicare & Medicaid Services/ National Committee for Quality Assurance |
|
N/A/ 381 |
77v4 |
EHR |
Effective Clinical Care |
HIV/AIDS: RNA Control for Patients with HIV
Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS, with at least two visits during the measurement year, with at least 90 days between each visit, whose most recent HIV RNA level is <200 copies/mL.
CMS did not receive any comments on this measure.
Response: According to clinical experts, this measure no longer reflects the evidence. CMS is finalizing its proposal to remove this measure because it no longer reflects clinical guidelines and evidence.
|
Centers for Medicare & Medicaid Services/ National Committee for Quality Assurance |
|
2452/ 399 |
N/A |
Registry |
Effective Clinical Care |
Post-Procedural Optimal Medical Therapy Composite (Percutaneous Coronary Intervention)
Percentage of patients aged 18 years and older for whom PCI is performed who are prescribed optimal medical therapy at discharge
Comments: Although CMS did not receive a comment regarding its proposal to remove the measure, we did receive a comment requesting the measure be modified.
Response: The measure steward will no longer support stewardship of this measure. Measures implemented in the quality measure program are required to be updated annually by the measure steward. Additionally, the request to modifiy the measure reaffirms the need for this measure to have a measure steward. Since the measure steward has removed its support to update this measure in 2017, CMS is finalizing its removal of this measure.
|
American College of Cardiology/American Heart Association/ American Medical Association-Physician Consortium for Performance Improvement |
Proposals Not Finalized
|
||||||
|
N/A/ 425 |
N/A |
Claims, Registry |
Effective Clinical Care
|
Photodocumentation of Cecal Intubation
The rate of screening and surveillance colonoscopies for which photodocumentation of landmarks of cecal intubation is performed to establish a complete examination
CMS proposed this measure for removal in Table H of the Appendix of the proposed rule (81 FR 28531) because CMS believed this measure is related to one of the conditions covered under the Core Quality Measure Collaborative but is not included in the core measure set.
Comments: CMS received several comments requesting that CMS not remove this measure from the program until performance data can be collected.
Response: CMS agrees that it would be premature to remove the measure from the program without adequate data to justify removal based on performance. Therefore, CMS will not finalize this measure for removal.
Final Decision: We are not finalizing our proposal to remove Q #425 for the 2017 Performance Period. Under section 1848(q)(2)(D)(vii) of the Act, existing quality measures shall be included in the final list of quality measures unless removed. Accordingly, CMS is finalizing Q #425 for the 2017 Performance Period. |
American College of Gastroenterology/ American Gastroenterological Association/ American Society for Gastrointestinal Endoscopy |
TABLE G: Measures Finalized with Substantive Changes for MIPS Reporting in 2017
Measure Title: |
Diabetes: Hemoglobin A1c Poor Control |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
0059/001 |
CMS E-Measure ID: |
CMS122v5 |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data Submission Method: |
Claims, Web Interface, Registry, EHR, Measures Group |
Current Measure Description: |
Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period |
Finalized Substantive Change |
|
Steward: |
National Committee for Quality Assurance |
Rationale: |
CMS is finalizing its proposal to change the measure description that clarifies the definition of Hemoglobin A1c required for poor control. This change does not constitute a change in measure intent or logic coding. Hemoglobin A1c >9.0% is consistent with clinical guidelines and practice. Additionally, in response to the finalized MIPS policy that no longer includes Measures Group, this measure is being removed from Measures Group as a data submission method. |
Measure Title: |
Coronary Artery Disease (CAD): Antiplatelet Therapy |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
0067/006 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data Submission Method: |
Registry, Measures Group |
Current Measure Description: |
Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period |
Finalized Substantive Change |
|
Steward: |
National Committee for Quality Assurance |
Rationale: |
CMS is finalizing its proposal to change the measure title to align with the NQF endorsed version of this measure and to clarify the intent of the measure. This change does not constitute a change in the measure intent. The measure description remains the same where patients diagnosed with CAD are prescribed an antiplatelet within 12 months. Additionally, in response to the finalized MIPS policy that no longer includes Measures Group, this measure is being removed from Measures Group as a data submission method. |
Measure Title: |
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
0083/008 |
CMS E-Measure ID: |
CMS144v5 |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data Submission Method: |
Web Interface, Registry, EHR, Measures Group |
Current Measure Description: |
Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge |
Finalized Substantive Change |
|
Steward: |
American Medical Association-Physician Consortium for Performance Improvement/ American College of Cardiology Foundation/ American Heart Association |
Rationale: |
CMS is finalizing its proposal to change the reporting mechanism for this measure by removing it from the Web Interface. The Web Interface measure set contains measures for primary care and also includes relevant measures from the PCMH Core Measure Set established by the Core Quality Measure Collaborative (CQMC). This measure is not a measure in the core set and is being finalized for removal from the Web Interface to align the Web Interface measure set with the PCMH Core Measure Set. |
Measure Title: |
Medication Reconciliation Post-Discharge |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
0097/046 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Communication and Care Coordination |
Current Data Submission Method: |
Claims, Registry |
Current Measure Description: |
The percentage of discharges from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years and older of age seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record This measure is reported as three rates stratified by age group: • Reporting Criteria 1: 18-64 years of age • Reporting Criteria 2: 65 years and older • Total Rate: All patients 18 years of age and older |
Finalized Substantive Change |
|
Steward: |
National Committee for Quality Assurance/ American Medical Association-Physician Consortium for Performance Improvement |
Rationale: |
CMS is finalizing its proposal to change the data submission method for this measure by adding it to the Web Interface. The Web Interface measure set contains measures for primary care and also includes relevant measures from the PCMH Core Measure Set established by the CQMC. This measure is a core measure and is being finalized for the Web Interface to align the Web Interface measure set with the PCMH Core Measure Set. Furthermore, this measure is replacing PQRS #130: Documentation of Current Medications in the Medical Record in the Web Interface. |
Measure Title: |
Appropriate Testing for Children with Pharyngitis |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A (previously 0002)/066 |
CMS E-Measure ID: |
CMS146v5 |
National Quality Strategy Domain: |
Efficiency and Cost Reduction |
Current Data submission Method: |
Registry, EHR |
Current Measure Description: |
Percentage of children 2-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode |
Finalized Substantive Change |
|
Steward: |
National Committee on Quality Assurance |
Rationale: |
CMS is finalizing its proposal to change the measure description due to guideline changes in 2013 where the age range changed to 3-18. Furthermore, this measure is no longer endorsed by the National Quality Forum (NQF), therefore, CMS proposes to remove the NQF number as a reference for this measure. |
Measure Title: |
Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
0389/102 |
CMS E-Measure ID: |
CMS129v6 |
National Quality Strategy Domain: |
Efficiency and Cost Reduction |
Current Data submission Method: |
Registry, EHR |
Measure Description: |
Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer |
Finalized Substantive Change |
|
Steward: |
American Medical Association-Physician Consortium for Performance Improvement |
Rationale: |
CMS is finalizing its proposal to change the measure description due to a change in clinical guidelines that includes very low and low risk of prostate cancer recurrence. CMS received a comment that supported this change in the measure description. CMS believes that this change does not change the intent of the measure but merely ensures the measure remains up-to-date according to clinical guidelines and practice. |
Measure Title: |
Breast Cancer Screening |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
2372 (previously not applicable)/112 |
CMS E-Measure ID: |
CMS125v5 |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data submission Method: |
Claims, Web Interface, Registry, EHR, Measures Group |
Current Measure Description: |
Percentage of women 40-69 years of age who had a mammogram to screen for breast cancer |
Finalized Substantive Change |
|
Steward: |
National Committee on Quality Assurance |
Rationale: |
CMS is finalizing its proposal to change the measure description due to clinical guideline changes that occurred in 2013 which changed the age requirement for mammograms from 40-69 years to 50-74 years. CMS believes that this change does not change the intent of the measure but merely ensures the measure remains up-to-date according to clinical guidelines and practice. Additionally, in response to the finalized MIPS policy that no longer includes Measures Group, this measure is being removed from Measures Group as a data submission method. Furthermore, this measure has been recently endorsed by NQF with the updated age range. Therefore, CMS proposes to add the NQF #2372 to the measure. |
Measure Title: |
Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy -- Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%) |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
0066/118 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data submission Method: |
Web Interface, Registry |
Current Measure Description: |
Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy |
Finalized Substantive Change |
|
Steward: |
American College of Cardiology/ American Heart Association/ American Medical Association-Physician Consortium for Performance Improvement |
Rationale: |
CMS is finalizing its proposal to change the data submission method for this measure by removing it from the Web Interface. The Web Interface measure set contains measures for primary care and also includes relevant measures from the PCMH Core Measure Set established by the CQMC. This measure is not a measure in the PCMH Core Measure Set and is being finalized for removal from the Web Interface to align the Web Interface measure set with the PCMH Core Measure Set. |
Measure Title: |
Diabetes: Urine Protein Screening |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
0062/119 |
CMS E-Measure ID: |
CMS134v4 |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data submission Method: |
Registry, EHR, Measures Group |
Current Measure Description: |
The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period |
Finalized Substantive Change |
|
Steward: |
National Committee for Quality Assurance |
Rationale: |
CMS is finalizing its proposal to revise the title of this measure to align with the measure’s intent to increase reporting clarity and to match the NQF endorsed measure’s title. Additionally, in response to the finalized MIPS policy that no longer includes Measures Group, this measure is being removed from Measures Group as a data submission method. |
Measure Title: |
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
0421/128 |
CMS E-Measure ID: |
CMS69v5 |
National Quality Strategy Domain: |
Community/Population Health |
Current Data submission Method: |
Claims, Web Interface, Registry, Measures Group |
Measure Description: |
Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter
Normal Parameters: -Age 65 years and older BMI => 23 and < 30 kg/m2 -Age 18 - 64 years BMI => 18.5 and < 25 kg/m2 |
Finalized Substantive Change |
|
Steward: |
Centers for Medicare & Medicaid Services/ Mathematica/ Quality Insights of Pennsylvania |
Rationale: |
CMS is finalizing its proposal to remove the upper parameter from the measure description to align with the recommendations of technical expert panel and clinical expertise. Additionally, in response to the finalized MIPS policy that no longer includes Measures Group, this measure is being removed from Measures Group as a data submission method. |
Measure Title: |
Documentation of Current Medications in the Medical Record |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
0419/130 |
CMS E-Measure ID: |
CMS68v6 |
National Quality Strategy Domain: |
Patient Safety |
Current Data submission Method: |
Claims, Web Interface, Registry, EHR, Measures Group |
Measure Description: |
Percentage of visits for patients aged 18 years and older for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration |
Finalized Substantive Change |
|
Steward: |
Centers for Medicare & Medicaid Services/ Mathematica/ Quality Insights of Pennsylvania |
Rationale: |
CMS is finalizing its proposal to revise the data submission method of this measure to remove it from use in the Web Interface. This measure is being replaced in the Web Interface with the core measure, PQRS #46: Medication Reconciliation Post-Discharge. Since these measures cover similar topic areas, CMS proposes to remove this measure from the Web Interface. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being removed from Measures Group. |
Measure Title: |
Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
0418/134 |
CMS E-Measure ID: |
CMS2v6 |
National Quality Strategy Domain: |
Community/Population Health |
Current Data submission Method: |
Claims, Web Interface, Registry, EHR, Measures Group |
Measure Description: |
Percentage of patients aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen |
Finalized Substantive Change |
|
Steward: |
Centers for Medicare & Medicaid Services/ Mathematica/ Quality Insights of Pennsylvania |
Rationale: |
CMS is finalizing its proposal to revise the title and measure description to align with the recommendations of the technical expert panel and clinical expertise in the field. CMS believes the revision provides clarity to providers when reporting depression screening and follow-up. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being removed from Measures Group. |
Measure Title: |
HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
0405/160 |
CMS E-Measure ID: |
52v5 |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data submission Method: |
EHR, Measures Group |
Measure Description: |
Percentage of patients aged 6 weeks and older with a diagnosis of HIV/AIDS who were prescribed Pneumocystis Jiroveci Pneumonia (PCP) prophylaxis |
Finalized Substantive Change |
|
Steward: |
National Committee for Quality Assurance |
Rationale: |
CMS is finalizing its proposal to change the data submission method for this measure from Measures Group to EHR only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being removed from Measures Group. |
Measure Title: |
Diabetes: Foot Exam |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
0056/163 |
CMS E-Measure ID: |
CMS123v5 |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data submission Method: |
EHR |
Current Measure Description: |
Percentage of patients aged 18-75 years of age with diabetes who had a foot exam during the measurement period |
Finalized Substantive Change |
|
Steward: |
National Committee for Quality Assurance |
Rationale: |
CMS is finalizing the measure description as written above to improve clarity for providers about what constitutes a foot exam. CMS believes this change does not change the intent of the measure, but merely provides clarity in response to providers’ feedback. Additionally, CMS received a comment that the measure description as proposed was not consistent with other measure descriptions with “the” preceding the word “percentage”. CMS is correcting the description by removing the word “the” from the beginning of the measure description. |
Measure Title: |
Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
0130/165 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data submission Method: |
Measures Group |
Measure Description: |
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who, within 30 days postoperatively, develop deep sternal wound infection involving muscle, bone, and/or mediastinum requiring operative intervention |
Finalized Substantive Change |
|
Steward: |
Society of Thoracic Surgeons |
Rationale: |
CMS is finalizing its proposal to change the reporting mechanism for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
Measure Title: |
Coronary Artery Bypass Graft (CABG): Stroke |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
0131/166 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data submission Method: |
Measures Group |
Measure Description: |
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who have a postoperative stroke (i.e., any confirmed neurological deficit of abrupt onset caused by a disturbance in blood supply to the brain) that did not resolve within 24 hours |
Finalized Substantive Change |
|
Steward: |
Society of Thoracic Surgeons |
Rationale: |
CMS is finalizing its proposal to change the reporting mechanism for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
Measure Title: |
Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
0114/167 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data submission Method: |
Measures Group |
Measure Description: |
Percentage of patients aged 18 years and older undergoing isolated CABG surgery (without pre-existing renal failure) who develop postoperative renal failure or require dialysis |
Finalized Substantive Change |
|
Steward: |
Society of Thoracic Surgeons |
Rationale: |
CMS is finalizing its proposal to change the reporting mechanism for this measure from Measures Group only to registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
Measure Title: |
Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
0115/168 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data submission Method: |
Measures Group |
Measure Description: |
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require a return to the operating room (OR) during the current hospitalization for mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction, or other cardiac reason |
Finalized Substantive Change |
|
Steward: |
Society of Thoracic Surgeons |
Rationale: |
CMS finalizing its proposal to change the reporting mechanism for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
Measure Title: |
Rheumatoid Arthritis (RA): Tuberculosis Screening |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/176 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data submission Method: |
Measures Group |
Measure Description: |
Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have documentation of a tuberculosis (TB) screening performed and results interpreted within 6 months prior to receiving a first course of therapy using a biologic disease-modifying anti-rheumatic drug (DMARD) |
Finalized Substantive Change |
|
Steward: |
American College of Rheumatology |
Rationale: |
CMS is finalizing its proposal to change the reporting mechanism for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
Measure Title: |
Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/177 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data submission Method: |
Measures Group |
Measure Description: |
Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease activity within 12 months |
Finalized Substantive Change |
|
Steward: |
American College of Rheumatology |
Rationale: |
CMS is finalizing its proposal to change the reporting mechanism for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
Measure Title: |
Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/179 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data submission Method: |
Measures Group |
Measure Description: |
Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease prognosis at least once within 12 months |
Finalized Substantive Change |
|
Steward: |
American College of Rheumatology |
Rationale: |
CMS is finalizing its proposal to change the reporting mechanism for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
Measure Title: |
Rheumatoid Arthritis (RA): Glucocorticoid Management |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/180 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data submission Method: |
Measures Group |
Measure Description: |
Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone ≥ 10 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months |
Finalized Substantive Change |
|
Steward: |
American College of Rheumatology |
Rationale: |
CMS is finalizing its proposal to change the reporting mechanism for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
Measure Title: |
Stroke and Stroke Rehabilitation: Thrombolytic Therapy |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/187 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data submission Method: |
Registry |
Current Measure Description: |
Percentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who arrive at the hospital within two hours of time last known well and for whom IV t-PA was initiated within three hours of time last known well |
Finalized Substantive Change |
|
Steward: |
American Society of Anesthesiologists/ The Joint Commission |
Rationale: |
CMS is finalizing its proposal to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis, CMS believes the classification of this measure is process measure. |
Measure Title: |
Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
0068/204 |
CMS E-Measure ID: |
CMS164v5 |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data submission Method: |
Claims, Web Interface, Registry, EHR, Measures Group |
Current Measure Description: |
Percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antithrombotic during the measurement period |
Finalized Substantive Change |
|
Steward: |
National Committee for Quality Assurance |
Rationale: |
CMS is finalizing its proposal to revise the measure title and description to align with the measure’s intent and to provide clarity for providers. Additionally, in response to the finalized MIPS policy to no longer include measure groups as a data submission method, this measure is being removed from measure group. |
Measure Title: |
Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Knee Impairments |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
0422/217 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Communication and Care Coordination |
Current Data submission Method: |
Registry |
Current Measure Type: |
Process |
Current Measure Description: |
Percentage of patients aged 18 or older that receive treatment for a functional deficit secondary to a diagnosis that affects the knee in which the change in their Risk-Adjusted Functional Status is measured |
Finalized Substantive Change |
|
Steward: |
Focus on Therapeutic Outcomes, Inc. |
Rationale: |
CMS is finalizing its proposal to revise the measure title and description to align with the NQF-endorsed version of the measure. The measure owner revised the title and description of the measure to be consistent with the change in numerator details that now calculate the change in functional status score and denominator details that include patients that completed the FOTO knee FS PROM at admission and discharge. Additionally, this change in numerator and denominator details entails that the measure type changes from process to outcome |
Measure Title: |
Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Hip Impairments |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
0423/218 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Communication and Care Coordination |
Current Data submission Method: |
Registry |
Current Measure Type: |
Outcome |
Current Measure Description: |
Percentage of patients aged 18 or older that receive treatment for a functional deficit secondary to a diagnosis that affects the hip in which the change in their Risk-Adjusted Functional Status is measured |
Finalized Substantive Change |
|
Steward: |
Focus on Therapeutic Outcomes, Inc. |
Rationale: |
CMS is finalizing its proposal to revise the measure title and description to align with the NQF-endorsed version of the measure. The measure owner revised the title and description of the measure to be consistent with the change in numerator details that now calculate the average change in functional status scores in patients who were treated in a 12 month period and denominator details that include patients that completed the FOTO hip FS PROM at admission and discharge. |
Measure Title: |
Functional Deficit: Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Lower Leg, Foot or Ankle Impairments |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
0424/219 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Communication and Care Coordination |
Current Data submission Method: |
Registry |
Current Measure Type: |
Outcome |
Current Measure Description: |
Percentage of patients aged 18 or older that receive treatment for a functional deficit secondary to a diagnosis that affects the lower leg, foot or ankle in which the change in their Risk-Adjusted Functional Status is measured |
Finalized Substantive Change |
|
Steward: |
Focus on Therapeutic Outcomes, Inc. |
Rationale: |
CMS is finalizing its proposal to revise the measure title and description to align with the NQF-endorsed version of the measure. The measure owner revised the title and description of the measure to be consistent with the change in numerator details that now calculate the average change in functional status score in patients who were treated in a 12-month period and denominator details that include patients that completed the FOTO foot and ankle PROM at admission and discharge. |
Measure Title: |
Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Lumbar Spine Impairments |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
0425/220 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Communication and Care Coordination |
Current Data submission Method: |
Registry |
Current Measure Type: |
Outcome |
Current Measure Description: |
Percentage of patients aged 18 or older that receive treatment for a functional deficit secondary to a diagnosis that affects the lumbar spine in which the change in their Risk-Adjusted Functional Status is measured |
Finalized Substantive Change |
|
Steward: |
Focus on Therapeutic Outcomes, Inc. |
Rationale: |
CMS is finalizing its proposal to revise the measure title and description to align with the NQF-endorsed version of the measure. The measure owner revised the title and description of the measure to be consistent with the change in numerator details that now calculate the average functional status score for patients treated in a 12-month period compared to a standard threshold and denominator details that include patients that completed the FOTO (lumbar) PROM. |
Measure Title: |
Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Shoulder Impairments |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
0426/221 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Communication and Care Coordination |
Current Data submission Method: |
Registry |
Current Measure Type: |
Outcome |
Current Measure Description: |
Percentage of patients aged 18 or older that receive treatment for a functional deficit secondary to a diagnosis that affects the shoulder in which the change in their Risk-Adjusted Functional Status is measured |
Finalized Substantive Change |
|
Steward: |
Focus on Therapeutic Outcomes, Inc. |
Rationale: |
CMS is finalizing its proposal to revise the measure title and description to align with the NQF-endorsed version of the measure. The measure owner revised the title and description of the measure to be consistent with the change in numerator details that now calculate the average functional status score in patients treated in a 12-month period and denominator details that include patients that completed the FOTO shoulder FS outcome instrument at admission and discharge. |
Measure Title: |
Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Elbow, Wrist or Hand Impairments |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
0427/222 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Communication and Care Coordination |
Current Data submission Method: |
Registry |
Current Measure Type: |
Outcome |
Current Measure Description: |
Percentage of patients aged 18 or older that receive treatment for a functional deficit secondary to a diagnosis that affects the elbow, wrist or hand in which the change in their Risk-Adjusted Functional Status is measured |
Finalized Substantive Change |
|
Steward: |
Focus on Therapeutic Outcomes, Inc. |
Rationale: |
CMS is finalizing its proposal to revise the measure title and description to align with the NQF-endorsed version of the measure. The measure owner revised the title and description of the measure to be consistent with the change in numerator details that now calculate the average functional status scores for patients treated over a 12 month period and denominator details that include patients that completed the FOTO (elbow, wrist, and hand) PROM. |
Measure Title: |
Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Neck, Cranium, Mandible, Thoracic Spine, Ribs, or Other General Orthopedic Impairments |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
0428/223 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Communication and Care Coordination |
Current Data submission Method: |
Registry |
Current Measure Type: |
Outcome |
Current Measure Description: |
Percentage of patients aged 18 or older that receive treatment for a functional deficit secondary to a diagnosis that affects the neck, cranium, mandible, thoracic spine, ribs, or other general orthopedic impairment in which the change in their Risk-Adjusted Functional Status is measured |
Finalized Substantive Change |
|
Steward: |
Focus on Therapeutic Outcomes, Inc. |
Rationale: |
CMS is finalizing its proposal to revise the measure title and description to align with the NQF-endorsed version of the measure. The measure owner revised the title and description of the measure to be consistent with the change in numerator details that now calculate the change in functional status scores for patients over a 12 month period and denominator details that include patients that completed the FOTO (general orthopedic) PROM. |
Measure Title: |
Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
1814/268 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data submission Method: |
Claims, Registry |
Current Measure Description: |
All female patients of childbearing potential (12 - 44 years old) diagnosed with epilepsy who were counseled or referred for counseling for how epilepsy and its treatment may affect contraception OR pregnancy at least once a year |
Finalized Substantive Change |
|
Steward: |
American Academy of Neurology |
Rationale: |
CMS is finalizing its proposal to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis of the measure specification, CMS believes the classification of this measure to be a process measure. This would be consistent with the clinical action required for the measure and would align the measure type with the NQF-endorsed version. |
Measure Title: |
Sleep Apnea: Assessment of Sleep Symptoms |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/276 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data submission Method: |
Measures Group |
Measure Description: |
Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea that includes documentation of an assessment of sleep symptoms, including presence or absence of snoring and daytime sleepiness |
Finalized Substantive Change |
|
Steward: |
American Academy of Sleep Medicine/ American Medical Association-Physician Consortium for Performance Improvement |
Rationale: |
CMS is finalizing its proposal to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
Measure Title: |
Sleep Apnea: Assessment of Sleep Symptoms |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/277 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data submission Method: |
Measures Group |
Measure Description: |
Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) measured at the time of initial diagnosis |
Finalized Substantive Change |
|
Steward: |
American Academy of Sleep Medicine/ American Medical Association-Physician Consortium for Performance Improvement |
Rationale: |
CMS is finalizing its proposal to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the finalized MIPS policy to no longer include Measure Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
Measure Title: |
Sleep Apnea: Positive Airway Pressure Therapy Prescribed |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/278 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data submission Method: |
Measures Group |
Measure Description: |
Percentage of patients aged 18 years and older with a diagnosis of moderate or severe obstructive sleep apnea who were prescribed positive airway pressure therapy |
Finalized Substantive Change |
|
Steward: |
American Academy of Sleep Medicine/ American Medical Association-Physician Consortium for Performance Improvement |
Rationale: |
CMS is finalizing its proposal to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
Measure Title: |
Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/279 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data submission Method: |
Measures Group |
Measure Description: |
Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea who were prescribed positive airway pressure therapy who had documentation that adherence to positive airway pressure therapy was objectively measured |
Finalized Substantive Change |
|
Steward: |
American Academy of Sleep Medicine/ American Medical Association-Physician Consortium for Performance Improvement |
Rationale: |
CMS is finalizing its proposal to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
Measure Title: |
Dementia: Functional Status Assessment |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/282 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data submission Method: |
Measures Group |
Measure Description: |
Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of functional status is performed and the results reviewed at least once within a 12 month period |
Finalized Substantive Change |
|
Steward: |
American Academy of Neurology/ American Psychiatric Association |
Rationale: |
CMS is finalizing its proposal to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
Measure Title: |
Dementia: Neuropsychiatric Symptom Assessment |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/283 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data submission Method: |
Measures Group |
Measure Description: |
Percentage of patients, regardless of age, with a diagnosis of dementia and for whom an assessment of neuropsychiatric symptoms is performed and results reviewed at least once in a 12 month period |
Finalized Substantive Change |
|
Steward: |
American Academy of Neurology/ American Psychiatric Association |
Rationale: |
CMS is finalizing its proposal to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
Measure Title: |
Dementia: Management of Neuropsychiatric Symptoms |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/284 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data submission Method: |
Measures Group |
Measure Description: |
Percentage of patients, regardless of age, with a diagnosis of dementia who have one or more neuropsychiatric symptoms who received or were recommended to receive an intervention for neuropsychiatric symptoms within a 12 month period |
Finalized Substantive Change |
|
Steward: |
American Academy of Neurology/ American Psychiatric Association |
Rationale: |
CMS is finalizing its proposal to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
Measure Title: |
Dementia: Counseling Regarding Safety Concerns |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/286 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Patient Safety |
Current Data submission Method: |
Measures Group |
Measure Description: |
Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled or referred for counseling regarding safety concerns within a 12 month period |
Finalized Substantive Change |
|
Steward: |
American Academy of Neurology/ American Psychiatric Association |
Rationale: |
CMS is finalizing its proposal to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
Measure Title: |
Dementia: Caregiver Education and Support |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/288 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Communication and Care Coordination |
Current Data submission Method: |
Measures Group |
Measure Description: |
Percentage of patients, regardless of age, with a diagnosis of dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND referred to additional sources for support within a 12 month period |
Finalized Substantive Change |
|
Steward: |
American Academy of Neurology/ American Psychiatric Association |
Rationale: |
CMS is finalizing its proposal to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
Measure Title: |
Parkinson’s Disease: Psychiatric Symptoms Assessment for Patients with Parkinson’s Disease |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/290 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data submission Method: |
Measures Group |
Measure Description: |
All patients with a diagnosis of Parkinson’s disease who were assessed for psychiatric symptoms (e.g., psychosis, depression, anxiety disorder, apathy, or impulse control disorder) in the last 12 months |
Finalized Substantive Change |
|
Steward: |
American Academy of Neurology |
Rationale: |
CMS is finalizing its proposal to change the data submission for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. Additionally, CMS proposes to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis of the measure specification, CMS proposes to revise the classification of this measure to process measure to match the clinical action of psychiatric disease assessment. |
Measure Title: |
Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/291 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data submission Method: |
Measures Group |
Measure Description: |
All patients with a diagnosis of Parkinson’s disease who were assessed for cognitive impairment or dysfunction in the last 12 months |
Finalized Substantive Change |
|
Steward: |
American Academy of Neurology |
Rationale: |
CMS is finalizing its proposal to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. Additionally, CMS proposes to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis, CMS proposes to revise the classification of this measure to process measure in order to match the clinical action of assessment of cognitive impairment. |
Measure Title: |
Parkinson’s Disease: Rehabilitative Therapy Options |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/293 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Communication and Care Coordination |
Current Data submission Method: |
Measures Group |
Measure Description: |
All patients with a diagnosis of Parkinson’s disease (or caregiver(s), as appropriate) who had rehabilitative therapy options (e.g., physical, occupational, or speech therapy) discussed in the last 12 months |
Finalized Substantive Change |
|
Steward: |
American Academy of Neurology |
Rationale: |
CMS is finalizing its proposal to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. Additionally, CMS proposes to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis, CMS proposes to revise the classification of this measure to process measure in order to match the clinical action of communication about therapy options. |
Measure Title: |
Parkinson’s Disease: Parkinson’s Disease Medical and Surgical Treatment Options Reviewed |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/294 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Communication and Care Coordination |
Current Data submission Method: |
Measures Group |
Measure Description: |
All patients with a diagnosis of Parkinson’s disease (or caregiver(s), as appropriate) who had the Parkinson’s disease treatment options (e.g., non-pharmacological treatment, pharmacological treatment, or surgical treatment) reviewed at least once annually |
Finalized Substantive Change |
|
Steward: |
American Academy of Neurology |
Rationale: |
CMS is finalizing its proposal to change the reporting mechanism for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition In response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. Additionally, CMS proposes to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis, CMS proposes to revise the classification of this measure to process measure in order to match the clinical action of communicating treatment options. |
Measure Title: |
Cervical Cancer Screening |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
0032/309 |
CMS E-Measure ID: |
CMS124v5 |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data submission Method: |
EHR |
Current Measure Description: |
Percentage of women 21-64 years of age, who received one or more Pap tests to screen for cervical cancer |
Finalized Substantive Change |
Percentage of women 21–64 years of age who were screened for cervical cancer using either of the following criteria:
|
Steward: |
National Committee on Quality Assurance |
Rationale: |
CMS is finalizing its proposal to change the measure description of this measure to align with measure intent and 2012 USPSTF recommendation: U.S. Preventive Services Task Force. 2012. "Screening for Cervical Cancer: U.S. Preventive Services Task Force Recommendation Statement." Ann Intern Med. 156(12):880-91. |
Measure Title: |
Preventive Care and Screening: Screening for High Blood Pressure and Follow-up Documented |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/317 |
CMS E-Measure ID: |
CMS22v5 |
National Quality Strategy Domain: |
Community/Population Health |
Current Data submission Method: |
Claims, Web Interface, Registry, EHR, Measures Group |
Current Measure Description: |
Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated. |
Finalized Substantive Change |
|
Steward: |
Centers for Medicare & Medicaid Services/ Mathematica/ Quality Insights of Pennsylvania |
Rationale: |
CMS is finalizing its proposal a change to the data submission method for this measure and remove it from the Web Interface. The Web Interface measure set contains measures for primary care and also includes relevant measures from the PCMH Core Measure Set established by the CQMC. This measure is not a core measure and is being removed to align the Web Interface measure set with the PCMH Core Measure Set. Additionally, in response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being removed from Measures Group. |
Measure Title: |
Pediatric Kidney Disease: Adequacy of Volume Management |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/327 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data submission Method: |
Registry |
Measure Description: |
Percentage of calendar months within a 12-month period during which patients aged 17 years and younger with a diagnosis of End Stage Renal Disease (ESRD) undergoing maintenance hemodialysis in an outpatient dialysis facility have an assessment of the adequacy of volume management from a nephrologist.
|
Finalized Substantive Change |
|
Steward: |
Renal Physicians Association |
Rationale: |
CMS is finalizing its proposal to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis, CMS understands this measure to be a percentage of documented assessment rather than a health outcome. Therefore, CMS believes the classification of this measure to be a process measure. |
Measure Title: |
HIV Viral Load Suppression |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
2082/338 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data submission Method: |
Measures Group |
Measure Description: |
The percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year |
Finalized Substantive Change |
|
Steward: |
Health Resources and Services Administration |
Rationale: |
CMS is finalizing its proposal to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
Measure Title: |
HIV Medical Visit Frequency |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
2079/340 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Efficiency and Cost Reduction |
Current Data submission Method: |
Measures Group |
Measure Description: |
Percentage of patients, regardless of age with a diagnosis of HIV who had at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical visits |
Finalized Substantive Change |
|
Steward: |
Health Resources and Services Administration |
Rationale: |
CMS is finalizing its proposal to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
Measure Title: |
Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/350 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Communication and Care Coordination |
Current Data submission Method: |
Measures Group |
Measure Description: |
Percentage of patients regardless of age undergoing a total knee replacement with documented shared decision-making with discussion of conservative (non-surgical) therapy (e.g. Nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure |
Finalized Substantive Change |
|
Steward: |
American Association of Hip and Knee Surgeons |
Rationale: |
CMS is finalizing its proposal to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. Additionally, CMS is finalizing its proposal to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis, CMS believes the classification of this measure to be a process measure in order to match the clinical action of shared decision-making. |
Measure Title: |
Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/351 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Patient Safety |
Current Data submission Method: |
Measures Group |
Measure Description: |
Percentage of patients regardless of age undergoing a total knee replacement who are evaluated for the presence or absence of venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure (e.g. history of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), Myocardial Infarction (MI), Arrhythmia and Stroke) |
Finalized Substantive Change |
|
Steward: |
American Association of Hip and Knee Surgeons |
Rationale: |
CMS is finalizing its proposal to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. Additionally, CMS is finalizing its proposal to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis, CMS believes the classification of this measure to be a process measure. |
Measure Title: |
Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/352 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Patient Safety |
Current Data submission Method: |
Measures Group |
Measure Description: |
Percentage of patients regardless of age undergoing a total knee replacement who had the prophylactic antibiotic completely infused prior to the inflation of the proximal tourniquet |
Finalized Substantive Change |
|
Steward: |
American Association of Hip and Knee Surgeons |
Rationale: |
CMS is finalizing its proposal to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. Additionally, CMS is finalizing its proposal to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis, CMS believes the classification of this measure to be a process measure. |
Measure Title: |
Total Knee Replacement: Identification of Implanted |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/353 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Patient Safety |
Current Data submission Method: |
Measures Group |
Measure Description: |
Percentage of patients regardless of age undergoing a total knee replacement whose operative report identifies the prosthetic implant specifications including the prosthetic implant manufacturer, the brand name of the prosthetic implant and the size of each prosthetic implant |
Finalized Substantive Change |
|
Steward: |
American Association of Hip and Knee Surgeons |
Rationale: |
CMS is finalizing its proposal to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the finalized MIPS policy to no longer include Measure Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. Additionally, CMS is finalizing it proposal to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis, CMS believes the classification of this measure to be a process measure. |
Measure Title: |
Anastomotic Leak Intervention |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/354 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Patient Safety |
Current Data submission Method: |
Measures Group |
Measure Description: |
Percentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery |
Finalized Substantive Change |
|
Steward: |
American College of Surgeons |
Rationale: |
CMS is finalizing its proposal to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
Measure Title: |
Unplanned Reoperation within the 30 Day Postoperative Period |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/355 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Patient Safety |
Current Data submission Method: |
Measures Group |
Measure Description: |
Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period |
Finalized Substantive Change |
|
Steward: |
American College of Surgeons |
Rationale: |
CMS is finalizing its proposal to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
Measure Title: |
Unplanned Hospital Readmission within 30 Days of Principal Procedure |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/356 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data submission Method: |
Measures Group |
Measure Description: |
Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure |
Finalized Substantive Change |
|
Steward: |
American College of Surgeons |
Rationale: |
CMS is finalizing its proposal to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
Measure Title: |
Surgical Site Infection (SSI) |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/357 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data submission Method: |
Measures Group |
Measure Description: |
Percentage of patients aged 18 years and older who had a surgical site infection (SSI) |
Finalized Substantive Change |
|
Steward: |
American College of Surgeons |
Rationale: |
CMS is finalizing its proposal to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
Measure Title: |
Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging Description |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/359 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Communication and Care Coordination |
Current Data submission Method: |
Measures Group |
Measure Description: |
Percentage of computed tomography (CT) imaging reports for all patients, regardless of age, with the imaging study named according to a standardized nomenclature and the standardized nomenclature is used in institution’s computer systems |
Finalized Substantive Change |
|
Steward: |
American College of Radiology |
Rationale: |
CMS is finalizing its proposal to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
Measure Title: |
Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/360 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Patient Safety |
Current Data submission Method: |
Measures Group |
Measure Description: |
Percentage of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion studies) imaging reports for all patients, regardless of age, that document a count of known previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion) studies that the patient has received in the 12-month period prior to the current study |
Finalized Substantive Change |
|
Steward: |
American College of Radiology |
Rationale: |
CMS is finalizing its proposal to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
Measure Title: |
Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/361 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Patient Safety |
Current Data submission Method: |
Measures Group |
Measure Description: |
Percentage of total computed tomography (CT) studies performed for all patients, regardless of age, that are reported to a radiation dose index registry that is capable of collecting at a minimum selected data elements |
Finalized Substantive Change |
|
Steward: |
American College of Radiology |
Rationale: |
CMS is finalizing its proposal to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
Measure Title: |
Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison Purposes |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/362 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Communication and Care Coordination |
Current Data submission Method: |
Measures Group |
Measure Description: |
Percentage of final reports for computed tomography (CT) studies performed for all patients, regardless of age, which document that Digital Imaging and Communications in Medicine (DICOM) format image data are available to non-affiliated external healthcare facilities or entities on a secure, media free, reciprocally searchable basis with patient authorization for at least a 12-month period after the study |
Finalized Substantive Change |
|
Steward: |
American College of Radiology |
Rationale: |
CMS is finalizing its proposal to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition In response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
Measure Title: |
Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Studies Through a Secure, Authorized, Media-Free, Shared Archive |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/363 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Communication and Care Coordination |
Current Data submission Method: |
Measures Group |
Measure Description: |
Percentage of final reports of computed tomography (CT) studies performed for all patients, regardless of age, which document that a search for Digital Imaging and Communications in Medicine (DICOM) format images was conducted for prior patient CT imaging studies completed at non-affiliated external healthcare facilities or entities within the past 12-months and are available through a secure, authorized, media free, shared archive prior to an imaging study being performed |
Finalized Substantive Change |
|
Steward: |
American College of Radiology |
Rationale: |
CMS is finalizing its proposal to change the data submission method for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
Measure Title: |
Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/364 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Communication and Care Coordination |
Current Data submission Method: |
Measures Group |
Measure Description: |
Percentage of final reports for computed tomography (CT) imaging studies of the thorax for patients aged 18 years and older with documented follow-up recommendations for incidentally detected pulmonary nodules (e.g., follow-up CT imaging studies needed or that no follow-up is needed) based at a minimum on nodule size AND patient risk factors |
Finalized Substantive Change |
|
Steward: |
American College of Radiology |
Rationale: |
CMS is finalizing its proposal to change the reporting mechanism for this measure from Measures Group only to Registry only. As part of a measures group, this measure was part of a metric that provided relevant content for a specific condition. In response to the finalized MIPS policy to no longer include Measures Group as a data submission method, this measure is being finalized as an individual measure. CMS believes this measure continues to address a clinical performance gap even if it is reported as an individual measure. |
Measure Title: |
Depression Remission at Twelve Months |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
0710/370 |
CMS E-Measure ID: |
CMS159v5 |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data submission Method: |
Web interface, Registry, EHR |
Measure Description: |
Adult patients age 18 and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at twelve months defined as PHQ-9 score less than 5. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment |
Finalized Substantive Change |
|
Steward: |
Minnesota Community Measurement |
Rationale: |
CMS is finalizing its proposal to revise the measure description to provide clarity for reporting. This does not change the intent of the measure but merely provides clarity to ensure consistent reporting for eligible clinicians. Additionally, CMS is finalizing its proposal to change this measure type designation from intermediate outcome measure to outcome measure. This measure was previously finalized in PQRS as an intermediate outcome measure. However, upon further review and analysis, CMS believes the classification of this measure to be an outcome measure in order to match the outcome of depression remission.
|
Measure Title: |
Functional Status Assessment for Knee Replacement |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/375 |
CMS E-Measure ID: |
CMS66v5 |
National Quality Strategy Domain: |
Person and Caregiver-Centered Experience and Outcomes |
Current Data submission Method: |
EHR |
Measure Description: |
Percentage of patients aged 18 years and older with primary total knee arthroplasty (TKA) who completed baseline and follow-up (patient-reported) functional status assessments. |
Finalized Substantive Change |
|
Steward: |
Centers for Medicare & Medicaid Services/ National Committee for Quality Assurance |
Rationale: |
CMS is finalizing its proposal to revise the title and description of the measure to align with the intent of the measure. This does not change the intent of the measure but merely provides clarity to ensure consistent reporting for eligible clinicians. |
Measure Title: |
Functional Status Assessment for Hip Replacement |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/376 |
CMS E-Measure ID: |
CMS56v5 |
National Quality Strategy Domain: |
Person and Caregiver-Centered Experience and Outcomes |
Current Data submission Method: |
EHR |
Measure Description: |
Percentage of patients aged 18 years and older with primary total hip arthroplasty (THA) who completed baseline and follow-up (patient-reported) functional status assessments |
Finalized Substantive Change |
|
Steward: |
Centers for Medicare & Medicaid Services/ National Committee for Quality Assurance |
Rationale: |
CMS is finalizing its proposal to revise the title and description of the measure to align with the intent of the measure. This change does not change the intent of the measure but merely provides clarity to ensure consistent reporting for eligible clinicians. |
Measure Title: |
Functional Status Assessment for Complex Chronic Conditions |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/377 |
CMS E-Measure ID: |
CMS90v6 |
National Quality Strategy Domain: |
Person and Caregiver-Centered Experience and Outcomes |
Current Data submission Method: |
EHR |
Measure Description: |
Percentage of patients aged 65 years and older with heart failure who completed initial and follow-up patient-reported functional status assessments |
Finalized Substantive Change |
|
Steward: |
Centers for Medicare & Medicaid Services/ Mathematica |
Rationale: |
CMS is finalizing its proposal to revise the title and description of the measure to add clarity in response to provider feedback. This does not change the intent of the measure but merely provides clarity to ensure consistent reporting for eligible clinicians. CMS received a comment that believes this measure is based on outdated evidence and should not be included in the program. Although there are a few studies listed in the scientific statement that support the use of patient-reported health status assessments, the AHA determined that there is limited evidence on how physicians should use these tools in clinical practice (Rumsfeld, 2013). Since there is a need for further research and because there was not enough evidence to determine best practices for implementing and interpreting patient-reported health assessments in clinical practice, CMS will implement the measure as proposed. |
Measure Title: |
Varicose Vein Treatment with Saphenous Ablation: Outcome Survey |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/420 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data submission Method: |
Registry |
Current Measure Description: |
Percentage of patients treated for varicose veins (CEAP C2-S) who are treated with saphenous ablation (with or without adjunctive tributary treatment) that report an improvement on a disease specific patient reported outcome survey instrument after treatment. |
Finalized Substantive Change |
|
Steward: |
Society of Interventional Radiology |
Rationale: |
CMS is finalizing its proposal to change this measure type designation from process measure to outcome measure. This measure was previously finalized in PQRS as a process measure. However, upon further review and analysis of the measure specification, CMS is finalizing tis proposal to revise the classification of this measure to outcome measure because it assesses improvement on a patient reported outcome survey instrument. |
Measure Title: |
Appropriate Assessment of Retrievable Inferior Vena Cava Filters for Removal |
MIPS ID Number: |
N/A |
NQF/PQRS #: |
N/A/421 |
CMS E-Measure ID: |
N/A |
National Quality Strategy Domain: |
Effective Clinical Care |
Current Data submission Method: |
Registry |
Current Measure Description: |
Percentage of patients in whom a retrievable IVC filter is placed who, within 3 months post-placement, have a documented assessment for the appropriateness of continued filtration, device removal or the inability to contact the patient with at least two attempts |
Finalized Substantive Change |
|
Steward: |
Society of Interventional Radiology |
Rationale: |
CMS is finalizing its proposal to change this measure type designation from outcome measure to process measure. This measure was previously finalized in PQRS as an outcome measure. However, upon further review and analysis of the measure specification, CMS is finalizing its proposal to revise the classification of this measure to process measure in order to match the clinical action of appropriate care assessment. |
| File Type | application/msword |
| Author | Terri Plumb |
| Last Modified By | Stein, Lee R |
| File Modified | 2016-10-13 |
| File Created | 2016-10-13 |