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Measures Under Consideration Entry/Review and Information Tool 2024 Data Template for Candidate Measures
Instructions:
1. Before accessing the CMS MERIT (Measures Under Consideration Entry/Review and Information Tool) online system, you are invited to complete
the measure template below by entering your candidate measure information in the column titled “Add Your Content Here.”
2. All rows that have an asterisk symbol * in the Field Label require a response, unless otherwise indicated in the template.
3. For each row, the “Guidance” column provides details on how to complete the template and what kinds of data to include. Unless otherwise
specified, the character limit for text fields in CMS MERIT is 8000 characters.
4. For check boxes, note whether the field is “select one” or “select all that apply.” You can click on the box to place or remove the “X.”
5. For all fields, especially Numerator and Denominator, use plain text whenever possible. Please convert any special symbols, math expressions,
or equations to plain text (keyboard alphanumeric, such as + - * /).
6. For all free-text fields: Be sure to spell out all abbreviations and define special terms at their first occurrence.
7. Numeric fields are noted, where applicable, in the “Add Your Content Here” column.
8. Row numbers are for convenience only and do not appear on the CMS MERIT user interface.
9. Send any questions to MMSsupport@battelle.org with the subject line “Pre-Rulemaking”.
2024 CMS MERIT DATA TEMPLATE
1
1/31/2024
PROPERTIES
Subsection
Measure
Information
Row
001
*Measure Title
Field Label
Measure
Information
002
*Measure Description
2024 CMS MERIT DATA TEMPLATE
Guidance
Provide the measure title only (255 characters or less).
Put any program-specific identification (ID) number
under Characteristics, not in the title.
Note: Do not enter the CMIT ID, consensus-based entity
(endorsement) ID, former Jira MUC ID number, or any
other ID numbers here (see other fields below). The
CMS program name should not ordinarily be part of the
measure title, because each measure record already
has a required field that specifies the CMS program. An
exception would be if there are several measures with
otherwise identical titles that apply to different
programs. In this case, including or imbedding a
program name in the title (to prevent there being any
otherwise duplicate titles) is helpful. For additional
information on measure title, see:
https://mmshub.cms.gov/measure-lifecycle/measurespecification/document-measure.
Provide a brief description of the measure. For
additional information on measure description, see:
https://mmshub.cms.gov/measure-lifecycle/measurespecification/document-measure.
2
ADD YOUR CONTENT HERE
Free text field
Free text field
1/31/2024
Subsection
Measure
Information
Row
003
Field Label
*Select the CMS program(s)
for which the measure is
being submitted.
Guidance
Select all that apply. Please note, measures specified
and intended for use at more than one level of analysis
must be submitted separately for each level of analysis
(e.g., individual clinician, facility).
If you choose multiple programs for this submission,
please ensure the programs fall under the same level of
analysis. If you choose multiple programs and need
guidance as to whether your selection represents
multiple levels of analysis, please contact
MMSSupport@battelle.org. There is functionality
within CMS MERIT to decrease the data entry process
for multiple submissions of the same measure. Please
reach out to MMSSupport@battelle.org
for guidance and support.
If you are submitting for MIPS, there are two choices of
program. Do NOT enter both MIPS-Quality and MIPSCost for the same measure. Choose MIPS-Quality for
measures that pertain to quality and/or efficiency.
Choose MIPS-Cost only for measures that pertain to
cost.
n/a
n/a
If you select “Merit-based
Incentive Payment System Quality” in Row 003, then
Row 004 becomes an
optional field. If you do not
select “Merit-based
Incentive Payment System Quality” in Row 003, then
skip to Row 005.
2024 CMS MERIT DATA TEMPLATE
n/a
3
ADD YOUR CONTENT HERE
☐ Ambulatory Surgical Center Quality Reporting
Program
☐ End-Stage Renal Disease (ESRD) Quality Incentive
Program
☐ Home Health Quality Reporting Program
☐ Hospice Quality Reporting Program
☐ Hospital Inpatient Quality Reporting Program
☐ Hospital Outpatient Quality Reporting Program
☐ Hospital Readmissions Reduction Program
☐ Hospital Value-Based Purchasing Program
☐ Hospital-Acquired Condition Reduction Program
☐ Inpatient Psychiatric Facility Quality Reporting
Program
☐ Inpatient Rehabilitation Facility Quality Reporting
Program
☐ Long-Term Care (LTC) Hospital Quality Reporting
Program
☐ Medicare Promoting Interoperability Program
☐ Medicare Shared Savings Program
☐ Merit-based Incentive Payment System-Cost
☐ Merit-based Incentive Payment System-Quality
☐ Part C Star Ratings
☐ Part D Star Ratings
☐ Prospective Payment System-Exempt Cancer
Hospital Quality Reporting Program
☐ Rural Emergency Hospital Quality Reporting
Program
☐ Skilled Nursing Facility Quality Reporting Program
☐ Skilled Nursing Facility Value-Based Purchasing
Program
This is not a data entry field.
1/31/2024
Subsection
Measure
Information
Row
004
Measure
Information
005
Field Label
MIPS Quality: Identify any
links with related Cost
measures and Improvement
Activities
*Completed Stage(s) of
Development
Guidance
Where available, provide description of linkages and a
rationale that correlates this MIPS quality measure to
other performance category measures and activities.
ADD YOUR CONTENT HERE
Free text field
Select all stages of development that have been
completed. There are five stages in the Measure
Lifecycle: conceptualization; specification; testing;
implementation; and use, continuing evaluation, and
maintenance. Measure conceptualization is the first
stage; however, the stages are not necessarily
sequential. Instead, the stages are iterative and can
occur concurrently.
☐ Measure Conceptualization
☐ Measure Specification
☐ Measure Testing
☐ Measure Use, Continuing Evaluation &
Maintenance
The measure conceptualization stage initiates
information gathering and business case development.
The measure specification stage involves establishing
the basic elements of the measure, including the
numerator, calculation algorithm, and data source
identification.
The measure testing stage examines the specifications,
usually with a limited number of real settings, to make
sure the measure is scientifically acceptable and
feasible.
Measure specification and measure testing are
iterative.
n/a
n/a
If you select only “Measure
Conceptualization” and/or
“Measure Specification” in
Row 005, then Row 006
becomes a required field. If
your selections include
“Measure Testing” or
“Measure Use, Continuing
Evaluation & Maintenance”
in Row 005, then skip to Row
007.
2024 CMS MERIT DATA TEMPLATE
For additional information regarding stage of
development, see: https://mmshub.cms.gov/blueprintmeasure-lifecycle-overview.
n/a
4
This is not a data entry field.
1/31/2024
Subsection
Measure
Information
Measure
Information
Row
006
Field Label
*Stage of Development
Details
007
*Level of Analysis
Guidance
If testing is not yet completed, describe when testing is
planned (i.e., specific dates), what type of testing is
planned (e.g., alpha, beta) as well as the types of
facilities in which the measure will be tested.
For additional information, see:
https://mmshub.cms.gov/blueprint-measure-lifecycleoverview.
Select one. Select the level of analysis at which the
measure is specified and intended for use. If the
measure is specified and intended for use at more than
one level, submit the other levels separately. Any
testing results provided in subsequent sections of this
submission must be conducted at the level of analysis
selected here.
For submission to the MIPS-Quality program, you must
report, at minimum, the results of individual clinicianlevel testing. If testing is performed at both clinicianindividual and clinician-group levels of analysis, you
may select “Clinician: Individual and Group.” Please
submit results of individual clinician-level testing in this
form and group-level testing results in an attachment.
ADD YOUR CONTENT HERE
Free text field
☐ Accountable Care Organization
☐ Clinician: Group
☐ Clinician: Individual
☐ Clinician: Individual and Group
☐ Facility
☐ Health plan
☐ Integrated Delivery System
☐ Medicaid program (e.g., Health Home or 1115)
☐ Population: Community, County or City
☐ Population: Regional and State
For submission to the MIPS-Cost program, clinician
group-level testing is sufficient.
2024 CMS MERIT DATA TEMPLATE
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1/31/2024
Subsection
Measure
Information
Row
008
Field Label
*In which setting(s) was this
Guidance
Select all that apply.
measure tested?
Measure
Information
009
*Multiple Scores
n/a
n/a
If you select “Yes” in Row
009, then Rows 010-012
become required fields. If
you select, “No”, then skip to
Row 013.
Measure
Information
010
*Measures with Multiple
Scores: Number of Scores
2024 CMS MERIT DATA TEMPLATE
Does the submitter recommend that more than one
measure score be separately reported for this measure
(e.g., 7- and 30-day rate, rates for different procedure
types, etc.)? This does not include index measures,
where component measure scores result in one overall
index score. Note: If “Yes”, please describe one score
only in this form. Submit separate attachments for each
of the other scores.
n/a
How many measure scores are recommended for this
measure?
6
ADD YOUR CONTENT HERE
☐ Ambulatory surgery center
☐ Ambulatory/office-based care
☐ Behavioral health clinic
☐ Community hospital
☐ Dialysis facility
☐ Emergency department
☐ Federally qualified health center (FQHC)
☐ Health and Drug Plans
☐ Hospital outpatient department (HOD)
☐ Home health
☐ Hospice
☐ Hospital inpatient acute care facility
☐ Inpatient psychiatric facility
☐ Inpatient rehabilitation facility
☐ Long-term care hospital
☐ Nursing home
☐ PPS-exempt cancer hospital
☐ Skilled nursing facility
☐ Veterans Health Administration facility
☐ Not yet tested
☐ Other (enter here):
☐ Yes
☐ No
This is not a data entry field.
Numeric field
1/31/2024
Subsection
Measure
Information
Row
011
Measure
Information
012
Measure
Information
013
Field Label
*Measures with Multiple
Scores: Names of Score
Reported in MERIT Form
*Measures with Multiple
Scores: Names of Scores
*Is the measure a
composite and/or a paired
measure?
n/a
n/a
If you select “Yes, this is a
paired measure” in Row 013,
then Rows 014-015 become
required fields. If you do not
select “Yes, this is a paired
measure” in this field, then
skip to Row 016.
Measure
Information
014
*How many measures are
Measure
Information
015
intended to be paired with
this measure?
*What are the titles of all
measures that should be
paired with this measure?
2024 CMS MERIT DATA TEMPLATE
Guidance
Please enter the name of the score described in this
MERIT form.
ADD YOUR CONTENT HERE
Free text field
Please enter the names of all additional scores included
in this measure but not described in this MERIT form.
Please enter the names separated by a semicolon and
do not enter any additional information in this field.
Select all that apply.
Free text field
A composite measure contains two or more individual
measures, resulting in a single measure and a single
score. This includes index measures. If this measure is a
composite measure, please enter data pertaining to the
overall composite measure into this form. Please attach
any additional information pertaining to individual
components.
Paired measures have different measure scores, but
results require them to be reported together to be
interpreted appropriately. Note: Individual measures
comprising a paired measure must be submitted
individually.
n/a
☐ Yes, this is a composite measure
☐ Yes, this is a paired measure
☐ No, this is neither a composite nor a paired
measure
This is not a data entry field.
How many other measures are intended to be paired
with this measure? Do not include this measure in the
count.
Numeric field
Please enter the measure titles for all other measures
that should be paired with this measure. Do not include
this measure in the list. Please enter the measure titles
separated by a semicolon, and do not enter any
additional information in this field.
Free text field
7
1/31/2024
Subsection
Measure
Information
Row
016
*Numerator
Field Label
Measure
Information
017
*Numerator Exclusions
Measure
Information
018
*Denominator
Measure
Information
019
*Denominator Exclusions
Measure
Information
020
*Denominator Exceptions
Measure
Information
021
*Briefly describe the
rationale for the measure
2024 CMS MERIT DATA TEMPLATE
Guidance
The upper portion of a fraction used to calculate a rate,
proportion, or ratio. An action to be counted as
meeting a measure's requirements.
For additional information on exclusions/exceptions,
see: https://mmshub.cms.gov/measurelifecycle/measure-testing/evaluation-criteria/scientificacceptability/exclusions. If not applicable, enter 'N/A.'
The lower part of a fraction used to calculate a rate,
proportion, or ratio. The denominator is associated
with a given population that may be counted as eligible
to meet a measure’s inclusion requirements.
For additional information on exclusions/exceptions,
see: https://mmshub.cms.gov/measurelifecycle/measure-testing/evaluation-criteria/scientificacceptability/exclusions. If not applicable, enter 'N/A.'
For additional information on exclusions/exceptions,
see: https://mmshub.cms.gov/measurelifecycle/measure-testing/evaluation-criteria/scientificacceptability/exclusions. If not applicable, enter ‘N/A.’
Briefly describe the rationale for the measure and/or
the impact the measure is anticipated to achieve.
Details about the evidence to support the measure will
be captured in the Evidence section.
8
ADD YOUR CONTENT HERE
Free text field
Free text field
Free text field
Free text field
Free text field
Free text field
1/31/2024
Subsection
Measure
Implementa
tion
Row
022
Field Label
*Feasibility of Data
Elements
Guidance
Select one. Select the extent to which the specified
data elements are available in electronic fields.
Electronic fields should include a designated location
and format for the data in claims, EHRs, registries, etc.
• Select “ALL data elements are in defined fields in
electronic sources” if the data elements needed to
calculate the measure are all available in discrete and
electronically defined fields.
• Select “Some data elements are in defined fields in
electronic sources” if the data elements needed to
calculate the measure are not all available in discrete
and electronically defined fields.
• Select “No data elements are in defined fields in
electronic sources” if none of the data elements
needed to calculate the measure are available in
discrete and electronically defined fields.
• Select “Not applicable" ONLY for CAHPS measures.
• Select “Unable to Determine” ONLY if a feasibility
assessment has not yet been completed.
n/a
n/a
If you select “ALL data
elements are in defined
fields in electronic sources”
or “Some data elements are
in defined fields in electronic
sources in Row 022, then
Row 023 becomes a required
field, otherwise, skip to row
024.
2024 CMS MERIT DATA TEMPLATE
For a PRO-PM, select the most appropriate option
based on the data collection format(s).
n/a
9
ADD YOUR CONTENT HERE
☐ ALL data elements are in defined fields in electronic
sources
☐ Some data elements are in defined fields in
electronic sources
☐ No data elements are in defined fields in electronic
sources
☐ Not applicable (applies only for CAHPS measures)
☐ Unable to determine (applies only if a feasibility
assessment has not yet been completed)
This is not a data entry field.
1/31/2024
Subsection
Measure
Implementa
tion
Row
023
Field Label
*USCDI Data Elements
Guidance
Select one. Indicate the extent to which the data
elements that are in defined fields in electronic sources
align with United States Core Data for Interoperability
(USCDI) v4 or USCDI+ Quality draft standard definitions.
For more information about USCDI, please refer to the
HealthIT.gov website available at:
https://www.healthit.gov/isa/united-states-core-datainteroperability-uscdi
ADD YOUR CONTENT HERE
☐ ALL data elements align with USCDI/USCDI+ Quality
standard definitions
☐ Some data elements align with USCDI/USCDI+
Quality standard definitions
☐ None of the data elements align with USCDI/USCDI+
Quality standard definitions
☐ USCDI/USCDI+ Quality alignment not assessed
For more information about USCDI+ Quality, please
refer to the HealthIT.gov website available at:
https://www.healthit.gov/topic/interoperability/uscdiplus
2024 CMS MERIT DATA TEMPLATE
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1/31/2024
Subsection
Measure
Implementa
tion
Row
024
Field Label
Measure
Implementa
tion
n/a
If you select "Combination"
in Row 024, then Row 025
becomes a required field;
otherwise, skip to Row 026.
Measure
Implementa
tion
025
*Combination measure:
*Method of Measure
Calculation
Methods of calculation
2024 CMS MERIT DATA TEMPLATE
Guidance
Select one. Select the method used to calculate
measure scores for the version of the measure
proposed in this submission form. Please review
guidance before making selections:
• Select “Electronically Derived Administrative Data
(Claims and/or Non-Claims)” if the measure can be
calculated exclusively from administrative data
submitted electronically for billing or other purposes.
• Select “eCQM” if the measure is exclusively specified
and formatted to use data from electronic health
record (EHRs) and/or health information technology
systems, using the Quality Data Model (QDM) to
define the data elements and Clinical Quality
Language (CQL) to express measure logic.
• Select “Other digital method” if the measure does
not meet the definition of an eCQM as described
above, but can be calculated electronically (e.g.,
registry, MDS, OASIS).
• Select “Manual abstraction” if all data elements in
the measure requires manual review of records,
paper-based billing, or manual calculation (e.g.,
CAHPS).
• Select “Combination” if two or more types of data
sources are required to calculate the measure score.
For all other measures that rely on patient surveys
(e.g., PRO-PMs), select the option that best describes
the way the measure is calculated. For example, if a
patient survey is collected electronically and does
not require manual abstraction, select "Other digital
method" or "eCQM" depending on where the data
are collected.
n/a
ADD YOUR CONTENT HERE
☐ Electronically Derived Administrative Data (Claims
and/or Non-Claims)
☐ eCQM
☐ Other digital method
☐ Manual abstraction
☐ Combination
Select all that apply. A minimum of two options must
be selected.
☐ Electronically Derived Administrative Data (Claims
and/or Non-Claims)
☐ eCQM
☐ Other digital method
☐ Manual abstraction
11
This is not a data entry field.
1/31/2024
Subsection
Measure
Implementa
tion
Row
026
Field Label
*How is the measure
expected to be reported to
the program?
2024 CMS MERIT DATA TEMPLATE
Guidance
This is the anticipated data submission method. Select
all that apply. Use the “Submitter Comments” field to
specify or elaborate on the type of reporting data, if
needed to define your measure.
12
ADD YOUR CONTENT HERE
☐ eCQM
☐ Clinical Quality Measure (CQM)
☐ Claims
☐ Web interface
☐ Other (enter here):
1/31/2024
Subsection
Burden
Row
027
Field Label
Guidance
*Did the provider workflow
Select one.
have to be modified to
collect additional data
needed to report the
measure?
Select “Yes” if workflow modifications impose
moderate to significant additional data entry burden on
a clinician or other provider to collect the data
elements to report the measure because data are not
routinely collected during clinical care, OR EHR
interface changes were necessary.
ADD YOUR CONTENT HERE
☐ Yes
☐ No
☐ Not applicable
☐ Unable to determine
Select “No” if workflow modifications impose no or
limited additional data entry burden on a clinician or
other provider to collect the data elements to report
the measure because data are routinely collected
during the clinical care, AND no EHR interface changes
were necessary.
Select "Not applicable" if the measure imposes no data
entry burden on the clinician or provider because:
A) the measure is calculated by someone other than
the clinician or provider AND uses data that are
routinely generated (i.e., administrative data and
claims), OR
B) the data are collected by someone other than the
clinician or provider (e.g., CAHPS), OR
C) the measure repurposes existing data sets to
calculate a measure score (e.g., HEDIS).
Select "Unable to determine” if a workflow analysis was
not completed and/or it cannot be determined whether
the workflow modifications impose additional data
entry burden to collect data needed to report the
measure.
2024 CMS MERIT DATA TEMPLATE
13
1/31/2024
Subsection
Groups
Row
028
Field Label
*Is this measure an
electronic clinical quality
measure (eCQM)?
Guidance
Select 'Yes' or 'No'. If your answer is yes, the Measure
Authoring Tool (MAT) ID number must be provided
below. For more information on eCQMs, see:
https://www.emeasuretool.cms.gov/
ADD YOUR CONTENT HERE
☐ Yes
☐ No
Groups
n/a
If you select “Yes” in Row
028, then Rows 029-031
become required fields. If
you select “No” in Row 028,
then skip to Row 032.
n/a
This is not a data entry field.
Groups
029
*Measure Authoring Tool
You must attach Bonnie test cases for this measure,
with 100% logic coverage (test cases should be
appended), attestation that value sets are published in
Value Set Authority Center (VSAC), and feasibility
scorecard. If not an eCQM, or if MAT number is not
available, enter 0.
ADD YOUR CONTENT HERE
Select 'Yes' or 'No'. For additional information on HQMF
standards, see: https://ecqi.healthit.gov/tool/hqmf
☐ Yes
☐ No
Enter the number of unique EHR vendors represented
in the dataset to demonstrate that measure data
elements are valid and that the measure score can be
accurately calculated across different systems (e.g.,
Epic, Cerner, etc.).
Numeric field
(MAT) Number
Groups
030
*If eCQM, does the measure
have a Health Quality
Measures Format (HQMF)
specification in alignment
with the latest HQMF and
eCQM standards, and does
the measure align with
Clinical Quality Language
(CQL) and Quality Data
Model (QDM)?
Groups
031
*Number of unique EHR
vendors represented in
testing dataset
2024 CMS MERIT DATA TEMPLATE
14
1/31/2024
Subsection
Measure Score
Level
(Accountable
Entity Level)
Testing
Row
032
Field Label
*Reliability
Guidance
Indicate whether reliability testing was conducted for
the accountable entity-level measure scores.
Acceptable reliability tests include signal-to-noise (or
inter-unit reliability) or random split-half correlation.
For more information on accountable entity-level
reliability testing, refer to the Blueprint content on the
CMS Measures Management System (MMS) Hub
(https://mmshub.cms.gov/measure-lifecycle/measuretesting/evaluation-criteria/scientificacceptability/reliability).
ADD YOUR CONTENT HERE
☐ Yes
☐ No
Select “Yes” if acceptable accountable entity-level
reliability testing has been completed as of submission
of this form.
Select “No” if you are not able to provide the results of
acceptable accountable entity-level reliability testing in
this submission. If testing results are incomplete, or if
you are submitting a different type of reliability testing,
provide as an attachment.
Note: This section refers to the reliability of the
accountable entity-level measure scores in the final
performance measure. For testing of surveys or patient
reported tools, refer to the Patient-Reported Data
section. Note: for MIPS-Quality submissions, please
provide individual clinician-level results. If the measure
was also tested at the clinician group level, you may
include those results in an attachment.
n/a
n/a
If you select “Yes” in Row
032, then Row 33 becomes a
required field. If you select
“No” in Row 032, then skip
to Row 042.
2024 CMS MERIT DATA TEMPLATE
n/a
This is not a data entry field.
15
1/31/2024
Subsection
Measure Score
Level
(Accountable
Entity Level)
Testing
Row
033
Field Label
*Reliability: Type of analysis
Guidance
Select all that apply.
Signal-to-noise (or inter-unit reliability) is the precision
attributed to an actual construct versus random
variation (e.g., ratio of between unit variance to total
variance) (Adams J. The reliability of provider profiling:
a tutorial. Santa Monica, CA: RAND; 2009.
http://www.rand.org/pubs/technical_reports/TR653.ht
ml).
ADD YOUR CONTENT HERE
☐ Signal-to-Noise
☐ Random Split-Half Correlation
Random split-half correlation is the agreement
between two measures of the same concept, using data
derived from split samples drawn from the same entity
at a single point in time.
n/a
n/a
If you select “Signal-toNoise” in Row 033, then
Rows 034-037 become
required fields. If you select,
“Random Split-Half
Correlation” in Row 033,
then Rows 038-041 become
required fields.
n/a
This is not a data entry field.
Measure Score
Level
(Accountable
Entity Level)
Testing
034
*Signal-to-Noise: Level of
Select the level of analysis at which the signal-to-noise
analysis was conducted. If the measure is specified and
intended for use at more than one level, ensure the
results in this section are at the same level of analysis
selected in the Measure Information section of this
form.
☐ Accountable Care Organization
☐ Clinician – Group
☐ Clinician – Individual
☐ Facility
☐ Health plan
☐ Integrated Delivery System
☐ Medicaid program (e.g., Health Home or 1115)
☐ Population: Community, County or City
☐ Population: Regional and State
Analysis
For MIPS-Quality submissions, you must report the
results of individual clinician-level testing. If group-level
testing is available, you may submit those results as an
attachment.
Measure Score
Level
(Accountable
Entity Level)
Testing
035
*Signal-to-Noise: Sample
size
2024 CMS MERIT DATA TEMPLATE
Indicate the number of accountable entities sampled to
test the final performance measure. Note that this field
is intended to capture the number of measured entities
and not the number of individual patients or cases
included in the sample.
16
Numeric field
1/31/2024
Subsection
Measure Score
Level
(Accountable
Entity Level)
Testing
Row
036
Measure Score
Level
(Accountable
Entity Level)
Testing
037
Measure Score
Level
(Accountable
Entity Level)
Testing
038
Field Label
*Signal-to-Noise: Median
Statistical result
*Signal-to-Noise:
Interpretation of results
*Random Split-Half
Correlation: Level of Analysis
Guidance
Indicate the median result for the signal-to-noise
analysis used to assess accountable entity level
reliability. Results should range from 0.00 to 1.00.
Calculate reliability as the measure is intended to be
implemented (e.g., after applying minimum
denominator requirements, appropriate type of setting,
provider, etc.).
Describe the type of statistic and interpretation of the
results (e.g., low, moderate, high). Provide the
distribution of signal-to-noise results across measured
entities (e.g., min, max, percentiles). List accepted
thresholds referenced and provide a citation. If
applicable, include the precision of the statistical result
(e.g., 95% confidence interval) and/or an assessment of
statistical significance (e.g., p-value).
Free text field
Select the level of analysis at which the random splithalf analysis was conducted. If the measure is specified
and intended for use at more than one level, ensure the
results in this section are at the same level of analysis
selected in the Measure Information section of this
form.
☐ Accountable Care Organization
☐ Clinician – Group
☐ Clinician – Individual
☐ Facility
☐ Health plan
☐ Integrated Delivery System
☐ Medicaid program (e.g., Health Home or 1115)
☐ Population: Community, County or City
☐ Population: Regional and State
For MIPS-Quality submissions, you must report the
results of individual clinician-level testing. If group-level
testing is available, you may submit those results as an
attachment.
Measure Score
Level
(Accountability
Entity Level)
Testing
039
Measure Score
Level
(Accountability
Entity Level)
Testing
040
*Random Split-Half
Correlation: Sample size
*Random Split-Half
Correlation: Statistical result
2024 CMS MERIT DATA TEMPLATE
ADD YOUR CONTENT HERE
Numeric field
Indicate the number of accountable entities sampled to
test the final performance measure. If number varied
by sample, use the largest number of measured
entities. Note that this field is intended to capture the
number of measured entities and not the number of
individual patients or cases included in the sample.
Numeric field
Indicate the statistical result for the random split-half
correlation analysis used to assess accountable entity
level reliability. Results should range from -1.00 to 1.00.
Calculate reliability as the measure is intended to be
implemented (e.g., after applying minimum
denominator requirements, appropriate type of setting,
provider, etc.).
Numeric field
17
1/31/2024
Subsection
Measure Score
Level
(Accountability
Entity Level)
Testing
Row
041
Measure Score
Level
(Accountability
Entity Level)
Testing
042
Field Label
*Random Split-Half
Correlation: Interpretation
of results
*Empiric Validity
Guidance
Describe the type of statistic and interpretation of the
results (e.g., low, moderate, high). List accepted
thresholds referenced and provide a citation. If
applicable, include the precision of the statistical result
(e.g., 95% confidence interval) and/or an assessment of
statistical significance (e.g., p-value).
ADD YOUR CONTENT HERE
Free text field
Indicate whether empiric validity testing was conducted
for the accountable entity-level measure scores. For
more information on accountable entity level empiric
validity testing, refer to the Blueprint content on the
CMS MMS Hub (https://mmshub.cms.gov/measurelifecycle/measure-testing/evaluation-criteria/scientificacceptability/validity)
☐ Yes
☐ No
Note: This section refers to the empiric validity of the
accountable entity level measure scores in the final
performance measure. Refer to the Patient-Reported
Data section for testing of surveys or patient reported
tools.
Note: for MIPS-Quality submissions, please provide
individual clinician-level results. If the measure was also
tested at the clinician group level, you may include
those results in an attachment.
n/a
n/a
If you select “Yes” in Row
042, then Rows 043-046
become required fields. If
you select “No” in Row 042,
then skip to Row 047.
n/a
This is not a data entry field.
Measure Score
Level
(Accountable
Entity Level)
Testing
043
*Empiric Validity: Level of
Select the level of analysis at which the empiric validity
analysis was conducted. If the measure is specified and
intended for use at more than one level, ensure the
results in this section are at the same level of analysis
selected in the Measure Information section of this
form.
☐ Accountable Care Organization
☐ Clinician – Group
☐ Clinician – Individual
☐ Facility
☐ Health plan
☐ Integrated Delivery System
☐ Medicaid program (e.g., Health Home or 1115)
☐ Population: Community, County or City
☐ Population: Regional and State
Analysis
For MIPS-Quality submissions, you must report the
results of individual clinician-level testing. If group-level
testing is available, you may submit those results as an
attachment.
2024 CMS MERIT DATA TEMPLATE
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Subsection
Measure Score
Level
(Accountability
Entity Level)
Testing
Row
044
Measure Score
Level
(Accountability
Entity Level)
Testing
045
Measure Score
Level
(Accountable
Entity Level)
Testing
Measure Score
Level
(Accountable
Entity Level)
Testing
046
Field Label
*Empiric Validity: Sample
size
*Empiric Validity: Methods
and findings
*Empiric Validity:
Interpretation of results
047
*Face validity
Guidance
Indicate the number of accountable entities sampled to
test the final performance measure. Note that this field
is intended to capture the number of measured entities
and not the number of individual patients or cases
included in the sample.
ADD YOUR CONTENT HERE
Numeric field
Describe the methods used to assess accountable entity
level validity. Describe the comparison groups or
constructs used to verify the validity of the measure
scores, including hypothesized relationships (e.g.,
expected to be positively or negatively correlated).
Describe your findings for each analysis conducted,
including the statistical results and the strongest and
weakest results across analyses. If applicable, include
the precision of the statistical result(s) (e.g., 95%
confidence interval) and/or an assessment of statistical
significance (e.g., p-value). If methods and results
require more space, include as an attachment.
Free text field
Indicate whether the statistical result affirmed the
hypothesized relationship for the analysis conducted.
☐ Yes
☐ No
Indicate if a vote was conducted among experts and
patients/caregivers on whether the final performance
measure scores can be used to differentiate good from
poor quality of care.
☐ Yes
☐ No
Select “No” if experts and patients/caregivers did not
provide feedback on the final performance measure at
the specified level of analysis or if the feedback was
related to a property of the measure unrelated to its
ability to differentiate performance among measured
entities.
This item is intended to assess whether face validity
testing was conducted on the final performance
measure and is not intended to assess whether patientreported surveys or tools have face validity. Survey item
testing results can be provided in an attachment and
described in the Patient-Reported Data Section.
2024 CMS MERIT DATA TEMPLATE
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1/31/2024
Subsection
n/a
Row
n/a
Field Label
If you select “Yes” in Row
047, then Rows 048-050
become required fields. If
you select “No” in Row 047,
then skip to Row 051.
Measure Score
Level
(Accountable
Entity Level)
Testing
Measure Score
Level
(Accountable
Entity Level)
Testing
048
*Face validity: Total number
Measure Score
Level
(Accountable
Entity Level)
Testing
050
of voting experts and
patients/caregivers
049
*Face validity: Number of
experts and
patients/caregivers who
voted in agreement
Face validity: Interpretation
2024 CMS MERIT DATA TEMPLATE
Guidance
n/a
ADD YOUR CONTENT HERE
This is not a data entry field.
Indicate the number of experts and patients/caregivers
who voted on face validity (specifically, whether the
measure could differentiate good from poor quality
care among accountable entities).
Numeric field
Indicate the number of experts and patients/caregivers
who voted in agreement that the measure could
differentiate good from poor quality care among
accountable entities. If votes were conducted using a
scale, sum all responses in agreement with the
statement. Do not include neutral votes. If more than
one question was asked of the experts and
patients/caregivers, only provide results from the
question relating to the ability of the final performance
measure to differentiate good from poor quality care.
Numeric field
Briefly explain the interpretation of the result, including
any disagreement with the face validity of the
performance measure.
Free text field
20
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Subsection
Patient/Enco
unter Level
(Data
Element
Level)
Testing
Row
051
Field Label
*Patient/Encounter Level
Testing
Guidance
Indicate whether patient/encounter level testing of the
individual data elements in the final performance
measure was conducted (i.e., measure of agreement
such as kappa or correlation coefficient). Prior studies
of the same data elements may be submitted.
ADD YOUR CONTENT HERE
☐ Yes
☐ No
☐ Not applicable
• Select “Yes” if data element agreement was assessed
at the individual data element level as of submission
of this form.
• Select “No” if you are not able to provide the results
of data element agreement in this submission. If you
are submitting preliminary testing results or a
different type of data element testing, provide as an
attachment.
• Select “No” and skip to the Patient-Reported Data
section if data element testing was only conducted
for a survey or patient reported tool (e.g., internal
consistency) rather than data element agreement for
the final performance measure.
• Select “Not applicable” if the measure relies entirely
on administrative data.
n/a
n/a
If you select “Yes” in Row
051, then Rows 052-056
become required fields. If
you select “No” or “Not
applicable” in Row 051, then
skip to Row 057.
2024 CMS MERIT DATA TEMPLATE
Note: This section includes tests of both data element
reliability and validity.
n/a
21
This is not a data entry field.
1/31/2024
Subsection
Patient/Enco
unter Level
(Data
Element
Level)
Testing
Patient/Enco
unter Level
(Data
Element
Level)
Testing
Patient/Enco
unter Level
(Data
Element
Level)
Testing
Row
052
Field Label
*Type of Analysis
053
*Sample Size
054
*Statistic Name
2024 CMS MERIT DATA TEMPLATE
Guidance
Select all that apply. For more information on
patient/encounter level testing, refer to the Blueprint
content on the CMS MMS Hub
(https://mmshub.cms.gov/measure-lifecycle/measuretesting/evaluation-criteria/scientificacceptability/reliability)
Note: This section refers to the patient/encounter level
data elements in the final performance measure. Refer
to the Patient-Reported Data section for testing of
patient/encounter level data elements in surveys or
patient reported tools.
Indicate the number of patients/encounters sampled.
Select one. Indicate the statistic used to assess
agreement (e.g., percent agreement, kappa, positive
predictive value, etc.). If more than one type of statistic
was calculated, list the one that best depicts the
reliability and/or validity of the data elements in your
measure. Other statistics and results should be
provided in the “Interpretation of results” field or
provided as an attachment.
22
ADD YOUR CONTENT HERE
☐ Agreement between two manual reviewers
☐ Agreement between eCQM and manual reviewer
☐ Agreement between other gold standard and manual
reviewer
Numeric field
☐ Percent agreement
☐ Kappa
☐ Correlation coefficient
☐ Sensitivity
☐ Positive Predictive Value
1/31/2024
Subsection
Patient/Enco
unter Level
(Data
Element
Level)
Testing
Row
055
Field Label
*Statistical Results:
Individual Data Element
Guidance
Indicate the single lowest critical data element result of
the statistic selected above. This field is intended to
capture the least reliable or least valid data element
included in the measure. Information about all critical
data elements should be provided in the
“Interpretation of results” field.
ADD YOUR CONTENT HERE
Numeric field
If providing kappa or a correlation coefficient, results
should be between -1 and 1.
If providing percent agreement, sensitivity, or positive
predictive value, results should be between 0% and
100%. The percent value should be entered as a whole
number; for example, 70% would be entered as 70 and
NOT 0.7.
Patient/Enco
unter Level
(Data
Element
Level)
Testing
056
*Interpretation of results
If not tested at the individual data element level, enter
9999.
Briefly describe the interpretation of results. Include a
list of all data elements tested including their
frequency, statistical results, and 95% confidence
intervals, as applicable. Include 95% confidence
intervals for the overall denominator and numerator
results, as applicable. Provide results broken down by
test site to demonstrate whether reliability/validity
varied between sites, if available. If more room is
needed and testing results are included in an
attachment, provide the name of the attachment and
location in the attachment.
Free text field
If any data element has low reliability or validity,
describe the anticipated impact and whether it could
introduce bias to measure scores. If there is variation in
reliability or validity scores across test sites/measured
entities, describe how this variation impacts overall
interpretation of the results.
2024 CMS MERIT DATA TEMPLATE
23
1/31/2024
Subsection
PatientReported
Data
Row
057
n/a
n/a
PatientReported
Data
058
Field Label
*Does the performance
measure use survey or
patient-reported data?
If you select “Yes” in Row
057, then Rows 058 and 059
become required fields. If
you select “No” in Row 057,
then skip to Row 060.
*Survey level testing
methodology and results
Guidance
Indicate whether the performance measure utilizes
data from structured surveys or patient-reported tools.
☐ Yes
☐ No
ADD YOUR CONTENT HERE
n/a
This is not a data entry field.
List each survey or patient-reported outcome tool
accepted by the performance measure. Indicate
whether the tool(s) are being used as originally
specified and tested or if modifications are required. If
available, provide each survey or tool as a link or
attachment.
Free text field
Describe the mode(s) of administration available (e.g.,
electronic, phone, mail) and the number of languages
the survey(s) or tool(s) are available in.
Indicate whether any of the surveys or tools is
proprietary requiring licenses or fees for use.
Briefly describe the method used to psychometrically
test or validate the patient survey or patient-reported
outcome tool. (e.g., Cronbach’s alpha, ICC, Pearson
correlation coefficient, Kuder-Richardson test). If the
survey or tool was developed prior to the development
of the performance measure, describe how the
intended use of the survey or tools for the performance
measure aligns with the survey or tool as originally
designed and tested. Indicate whether the measure
uses all components within a tool, or only parts of the
tool. Summarize the statistical results and briefly
describe the interpretation of results.
2024 CMS MERIT DATA TEMPLATE
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1/31/2024
Subsection
PatientReported
Data
Row
059
Measure
Performanc
e
060
Measure
Performanc
e
061
Measure
Performanc
e
062
Field Label
Guidance
Select all that apply. Survey instruments are expected
to be developed in Spanish, in addition to English.
ADD YOUR CONTENT HERE
☐ Survey instrument was developed in Spanish and
validated
☐ Survey instrument was developed in Spanish but not
yet validated
☐ Working on Spanish version of survey instrument
☐ There are no plans to develop a Spanish version of
survey instrument
type of score
Select one. Measure performance score type should be
at the level of accountable entity.
*Measure performance
Select one
☐ Categorical (e.g., measured entity scores yes/no,
pass/fail, or rating scale/score)
☐ Composite scale/non-weighted score
☐ Composite scale/weighted score
☐ Continuous variable (e.g., average)
☐ Count
☐ Frequency Distribution
☐ Proportion
☐ Rate
☐ Ratio
☐ Better quality = Higher score
☐ Better quality = Lower score
☐ Better quality = Score within a defined interval
☐ Passing score above a specified threshold defines
better quality
☐ Passing score below a specified threshold defines
better quality
Numeric field
*Spanish development of
the survey instrument.
*Measure performance -
score interpretation
*Number of accountable
entities included in analysis
Provide the number of accountable entities included in
the analysis of the distribution of performance scores.
Please enter a single value and do not enter a range.
Measure
Performanc
e
063
Measure
Performanc
e
064
*Number of accountable
entities: unit
*Number of persons
2024 CMS MERIT DATA TEMPLATE
If unknown or not available, enter 9999.
Provide the unit of accountable entities included in the
analysis of the distribution of performance scores.
Provide the number of persons included in the analysis
of the distribution of performance scores
25
Free text field
Numeric field
1/31/2024
Subsection
Measure
Performanc
e
Row
065
Field Label
*10th percentile
Guidance
Provide the performance score at the 10th percentile
for the testing sample that is relevant to the intended
use of the measure.
ADD YOUR CONTENT HERE
Numeric field
If this is a proportion measure, provide the 10th
percentile score in percentage form, without the
symbol. For example, if the 10th percentile
performance score is 21.2%, enter 21.2 and not 0.212.
Measure
Performanc
e
066
*50th percentile (median)
If a 10th percentile performance score is not available,
enter 9999.
Provide the median performance score (50th
percentile) for the testing sample that is relevant to the
intended use of the measure.
Numeric field
Please enter only one value in the response field and do
not enter a range of values.
If this is a proportion measure, provide the median
performance score in percentage form, without the
symbol. For example, if the median performance score
is 85.6%, enter 85.6 and not 0.856.
Measure
Performanc
e
067
*90th percentile
If a median performance score is not available, enter
9999.
Provide the performance score at the 90th percentile
for the testing sample that is relevant to the intended
use of the measure.
Numeric field
If this is a proportion measure, provide the 90th
percentile score in percentage form, without the
symbol. For example, if the 90th percentile
performance score is 85.6%, enter 85.6 and not 0.856.
If a 90th percentile performance score is not available,
enter 9999.
2024 CMS MERIT DATA TEMPLATE
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1/31/2024
Subsection
Measure
Performanc
e
Measure
Performanc
e
Row
068
Field Label
*Additional measure
performance information
069
*Is there evidence for
statistically significant gaps
in measure score
performance among select
subpopulations of interest
defined by one or more
social risk factors?
2024 CMS MERIT DATA TEMPLATE
Guidance
Provide the following additional measure performance
information, as applicable:
- Mean performance score across accountable entities
in the test sample that is relevant to the intended use
of the measure.
- Minimum and maximum performance score for the
testing sample that is relevant to the intended use of
the measure.
- Standard deviation of performance scores for the
testing sample that is relevant to the intended use of
the measure.
- Passing score for the performance measure.
- Performance score’s defined interval, including upper
and lower limit of the performance score.
Select one. Social risk factors may include age, race,
ethnicity, linguistic and cultural context, sex, gender,
sexual orientation, social relationships, residential and
community environments, Medicare/Medicaid dual
eligibility, insurance status (insured/uninsured),
urbanicity/rurality, disability, and health literacy.
27
ADD YOUR CONTENT HERE
Free text field
☐ Yes
☐ No
☐ Not tested
1/31/2024
Subsection
Importance
Row
070
n/a
n/a
Importance
071
Importance
072
Field Label
Guidance
Select one. Patients and/or caregivers can include any
of the following:
• Patients
• Primary caregivers
• Family
• Other relatives
ADD YOUR CONTENT HERE
☐ Yes
☐ No
☐ Not evaluated
n/a
This is not a data entry field.
Free text field
collected from
patients/caregivers
consulted
Describe the input collected from patient/caregivers
consulted about the measure, including the number of
patients/caregivers consulted and the number who
agreed that the measure is meaningful and produces
information that is valuable in making care decisions.
Description of input
collected from measured
entities.
Describe the input collected from measured entities, or
others such as consumers, purchasers, policy makers,
etc., using any of the following methods:
Free text field
*Meaningful to Patients. Did
the majority of
patients/caregivers
consulted agree that the
measure is meaningful
and/or produces
information that is valuable
to them in making their care
decisions?
If you select “Yes” in Row
070, then Row 071 becomes
a required field. If you select
“No” or “Not evaluated” in
Row 070, then skip to Row
072.
*Description of input
• Focus groups
• Structured interviews
• Surveys of potential users
Notes:
• This is separate from face validity testing of the
performance measure.
2024 CMS MERIT DATA TEMPLATE
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1/31/2024
Subsection
Background
Information
Row
073
Field Label
n/a
n/a
If you select “New measure
never reviewed by Measure
Applications Partnership
(MAP) Workgroup, or PreRulemaking Measure
Review (PRMR) or used in a
CMS Program” in Row 073,
then skip to Row 078. If you
select “Measure currently
used in a CMS program
being submitted without
substantive changes for a
new or different program”
or “Measure currently used
in a CMS program, but the
measure is undergoing
substantial change” then
Rows 074-077 become
required fields.
n/a
ADD YOUR CONTENT HERE
☐ New measure never reviewed by Measure
Applications Partnership (MAP) Workgroup, or PreRulemaking Measure Review (PRMR) or used in a
CMS program
☐ Submitted previously but not included in MUC List
☐ Measure previously submitted to MAP or PRMR,
refined, and resubmitted per MAP or PRMR
recommendation
☐ Measure currently used in a CMS program being
submitted without substantive changes for a new or
different program
☐ Measure currently used in a CMS program, but the
measure is undergoing substantive change
This is not a data entry field.
Background
Information
074
*Range of year(s) this
Example: Hospice Quality Reporting (2012-2018)
Free text field
*What is the history or
background for including
this measure on the
current year MUC List?
Guidance
Select one
Note:
•
“CMS program” in the response options refers
only to the Medicare programs that undergo the
Pre-Rulemaking process. A full list of these
programs can be found on the CMS Program
Measure Needs and Priorities report.
measure has been used by
CMS Program(s).
2024 CMS MERIT DATA TEMPLATE
29
1/31/2024
Subsection
Background
Information
Row
075
Field Label
*What other federal
programs are currently
using this measure?
2024 CMS MERIT DATA TEMPLATE
Guidance
Select all that apply. These should be current use
programs only, not programs for the upcoming year’s
submittal.
30
ADD YOUR CONTENT HERE
☐ Ambulatory Surgical Center Quality Reporting
Program
☐ End-Stage Renal Disease (ESRD) Quality Incentive
Program
☐ Home Health Quality Reporting Program
☐ Hospice Quality Reporting Program
☐ Hospital Inpatient Quality Reporting Program
☐ Hospital Outpatient Quality Reporting Program
☐ Hospital Readmissions Reduction Program
☐ Hospital Value-Based Purchasing Program
☐ Hospital-Acquired Condition Reduction Program
☐ Inpatient Psychiatric Facility Quality Reporting
Program
☐ Inpatient Rehabilitation Facility Quality Reporting
Program
☐ Long-Term Care Hospital Quality Reporting Program
☐ Medicare Promoting Interoperability Program
☐ Medicare Shared Savings Program
☐ Merit-based Incentive Payment System-Cost
☐ Merit-based Incentive Payment System-Quality
☐ Part C Star Rating
☐ Part D Star Rating
☐ Prospective Payment System-Exempt Cancer
Hospital Quality Reporting Program
☐ Rural Emergency Hospital Quality Reporting Program
☐ Skilled Nursing Facility Quality Reporting Program
☐ Skilled Nursing Facility Value-Based Purchasing
Program
☐ Other (enter here):
1/31/2024
Subsection
Background
Information
Row
076
Field Label
*How will this measure
align with the same
measure(s) that are
currently used in other
federal programs?
Background
Information
077
Previous
Measures
078
n/a
n/a
*If this measure is being
submitted to meet a
statutory requirement, list
the corresponding statute
*Was this measure
published on a previous
year’s Measures Under
Consideration List?
If you select “Yes” in Row
078, then Rows 079-085
become required fields. If
you select “No” in Row 078,
then skip to Row 086.
2024 CMS MERIT DATA TEMPLATE
Guidance
Describe how this measure will achieve alignment with
the same measure(s) that are currently used in other
federal programs. Please include the names of the
same measure(s) that are used in other federal
programs and include the corresponding unique
identifier (e.g., federal program ID, CBE#, etc.), if
available.
Alignment is achieved when a set of measures works
well across care settings or programs to produce
meaningful information without creating extra work
for those responsible for the measurement. Alignment
includes using the same quality measures in multiple
programs when possible. It can also come from
consistently measuring important topics across care
settings.
List title and other identifying citation information. If
this measure is not being submitted to meet a
statutory requirement, enter N/A.
ADD YOUR CONTENT HERE
Free text field
Free text field
Select “Yes” or “No.” If yes, you are submitting an
existing measure for expansion into additional CMS
programs or the measure has substantially changed
since originally published.
☐ Yes
☐ No
n/a
This is not a data entry field.
31
1/31/2024
Subsection
Previous
Measures
Row
079
Field Label
*In what prior year(s) was
this measure published on
the Measures Under
Consideration List?
2024 CMS MERIT DATA TEMPLATE
Guidance
Select all that apply. NOTE: If your measure was
published on more than one prior annual MUC List, as
you use the MERIT interface, click “Add Another
Measure” and complete the information section for
each of those years.
32
ADD YOUR CONTENT HERE
☐ 2011
☐ 2012
☐ 2013
☐ 2014
☐ 2015
☐ 2016
☐ 2017
☐ 2018
☐ 2019
☐ 2020
☐ 2021
☐ 2022
☐ 2023
1/31/2024
Subsection
Previous
Measures
Row
080
Previous
Measures
081
Previous
Measures
082
Previous
Measures
083
Previous
Measures
084
Previous
Measures
085
Field Label
*What was the MUC ID for
the measure in each year?
*List the CMS CBE
workgroup(s) (MAP or
PRMR) in each year
*What were the programs
that MAP or PRMR
reviewed the measure for
in each year?
*What was the MAP or
PRMR recommendation in
each year?
*Why was the measure
Guidance
List both the year and the associated MUC ID number
in each year. If unknown, enter N/A.
ADD YOUR CONTENT HERE
Free text field
List both the year and the associated workgroup name
in each year. MAP and PRMR workgroup options
include: Clinician; Hospital; Post-Acute Care/LongTerm Care; Coordinating Committee. Example:
“Clinician, 2014.”
List both the year and the associated CMS programs in
each year.
Free text field
List the year(s), the program(s), and the associated
recommendation(s) in each year. Options: Support; Do
Not Support; Conditionally Support; Refine and
Resubmit.
Briefly describe the reason(s) if known.
Free text field
List both the year and the associated MAP report page
number for each year.
Free text field
Free text field
Free text field
not recommended by the
MAP or PRMR workgroups
in those year(s)?
*MAP or PRMR report
page number being
referenced for each year
2024 CMS MERIT DATA TEMPLATE
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1/31/2024
Subsection
Row
Field Label
Guidance
ADD YOUR CONTENT HERE
n/a
n/a
If your selections in Row
086 only include digital
data sources, then skip to
Row 089. Otherwise, Row
087 becomes a required
field.
n/a
☐ Digital-Administrative systems: Administrative Data
(non-claims)
☐ Digital-Administrative systems: Claims Data
☐ Digital-Applications: Patient-Generated Health Data
(e.g., home blood pressure monitoring)
☐ Digital-Applications: Patient-Reported Health Data or
Survey Data (electronic)
☐ Digital-Case Management Systems
☐ Digital-Clinical Registries
☐ Digital-Electronic Clinical Data (non-EHR) or Social
Needs Assessments
☐ Digital-Electronic Health Record (EHR) Data
☐ Digital-Health Information Exchanges (HIE) Data
☐ Digital-Instrument Data (e.g., medical devices and
wearables)
☐ Digital-Laboratory Systems Data
☐ Digital-Patient Portal Data
☐ Digital-Prescription Drug Monitoring Program Data
☐ Digital-Standardized Patient Assessment Data
(electronic)
☐ Digital-Other (enter here):
☐ Non-Digital-Paper Medical Records
☐ Non-Digital-Standardized Patient Assessments
(paper-based)
☐ Non-Digital-Patient-Reported Health Data or Survey
Data (telephonic or paper-based)
☐ Non-Digital-Other (enter here):
This is not a data entry field.
Data Sources
087
*Measure version that
Select one. Indicate whether there is a version of the
measure that uses only digital data sources.
☐ Yes
☐ No
Data Sources
086
*What data sources are
Select all that apply.
used for the measure?
For example, if the measure uses survey data that are
captured both electronically and in paper format,
select the “Applications: Patient-Reported Health Data
or Survey Data (electronic)” from the “Digital Data
Sources” category and “Patient-Reported Health Data
or Survey Data (telephonic or paper-based)” from the
“Non-Digital Data Sources” category.
For more information about digital data sources,
please refer to the “Digital Data Sources” section of
the “dQMs - Digital Quality Measures” webpage on
the eCQI Resource Center available at:
https://ecqi.healthit.gov/dqm?qt-tabs_dqm=1
uses only digital data
sources
2024 CMS MERIT DATA TEMPLATE
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1/31/2024
Subsection
Row
Field Label
Guidance
ADD YOUR CONTENT HERE
n/a
n/a
If you select “Yes” in Row
087, then skip to Row 089.
Otherwise, Row 088
becomes a required field.
n/a
This is not a data entry field.
Data Sources
088
*Path to Digital Format
Select one. Indicate whether there is a viable path for
the measure to be transitioned to an exclusively digital
format.
☐ Yes
☐ No
2024 CMS MERIT DATA TEMPLATE
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1/31/2024
STEWARD
Subsection
Steward
Information
Row
089
*Measure Steward
Field Label
Guidance
Enter the current Measure Steward. Typically, this is an
organization or other agency/institution/entity name.
ADD YOUR CONTENT HERE
See Appendix A.085 for list choices.
Copy/paste or enter your choices here:
Steward
Information
090
*Measure Steward Contact
Please provide the contact information of the measure
steward.
ADD YOUR CONTENT HERE
Long-Term
Steward
Information
091
☐ Yes
☐ No
n/a
n/a
If you select “Yes” in Row
091, then Row 092 becomes
a required field. If you select
“No” in Row 091, then skip
to Row 093.
Entity or entities that will be the permanent measure
steward(s), responsible for maintaining the measure and
conducting CBE endorsement maintenance review. Select
all that apply.
n/a
Long-Term
Steward
Information
092
*Long-Term Measure
If different from Steward above, enter the required contact
information for the Long-Term Measure Steward listed
above
ADD YOUR CONTENT HERE
Submitter
Information
093
Select “Yes” or “No.”
n/a
n/a
If you select “No” in Row
093, then Row 094 becomes
a required field. If you select
“Yes” in Row 093, then skip
to Row 095.
n/a
☐ Yes
☐ No
This is not a data entry field.
Submitter
Information
094
*Primary Submitter Contact
Submitter
Information
095
If different from Steward above: Last name, First name;
Affiliation; Telephone number; Email address. NOTE: The
primary and secondary submitters entered here do not
automatically have read/write/change access to modify this
measure in CMS MERIT. To request such access for others,
when logged into the CMS MERIT interface, navigate to
“About” and “Contact Us,” and indicate the name and email address of the person(s) to be added.
If different from name(s) above: Last name, First name;
Affiliation; Telephone number; Email address.
Information
*Is the long-term steward
different than the steward?
Steward Contact
Information
Is primary submitter the
same as steward?
Information
Secondary Submitter
Contact Information
2024 CMS MERIT DATA TEMPLATE
36
This is not a data entry field.
ADD YOUR CONTENT HERE
ADD YOUR CONTENT HERE
1/31/2024
Subsection
n/a
Row
n/a
Field Label
If applicable, select from
drop-down menu “Other
MERIT users who will
contribute to this measure”
Guidance
n/a
ADD YOUR CONTENT HERE
This is not a data entry field.
CHARACTERISTICS
Subsection
General
Characteristics
Row
096
Field Label
n/a
n/a
If you select “PRO-PM or
Patient Experience of Care”
in Row 096, then Row 097
and Row 122 become
required fields. If not, then
skip to Row 098. If you
select “Outcome” in Row
096, then Row 122
becomes a required field.
n/a
ADD YOUR CONTENT HERE
☐ Cost/Resource Use
☐ Efficiency
☐ Intermediate Outcome
☐ Outcome
☐ PRO-PM or Patient Experience of Care
☐ Process
☐ Structure
This is not a data entry field.
General
Characteristics
097
*Assessment of patient
Select one. Indicate whether this measure assesses patient
experience of care.
☐ Yes
☐ No
General
Characteristics
098
Select Yes or No. Current measures can be found at
https://cmit.cms.gov/cmit/#/MeasureInventory
☐ Yes
☐ No
*Measure Type
experience of care
*Is this measure in the
CMS Measures Inventory
Tool (CMIT)?
2024 CMS MERIT DATA TEMPLATE
Guidance
Select only one type of measure. For definitions, see:
https://mmshub.cms.gov/about-quality/new-tomeasures/types.
37
1/31/2024
Subsection
n/a
Row
n/a
Field Label
If you select “Yes” in Row
098, then Row 099
becomes a required field. If
you select “No” in Row 098,
then skip to Row 100.
General
Characteristics
099
*CMIT ID
If the measure is currently in CMIT, enter the CMIT ID in the
format #####-##-X-PRGM. Current measures and CMIT IDs
can be found at
https://cmit.cms.gov/cmit/#/MeasureInventory
ADD YOUR CONTENT HERE
General
Characteristics
100
Alternate Measure ID
ADD YOUR CONTENT HERE
General
Characteristics
101
*What is the target
General
Characteristics
102
This is an alphanumeric identifier (if applicable), such as a
recognized program ID number for this measure (20
characters or less). Examples: 199 GPRO HF-5; ACO 28;
CTM-3; PQI #08. DO NOT enter consensus-based entity
(endorsement) ID, CMIT ID, or previous year MUC ID in this
field.
What populations are included in this measure? E.g.,
Medicare Fee for Service, Medicare Advantage, Medicaid,
Children’s Health Insurance Program (CHIP), All Payer, etc.
Select the ONE most applicable area of specialty.
General
Characteristics
103
Evidence of a performance gap among the units of analysis
in which the measure will be implemented. Provide analytic
evidence that the units of analysis have room for
improvement and, therefore, that the implementation of
the measure would be meaningful.
Free text field
General
Characteristics
population of the measure?
*What one area of
Guidance
n/a
specialty the measure is
aimed to, or which
specialty is most likely to
report this measure?
*Evidence of performance
gap
104
*Unintended
consequences
2024 CMS MERIT DATA TEMPLATE
If you have lengthy text add the evidence as an
attachment, named to clearly indicate the related form
field.
Summary of potential unintended consequences if the
measure is implemented. Information can be taken from
the CMS consensus-based entity Consensus Development
Process (CDP) manuscripts or documents. If referencing
CDP documents, you must submit the document or a link to
the document, and the page being referenced.
38
ADD YOUR CONTENT HERE
This is not a data entry field.
Free text field
See Appendix A.098 for list choices. Copy/paste or
enter your choice(s) here:
Free text field
1/31/2024
Subsection
Evidence
Row
105
Field Label
*Type of evidence to
support the measure
n/a
n/a
If you select “Clinical
Guidelines or USPSTF (U.S.
Preventive Services Task
Force) Guidelines” in Row
105, then Rows 106-113
become required fields. If
you select “Peer-Reviewed
Systematic Review” in Row
105, then Rows 114 and
115 become required fields.
If you select “PeerReviewed Original
Research” in Row 105, then
Rows 116 and 117 become
required fields. If you select
“Empirical data” in Row
105, then Rows 118 and
119 become required fields.
If you select “Grey
Literature” in Row 105,
then Rows 120 and 121
become required fields.
2024 CMS MERIT DATA TEMPLATE
Guidance
Select all that apply. Refer to the Blueprint content on the
CMS MMS Hub (https://mmshub.cms.gov/measurelifecycle/measure-conceptualization/informationgathering-overview) and the Environmental Scan
supplemental material (https://mmshub.cms.gov/toolsand-resources/mms-supplemental-materials) to obtain
updated guidance.
n/a
39
ADD YOUR CONTENT HERE
☐ Clinical Guidelines or USPSTF (U.S. Preventive
Services Task Force) Guidelines
☐ Peer-Reviewed Systematic Review
☐ Peer-Reviewed Original Research
☐ Empirical data
☐ Grey Literature
This is not a data entry field.
1/31/2024
Subsection
Evidence
Row
106
Field Label
*Outline the clinical
guideline(s) supporting this
measure
Guidance
Provide a detailed description of which guideline(s) support
the measure and indicate for each, whether they are
evidence-based or consensus-based.
ADD YOUR CONTENT HERE
Free text field
Summarize the meaning/rationale of the guideline
statements that are being referenced, their relation to the
measure concept and how they support the measure
whether directly or indirectly, and how the guideline
statement(s) relate to the measure’s intended accountable
entity. Describe the body of evidence that supports the
statement(s) by describing the quantity, quality and
consistency of the studies that are pertinent to the
guideline statements/sentence. Quantity of studies
represent the number of studies and not the number of
publications associated with a study. If the statement is
advised by 3 publications reporting outcomes from the
same RCT at 3 different time points, this is considered a
single study and not 3 studies.
If referencing a standard norm which may or may not be
driven by evidence, provide the description and rationale
for this norm or threshold as reasoned by the guideline
panel.
If this is an outcome measure or PRO-PM, indicate how the
evidence supports or demonstrates a link between at least
one process, structure, or intervention and the outcome.
Document the criteria used to assess the quality of the
clinical guidelines such as those proposed by the Institute
of Medicine or ECRI Guideline’s Trust (see the Information
Gathering Overview on the CMS MMS Hub
(https://mmshub.cms.gov/measure-lifecycle/measureconceptualization/information-gathering-overview) and the
Environmental Scan supplemental material section
addressing evidence review
(https://mmshub.cms.gov/tools-and-resources/mmssupplemental-materials).
If there is lengthy text, describe the guidelines in an
evidence attachment.
2024 CMS MERIT DATA TEMPLATE
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1/31/2024
Subsection
Evidence
Row
107
*Guideline citation
Field Label
Evidence
108
*List the guideline
statement that most
closely aligns with the
measure concept.
Evidence
109
*Is the guideline graded?
n/a
n/a
If you select “Yes” in Row
109, then Rows 110-111,
and 113 become required
fields.
Evidence
110
*List evidence grading
system used and all
categories and
corresponding definitions
for the evidence grading
system used to describe
strength of
recommendation in the
guideline.
2024 CMS MERIT DATA TEMPLATE
Guidance
Provide any of the following:
• Full citation for the primary clinical guideline in any
established citation style (e.g., AMA, APA, Chicago,
Vancouver, etc.)
• URL
• DOI or ISBN for clinical guideline document
If there are more than one statement from this clinical
guideline that may be relevant to this measure concept,
document the statement that most closely aligns with the
measure concept as it is written in the guideline document.
For example, Statement 1: In patients aged 65 years and
older who have prediabetes, we recommend a lifestyle
program similar to the Diabetes Prevention Program to
delay progression to diabetes. No more than one
statement should be written in the text box. All other
relevant statements should be submitted in a separate
evidence attachment.
A graded guideline is one which explicitly provides evidence
rating and recommendation grading conventions in the
document itself. Grades are usually found next to each
recommendation statement.
Select one.
n/a
ADD YOUR CONTENT HERE
☐ Citation (enter here)
☐ URL (enter here)
☐ DOI (enter here)
☐ Not available
Free text field
☐ Yes
☐ No
This is not a data entry field.
Insert the complete list of evidence grading systems,
grading categories, and category definitions used by the
clinical guideline (e.g., GRADE or USPSTF) to describe the
guideline statement’s strength of recommendation.
Free text field
If there is lengthy text, include details in a separate
evidence attachment.
41
1/31/2024
Subsection
Evidence
Row
111
Field Label
*For the guideline
statement that most
closely aligns with the
measure concept, what is
the associated strength of
recommendation?
Guidance
Select the associated strength of recommendation using
the convention used by the guideline developer.
Select one.
n/a
n/a
If you select “USPSTF Grade
D, Moderate or high
certainty that the service
has no net benefit or harm
outweighs benefit” in Row
111, then Row 112
becomes a becomes a
required field; otherwise,
skip to Row 113.
n/a
Evidence
112
*Is the selected guideline
Select one. Indicate whether the guideline statement
mentioned in “List the guideline statement that most
closely aligns with the measure concept” is used to
promote the practice of not performing a specific action,
process or intervention to support an inappropriate use or
inappropriate care measure.
Insert the complete list of grading categories and their
definitions.
statement used to support
an inappropriate use/care
measure?
Evidence
113
*List all categories and
corresponding definitions
for the evidence grading
system used to describe
level of evidence or level of
certainty in the evidence.
2024 CMS MERIT DATA TEMPLATE
42
ADD YOUR CONTENT HERE
☐ USPSTF Grade A, Strong recommendation or similar
☐ USPSTF Grade B, Moderate recommendation or
similar
☐ USPSTF Grade C or I, Conditional/weak
recommendation or similar
☐ Expert Opinion
☐ USPSTF Grade D, Moderate or high certainty that
service has no net benefit or harm outweighs benefit
☐ Best Practice Statement/Standard Practice
This is not a data entry field.
☐ Yes
☐ No
Free text field
1/31/2024
Subsection
Evidence
Row
114
Field Label
*Briefly summarize the
peer-reviewed systematic
review(s) that inform this
measure concept
Evidence
Evidence
115
116
review citation
If there is lengthy text, submit details via an evidence
attachment.
If more than one article was identified, provide at least one
of the following for one key article:
• Citation
• URL
• DOI
*Peer-reviewed original
Provide the complete list of citations with accompanying
DOI or URL in a separate attachment.
If the evidence synthesis provided to support this measure
concept was performed using peer-reviewed original
research articles, indicate whether a systematic search of
the literature was conducted.
*Peer-reviewed systematic
research
Evidence
117
Guidance
Summarize the peer-reviewed systematic review(s) that
address this measure concept. For each systematic review,
provide the number of studies within the systematic review
that addressed the specifications defined in this measure
concept, indicate whether a study-specific risk of
bias/quality assessment was performed for each study, and
describe the consistency of findings. Number of studies is
not equivalent to the number of publications. If there are
three publications from a single cohort study cited in the
systematic review, report one when indicating the number
of studies. If this is an outcome measure or PRO-PM,
indicate how the evidence supports or demonstrates a
relationship between at least one process, structure, or
intervention with the outcome.
*Peer-reviewed original
research citation
If “Yes,” please provide documentation of the search
strategy in an attachment (e.g., years searched, keywords
and search terms used, databases used, etc.).
If more than one article was identified, provide at least one
of the following for one key article:
• Citation
• URL
• DOI
ADD YOUR CONTENT HERE
Free text field
☐ Citation (enter here:)
☐ URL (enter here:)
☐ DOI (enter here:)
☐ Not available
☐ Yes
☐ No
☐ Citation (enter here:)
☐ URL (enter here:)
☐ DOI (enter here:)
☐ Not available
Provide the complete list of citations with accompanying
DOI or URL in a separate attachment.
2024 CMS MERIT DATA TEMPLATE
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1/31/2024
Subsection
Evidence
Row
118
Field Label
*Summarize the empirical
data
Evidence
Evidence
119
120
*Empirical data citation
*Summarize the grey
literature
Guidance
Provide a summary of the empirical data and how it
informs this measure concept. Describe the limitations of
the data. If this is an outcome measure or PRO-PM, indicate
how the evidence supports or demonstrates a link between
at least one process, structure, or intervention with the
outcome. Describe the source of the empirical data (e.g.,
peer-reviewed narrative literature review, published and
publicly available reports, internal data analysis, etc.).
If there is lengthy text, include details in a separate
evidence attachment.
If more than one empirical data was identified, provide at
least one of the following for one key empirical data:
• Citation
• URL
• DOI
Provide the complete list of citations with accompanying
DOI or URL in a separate attachment.
Provide a summary of the grey literature(s) used to inform
this measure concept. Describe the limitations of the data.
If this is an outcome measure or PRO-PM, indicate how the
evidence supports or demonstrates a link between at least
one process, structure, or intervention with the outcome.
ADD YOUR CONTENT HERE
Free text field
☐ Citation (enter here:)
☐ URL (enter here:)
☐ DOI (enter here:)
☐ Not available
ADD YOUR CONTENT HERE
Provide the complete list of citations with accompanying
DOI or URL in a separate attachment.
Evidence
121
*Grey literature citation
If more than one grey literature was identified, provide at
least one of the following for one key piece of evidence:
• Citation
• URL
• DOI
☐ Citation (enter here:)
☐ URL (enter here:)
☐ DOI (enter here:)
☐ Not available
Provide the complete list of citations with accompanying
DOI or URL in a separate attachment.
2024 CMS MERIT DATA TEMPLATE
44
1/31/2024
Subsection
Evidence
Row
122
Field Label
*Does the evidence discuss
a relationship between at
least one process,
structure, or intervention
with the outcome?
2024 CMS MERIT DATA TEMPLATE
Guidance
Select “Yes” if the evidence that was discussed in the
evidence section demonstrate a relationship between at
least one process, structure, or intervention with the
outcome.
45
ADD YOUR CONTENT HERE
☐ Yes
☐ No
1/31/2024
Subsection
Risk
Adjustment
and
Stratification
Row
123
Field Label
n/a
n/a
If you select “Yes” in Row
123, then Row 124
becomes a become
required field. If you select
“No” in Row 123, then skip
to Row 134.
Risk
Adjustment
and
Stratification
124
*Was a conceptual model
*Is the measure risk
adjusted?
outlining the pathway
between patient risk
factors, quality of care, and
the outcome of interest
established?
n/a
n/a
If you select “Yes” in Row
124, then Row 125
becomes a required field. If
you select “No” in Row 124,
then skip to Row 126.
Risk
Adjustment
and
Stratification
125
*Were all key risk factors
identified in the conceptual
model available for testing?
2024 CMS MERIT DATA TEMPLATE
Guidance
Indicate whether the final measure is risk adjusted.
Note that if you select “Yes,” you are encouraged to upload
documentation about the risk adjustment model as an
attachment.
n/a
Select “Yes” if a conceptual model was established based
on a review of published literature. The conceptual model
can be supplemented by other sources of information such
as expert opinion or empirical analysis.
Select “No” if a conceptual model was not established or
the conceptual model was based solely on expert opinion
or empirical analysis.
n/a
If some key risk factors were not available for testing or
inclusion in the risk model approach, select “No” and
describe the anticipated impact on measure scores (e.g.,
magnitude and direction of bias).
46
ADD YOUR CONTENT HERE
☐ Yes
☐ No
This is not a data entry field.
☐ Yes
☐ No
This is not a data entry field.
☐ Yes
☐ No (enter here:)
1/31/2024
Subsection
Risk
Adjustment
and
Stratification
Row
126
Field Label
Risk adjustment variable
types
Guidance
Select ALL risk adjustment variable types that are included
in your final risk model. For more information on how to
select risk factors for accountability measures, refer to the
Blueprint content on the CMS MMS Hub
(https://mmshub.cms.gov/measure-lifecycle/measurespecification/data-protocol/risk-adjustment).
Select “Patient-level demographics” if the measure uses
information related to each patient’s age, sex,
race/ethnicity, etc.
ADD YOUR CONTENT HERE
☐ Patient-level demographics
☐ Patient-level health status & clinical conditions
☐ Patient functional status
☐ Patient-level social risk factors
☐ Proxy social risk factors
☐ Patient community characteristics
☐ Other (enter here):
Select “Patient-level health status & clinical conditions” if
the measure uses information specific to each individual
patient about their health status prior to the start of care
(e.g., case-mix adjustment).
Select “Patient functional status” if the measure uses
information specific to each individual patient’s functional
status prior to the start of care (e.g., body function, ability
to perform activities of daily living, etc.)
Select “Patient-level social risk factors” if the measure uses
patient-reported information related to their individual
social risks (e.g., income, living alone, etc.).
Select “Proxy social risk factors” if the measure uses data
related to characteristics of the people in the patient’s
community (e.g., neighborhood level income from the
census).
Select “Patient community characteristics” if the measure
uses information about the patient’s community (e.g.,
percent of vacant houses, crime rate).
Select “Other” if the risk factor is related to the healthcare
provider, health system, or other factor that is not related
to the patient.
2024 CMS MERIT DATA TEMPLATE
47
1/31/2024
Subsection
Risk
Adjustment
and
Stratification
Row
n/a
Field Label
If you select “Patient-Level
Demographics” in Row 126,
then Row 127 becomes a
required field. If you select
“Patient-level health status
& clinical conditions” in
Row 126, then Row 128
becomes a required field. If
you select “Patient
functional status” in Row
126, then Row 129
becomes a required field. If
you select “Patient-level
social risk factors” in Row
126, then Row 130
becomes a required field. If
you select “Proxy social risk
factors” in Row 126, then
Row 131 becomes a
required field. If you select
“Patient community
characteristics” in Row 126,
then Row 132 becomes a
required field.
Risk
Adjustment
and
Stratification
127
*Patient-level
Risk
Adjustment
and
Stratification
128
Risk
Adjustment
and
Stratification
129
Guidance
n/a
☐ Age
☐ Sex
☐ Gender
☐ Race/ethnicity
☐ Other (enter here):
☐ Case-Mix Adjustment
☐ Severity of Illness
☐ Comorbidities
☐ Health behaviors/health choices
☐ Other (enter here):
☐ Body Function
☐ Ability to perform activities of daily living
☐ Other (enter here):
Select all that apply
demographics: please
select all that apply
*Patient-level health status
Select all that apply
& clinical conditions: please
select all that apply
*Patient functional status:
Select all that apply
please select all that apply
2024 CMS MERIT DATA TEMPLATE
ADD YOUR CONTENT HERE
This is not a data entry field.
48
1/31/2024
Subsection
Risk
Adjustment
and
Stratification
Row
130
Risk
Adjustment
and
Stratification
Risk
Adjustment
and
Stratification
131
Risk
Adjustment
and
Stratification
133
Field Label
*Patient-level social risk
Guidance
Select all that apply
factors: please select all
that apply
*Proxy social risk factors:
Select all that apply
please select all that apply
132
*Patient community
Select all that apply
characteristics: please
select all that apply
*Risk model performance
2024 CMS MERIT DATA TEMPLATE
Provide empirical evidence that the risk model adequately
accounts for confounding factors (e.g., assessment of
model calibration and discrimination). Describe your
interpretation of the results.
49
ADD YOUR CONTENT HERE
☐ Income
☐ Education
☐ Wealth
☐ Living Alone
☐ Social Support
☐ Other (enter here):
☐ Neighborhood Level Income from the Census
☐ Dual Eligibility for Medicare and Medicaid
☐ Other (enter here):
☐ Percent of Vacant Houses
☐ Crime Rate
☐ Urban/Rural
☐ Other (enter here):
Free text field
1/31/2024
Subsection
Risk
Adjustment
and
Stratification
n/a
Row
134
Field Label
*Is the measure
recommended to be
stratified based on
evidence from testing
and/or literature?
n/a
If you select a “Yes”
response in Row 134, then
Row 135 becomes a
required field. If you select
a “No” response in Row 134
AND selected a “No”
response in Row 123, then
Row 136 becomes a
required field. Otherwise
skip to Row 137.
2024 CMS MERIT DATA TEMPLATE
Guidance
Select one. Indicate whether the final measure is
recommended to be stratified. Indicate whether the
recommended stratification is intended to address an
equity gap.
Health equity elements for stratification include
sociodemographic data such as race, ethnicity, tribal
sovereignty, language, geography, sex, sexual orientation
and gender identity (SOGI), language, income, and
disability status, as well as social determinants of health
(SDOH) featured in the Healthy People 2030 SDOH
Framework across five domains: economic stability,
education access and quality, health care access and
quality, neighborhood and built environment, and social
and community context.
For more information about health equity elements, please
refer to the Equity Data Standardization page on the CMS
MMS Hub and the CMS Office of Minority Heath white
paper titled “The Path Forward: Improving Data to Advance
Health Equity Solutions,” available at:
https://mmshub.cms.gov/about-quality/quality-atCMS/goals/cms-focus-on-health-equity/equity-datastandardization.
n/a
50
ADD YOUR CONTENT HERE
☐ Yes, the measure is recommended to be stratified
to address an equity gap
☐ Yes, the measure is recommended to be stratified
for reasons unrelated to an equity gap
☐ Yes, the measure is recommended to be stratified
both to address an equity gap AND for other reasons
☐ No, the measure is not recommended to be
stratified
This is not a data entry field.
1/31/2024
Subsection
Risk
Adjustment
and
Stratification
Row
135
Field Label
*Stratification approach
Guidance
Describe the recommended stratification approach
including the data elements used to stratify scores for
subgroups. Demonstrate that there is sufficient sample size
within measured entities to stratify measure scores.
ADD YOUR CONTENT HERE
Free text field
Indicate whether the recommendation to stratify the
measure is based on evidence from testing and/or the
literature.
If findings from testing informed the recommendation to
stratify the measure, summarize the findings indicating that
stratification would improve interpretation of measure
results. If more room is needed, provide testing results as
an attachment and list the name of the attachment in this
field.
Risk
Adjustment
and
Stratification
136
*Rationale for using
neither risk adjustment nor
stratification
2024 CMS MERIT DATA TEMPLATE
If evidence from the literature informed the
recommendation to stratify the measure, provide citations
supporting your stratification approach.
Select ALL reasons for not implementing a risk adjustment
model or stratification approach in the measure. For more
information, refer to the Risk Adjustment in Quality
Measurement supplemental material on the CMS MMS
Hub (https://mmshub.cms.gov/tools-and-resources/mmssupplemental-materials) and the guidance on defining
stratification schemes (https://mmshub.cms.gov/measurelifecycle/measure-specification/developspecification/stratification)
51
☐ Addressed through exclusions (e.g., process
measures)
☐ Risk adjustment not appropriate based on
conceptual or empirical rationale (enter here):
☐ Data were not available to evaluate risk adjustment
or stratification (enter here):
☐ Risk adjustment and stratification were not
considered during development or testing
☐ Other (enter here):
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Subsection
Healthcare
Domain
Row
137
Healthcare
Domain
138
Other Priorities
Field Label
*What one Meaningful
Measures 2.0 priority is
most applicable to this
measure?
139
Guidance
Select the ONE most applicable Meaningful Measures 2.0
priority. For more information, see:
https://www.cms.gov/meaningful-measures-20-movingmeasure-reduction-modernization
What, if any, additional
Meaningful Measures 2.0
priorities apply to this
measure?
Select up to two additional Meaningful Measures 2.0
priorities that apply to this measure.
*Does this measure
Select one.
For more information, see:
https://www.cms.gov/meaningful-measures-20-movingmeasure-reduction-modernization
address CMS priorities to
improve maternal health
care or maternal
outcomes?
2024 CMS MERIT DATA TEMPLATE
52
ADD YOUR CONTENT HERE
☐ Person-Centered Care
☐ Equity
☐ Safety
☐ Affordability and Efficiency
☐ Chronic Conditions
☐ Wellness and Prevention
☐ Seamless Care Coordination
☐ Behavioral Health
☐ Person-Centered Care
☐ Equity
☐ Safety
☐ Affordability and Efficiency
☐ Chronic Conditions
☐ Wellness and Prevention
☐ Seamless Care Coordination
☐ Behavioral Health
☐ Yes
☐ No
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Subsection
Endorsement
Characteristics
Row
140
Endorsement
Characteristics
141
Endorsement
Characteristics
142
n/a
n/a
Endorsement
Characteristics
143
Endorsement
Characteristics
144
Endorsement
Characteristics
145
Field Label
*What is the endorsement
status of the measure?
*CBE ID (CMS consensusbased entity, or
endorsement ID)
If endorsed: Is the measure
being submitted exactly as
endorsed by the CMS CBE?
If you select “No” in Row
142, then Rows 143-144
become required fields.
If not exactly as endorsed,
specify the locations of the
differences
If not exactly as endorsed,
describe the nature of the
differences
If endorsed: Year of most
recent CBE endorsement
2024 CMS MERIT DATA TEMPLATE
Guidance
Select only one. For information on consensus-based entity
(CBE) endorsement, measure ID, and other information,
refer to: https://p4qm.org/
Four- or five-character identifier with leading zeros and
following letter if needed. Add a letter after the ID (e.g.,
0064e) and place zeros ahead of ID if necessary (e.g., 0064).
If no CBE ID number is known, enter numerals 9999.
Select 'Yes' or 'No'. Note that 'Yes' should only be selected
if the submission is an EXACT match to the CBE-endorsed
measure.
n/a
Indicate which specification fields are different. Select all
that apply
Briefly describe the differences
ADD YOUR CONTENT HERE
☐ Endorsed
☐ Endorsed with conditions
☐ Endorsement removed
☐ Submitted
☐ Failed endorsement or decision to not endorse
☐ Never submitted
ADD YOUR CONTENT HERE
☐ Yes
☐ No
This is not a data entry field.
☐ Measure title
☐ Description
☐ Numerator
☐ Denominator
☐ Exclusions
☐ Target population
☐ Setting (for testing)
☐ Level of analysis
☐ Data source
☐ eCQM status
☐ Other (enter here and see next field):
Free text field
☐ 2017
☐ 2018
☐ 2019
☐ 2020
☐ 2021
☐ 2022
☐ 2023
Select one
53
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Subsection
Endorsement
Characteristics
Row
146
Field Label
Year of next anticipated
CBE endorsement review
2024 CMS MERIT DATA TEMPLATE
Guidance
Select one. If you are submitting for initial endorsement,
select the anticipated year.
54
ADD YOUR CONTENT HERE
☐ 2024
☐ 2025
☐ 2026
☐ 2027
☐ 2028
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SIMILAR MEASURES
Subsection
Related and
Competing
Measures
Row
147
n/a
n/a
Related and
Competing
Measures
148
Related and
Competing
Measures
149
Related and
Competing
Measures
150
Related and
Competing
Measures
151
Field Label
*Is this measure related to
and/or competing with
measure(s) already in a
program?
If you select “Yes” in Row
147, then Rows 148-150
become required fields. If
you select “No” in Row
147, then skip to Row 151.
*Which measure(s)
already in a program is
your measure related to
and/or competing with?
*How will this measure
add value to the CMS
program?
*How will this measure be
distinguished from other
related and/or competing
measures?
*Universal Foundation
Measure
Guidance
Select either Yes or No. Consider other measures with
related purposes.
☐ Yes
☐ No
n/a
This is not a data entry field.
Identify the other measure(s) including title and any
other unique identifier.
Free text field
Describe benefits of this measure, in comparison to
measure(s) already in a program.
Free text field
Describe key differences that set this measure apart
from others.
Free text field
Select one. Indicate whether this measure is a Universal
Foundation quality measure.
☐ Measure is a Universal Foundation quality measure
(populations must align)
☐ Measure is not a Universal Foundation quality
measure
To be considered a Universal Foundation quality
measure, the submitted measure’s population must align
with the population of the existing Universal Foundation
measure (i.e., adult and/or pediatric).
ADD YOUR CONTENT HERE
Please refer to the “Aligning Quality Measures Across
CMS – the Universal Foundation” webpage for more
information about Universal Foundation of quality
measures available at: https://www.cms.gov/aligningquality-measures-across-cms-universal-foundation
2024 CMS MERIT DATA TEMPLATE
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ATTACHMENTS
Subsection
N/A
Row
152
Field Label
Attachment(s)
Guidance
You are encouraged to attach the measure information
form (MIF) if available. This is a detailed description of
the measure used by the CMS consensus-based entity
(CBE) during endorsement proceedings. If a MIF is not
available, comprehensive measure methodology
documents are encouraged.
ADD YOUR CONTENT HERE
ADD YOUR CONTENT HERE
If you are submitting for MIPS (either Quality or Cost),
you are required to download the MIPS Peer Reviewed
Journal Article Template and attach the completed form
to your submission using the “Attachments” feature.
See https://www.cms.gov/Medicare/Quality-InitiativesPatient-Assessment-Instruments/QualityMeasures/PreRulemaking
If your measure is risk adjusted, you are encouraged to
attach documentation that provides additional detail
about the measure risk adjustment model such as
variables included, associated code system codes, and
risk adjustment model coefficients
N/A
153
MIPS Peer Reviewed
Journal Article Template
If eCQM, you must attach MAT Output/HQMF, Bonnie
test cases for this measure, with 100% logic coverage
(test cases should be appended), attestation that value
sets are published in VSAC, and feasibility scorecard.
Select Yes or No. For those submitting measures to
MIPS program, enter “Yes.” Attach your completed Peer
Reviewed Journal Article Template.
☐ Yes
☐ No
SUBMITTER COMMENTS
Subsection
N/A
Row
154
Field Label
Submitter Comments
Guidance
Any notes, qualifiers, external references, or other
information not specified above.
ADD YOUR CONTENT HERE
Free text field
Send any questions to MMSsupport@battelle.org
2024 CMS MERIT DATA TEMPLATE
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1/31/2024
Appendix: Lengthy Lists of Choices
A. 085 Choices for Measure Steward and Long-Term Measure Steward (if different)
Agency for Healthcare Research & Quality
Alliance of Dedicated Cancer Centers
Ambulatory Surgical Center (ASC) Quality Collaboration
American Academy of Allergy, Asthma & Immunology (AAAAI)
American Academy of Dermatology
American Academy of Neurology
American Academy of Ophthalmology
American Academy of Otolaryngology – Head and Neck Surgery (AAOHN)
American College of Cardiology
American College of Cardiology/American Heart Association
American College of Emergency Physicians
American College of Emergency Physicians (previous steward Partners-Brigham &
Women's)
American College of Obstetricians and Gynecologists (ACOG)
American College of Radiology
American College of Rheumatology
American College of Surgeons
American Gastroenterological Association
American Health Care Association
American Medical Association
American Nurses Association
American Psychological Association
American Society for Gastrointestinal Endoscopy
American Society for Radiation Oncology
American Society of Addiction Medicine
American Society of Anesthesiologists
American Society of Clinical Oncology
American Society of Clinical Oncology
American Urogynecologic Society
American Urological Association (AUA)
Audiology Quality Consortium/American Speech-Language-Hearing Association
(AQC/ASHA)
Bridges to Excellence
Centers for Disease Control and Prevention
Centers for Medicare & Medicaid Services
Eugene Gastroenterology Consultants, PC Oregon Endoscopy Center, LLC
Health Resources and Services Administration (HRSA) - HIV/AIDS Bureau
2024 CMS MERIT DATA TEMPLATE
Heart Rhythm Society (HRS)
Indian Health Service
Infectious Diseases Society of America (IDSA)
Intersocietal Accreditation Commission (IAC)
KCQA- Kidney Care Quality Alliance
Minnesota (MN) Community Measurement
National Committee for Quality Assurance
National Minority Quality Forum
Office of the National Coordinator for Health Information Technology/Centers for
Medicare & Medicaid Services
Oregon Urology Institute
Oregon Urology Institute in collaboration with Large Urology Group Practice Association
Pharmacy Quality Alliance
Philip R. Lee Institute for Health Policy Studies
Primary (care) Practice Research Network (PPRNet)
RAND Corporation
Renal Physicians Association; joint copyright with American Medical Association Seattle Cancer Care Alliance
Society of Gynecologic Oncology
Society of Interventional Radiology
The Academy of Nutrition and Dietetics
The Joint Commission
The Society for Vascular Surgery
The University of Texas MD Anderson Cancer Center
University of Minnesota Rural Health Research Center
University of North Carolina- Chapel Hill
Wisconsin Collaborative for Healthcare Quality (WCHQ)
Other (enter in Row 084 and/or Row 086)
57
1/31/2024
A.098 Choices for Areas of specialty
Addiction medicine
Allergy/immunology
Anesthesiology
Behavioral health
Cardiac electrophysiology
Cardiac surgery
Cardiovascular disease (cardiology)
Chiropractic medicine
Colorectal surgery (proctology)
Critical care medicine (intensivists)
Dermatology
Diagnostic radiology
Electrophysiology
Emergency medicine
Endocrinology
Family practice
Gastroenterology
General practice
General surgery
Geriatric medicine
Gynecological oncology
Hand surgery
Hematology/oncology
Hospice and palliative care
Infectious disease
Internal medicine
Interventional pain management
Interventional radiology
Maxillofacial surgery
Medical oncology
Nephrology
Neurology
Neuropsychiatry
Neurosurgery
Nuclear medicine
Nursing
Nursing homes
Obstetrics/gynecology
Ophthalmology
Optometry
Oral surgery (dentists only)
Orthopedic surgery
Osteopathic manipulative medicine
Otolaryngology
Pain management
Palliative care
Pathology
Pediatric medicine
Peripheral vascular disease
Physical medicine and rehabilitation
Plastic and reconstructive surgery
Podiatry
Preventive medicine
Primary care
Psychiatry
Public and/or population health
Pulmonary disease
Pulmonology
Radiation oncology
Rheumatology
Sleep medicine
Sports medicine
Surgical oncology
Thoracic surgery
Urology
Vascular surgery
Other (enter in Row 097)
Send any questions to MMSsupport@battelle.org
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0938-1314 (Expiration date: 01/31/2025). The time required to complete this information collection is estimated to
average 3.5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information
collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard,
Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments,
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information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or
concerns regarding where to submit your documents, please contact QPP at qpp@cms.hhs.gov.
2024 CMS MERIT DATA TEMPLATE
58
1/31/2024
| File Type | application/pdf |
| File Title | Measures Under Consideration 2024 Data Template |
| Subject | Health, physician, hospital, quailty, measure, efficiency |
| Author | Centers for Medicare & Medicaid Services (CMS) |
| File Modified | 2024-06-27 |
| File Created | 2024-06-27 |