Appendix E Measures under Consideration 2023 Data Template for Cand

Quality Payment Program (QPP)/Merit-Based Incentive Payment System (MIPS) (CMS-10621)

Appendix E 2023 MUC Data Template

CY 2024 Performance Period/2026 MIPS Payment Year Burden Summary

OMB: 0938-1314

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Centers for Medicare & Medicaid Services
Measures Under Consideration Entry/Review and Information Tool 2023 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. Numeric fields are noted, where applicable, in the “Add Your Content Here” column.
6. Row numbers are for convenience only and do not appear on the CMS MERIT user interface.
7. Send any questions to MMSsupport@battelle.org.

PROPERTIES
Subsection
Measure
Information

Row
001

Field Label

*Measure Title

Measure
Information

002

*Measure description

2023 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.

ADD YOUR CONTENT HERE
ADD YOUR CONTENT HERE

ADD YOUR CONTENT HERE

04/05//2023

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 MSSupport@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

Measure
Information

004

If you select “Merit-based
Incentive Payment System Quality” in Row 003, then
Row 004 becomes an
optional field.
MIPS Quality: Identify any
links with related Cost
measures and Improvement
Activities

2023 CMS MERIT DATA TEMPLATE

n/a

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
☐ 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 for
Eligible Hospitals and Critical Access Hospitals (CAHs)
☐ Medicare Shared Savings Program
☐ Merit-based Incentive Payment System-Cost
☐ Merit-based Incentive Payment System-Quality
☐ Part C & D Star Ratings [Medicare]
☐ 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.

ADD YOUR CONTENT HERE

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Subsection
Measure
Information

Row
005

Field Label

*Stage of Development

Guidance
Select the measure’s current stage of development. A
fully developed measure is a measure that has
completed beta testing. Note that fully developed
measures are highly preferred.

ADD YOUR CONTENT HERE
☐ Conceptualization
☐ Specification
☐ Field (Beta) Testing
☐ Fully Developed

For additional information regarding stage of
development, see: https://mmshub.cms.gov/blueprintmeasure-lifecycle-overview.
n/a

n/a

Measure
Information

006

If you select
“Conceptualization,”
“Specification”, or “Field
(Beta) Testing” in Row 005,
then Row 006 becomes a
required field. If you select
“Fully Developed” in Row
005, then skip to Row 007.
* Stage of Development
Details

n/a

This is not a data entry field.

If “Conceptualization,” “Specification,” or “Field (Beta)
Testing,” 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.

ADD YOUR CONTENT HERE

For additional information, see:
https://mmshub.cms.gov/blueprint-measure-lifecycleoverview.

2023 CMS MERIT DATA TEMPLATE

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Subsection
Measure
Information

Measure
Information

Row
007

008

Field Label

*Level of Analysis

*In which setting(s) was this
measure tested?

2023 CMS MERIT DATA TEMPLATE

Guidance
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 (MIPSQuality only).” Please submit results of individual
clinician-level testing in this form and group-level
testing results in an attachment.
For submission to the MIPS-Cost program, clinician
group-level testing is sufficient.
Select all that apply.

ADD YOUR CONTENT HERE
☐ Clinician: Individual only
☐ Clinician: Group
☐ Facility
☐ Clinician: Individual and Group (MIPS-Quality only)
☐ Health plan
☐ Population: Regional and State
☐ Accountable Care Organization
☐ Integrated Delivery System
☐ Medicaid program (e.g., Health Home or 1115)
☐ Population: Community, County or City

☐ Ambulatory surgery center
☐ Ambulatory/office-based care
☐ Behavioral health clinic
☐ Inpatient psychiatric facility
☐ 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 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):

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Subsection
Measure
Information

Row
009

n/a

Measure
Information

010

Measure
Information

011

Measure
Information

012

Field Label

*Multiple Scores

If you select “Yes” in Row
009, then Rows 010-012
become required fields. If
you select, “No”, then skip to
Row 013.

Guidance
Does the submitter recommend that more than one
measure score be reported for this measure (e.g., 7and 30-day rate, rates for different procedure types,
etc.)? Note: If “Yes”, please describe one score only in
this form. Submit separate attachments for each of the
other scores.

☐ Yes
☐ No

ADD YOUR CONTENT HERE

n/a

This is not a data entry field.

*Measures with Multiple

How many measure scores are recommended for this
measure?

Numeric field

*Measures with Multiple

Please enter the name of the score described in this
MERIT form.

Free text field

*Measures with Multiple
Scores: Names of Scores

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.

Free text field

Scores: Number of Scores
Scores: Names of Score
Reported in MERIT Form

2023 CMS MERIT DATA TEMPLATE

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Subsection
Measure
Information

Row
013

Measure
Information

014

Field Label

*Is the measure a

composite?

n/a

Measure
Information

015

Measure
Information

016

*Is this a paired measure?

If you select “Yes” in Row
014, then Rows 015-016
become required fields. If
you select “No” in this field,
then skip to Row 017.

*How many measures are
intended to be paired with
this measure?
*What are the titles of all

measures that should be
paired with this measure?

2023 CMS MERIT DATA TEMPLATE

Guidance
Select one. A composite measure contains two or more
individual measures, resulting in a single measure and a
single score. If this measure is a composite measure,
please enter data relevant to the overall composite into
this form. Please attach any additional information
pertaining to individual components.
Select one. 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
☐ No

ADD YOUR CONTENT HERE

☐ Yes
☐ No

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

04/05//2023

Subsection
Measure
Information

Row
017

Field Label

*Numerator

Measure
Information

018

*Numerator Exclusions

Measure
Information

019

*Denominator

Measure
Information

020

*Denominator Exclusions

Measure
Information

021

*Denominator Exceptions

Measure
Information

022

*Briefly describe the
rationale for the measure

2023 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 all fields,
especially Numerator and Denominator, use plain text
whenever possible. If needed, convert any special
symbols, math expressions, or equations to plain text
(keyboard alphanumeric, such as + - * /). This will help
reduce errors and speed up data conversion, team
evaluation, and MUC report formatting.
For all free-text fields: Be sure to spell out all
abbreviations and define special terms at their first
occurrence. This will save time and revision/editing
cycles during clearance.
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.

ADD YOUR CONTENT HERE
ADD YOUR CONTENT HERE

ADD YOUR CONTENT HERE

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Subsection
Measure
Implementa
tion

Row
023

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 measures that are
not fully developed OR for CAHPS measures.

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

For a PRO-PM, select the most appropriate option
based on the data collection format(s).

2023 CMS MERIT DATA TEMPLATE

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Subsection
Measure
Implementa
tion

Row
024

Measure
Implementa
tion
Measure
Implementa
tion

n/a

Field Label

*Method of measure

calculation

025

If you select "Combination"
in Row 024, then Row 025
becomes a required field.

*Combination measure:

Methods of calculation

2023 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 Claims”
if the measure can be calculated exclusively from
claims 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 Claims
☐ eCQM
☐ Other digital method
☐ Manual abstraction
☐ Combination

Select all that apply. A minimum of two options must
be selected.

☐ Electronically Derived Administrative Claims
☐ eCQM
☐ Other digital method
☐ Manual abstraction

This is not a data entry field.

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Subsection
Measure
Implementa
tion

Row
026

Subsection
Burden

Row
027

n/a

Burden

028

Field Label

*How is the measure

expected to be reported to
the program?

Field Label

*Burden for Provider: Was a
provider workflow analysis
conducted?
If you select “Yes” in Row
027, then Rows 028 and 029
become required fields. If
you select “No” in Row 027,
then skip to Row 030.

*If yes, how many sites

were evaluated in the
provider workflow analysis?

2023 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.

ADD YOUR CONTENT HERE
☐ eCQM
☐ Clinical Quality Measure (CQM) Registry
☐ Claims
☐ Web interface
☐ Other (enter here):

Guidance
Select one. Select "Not applicable" if the measure
imposes no burden on the provider (e.g., CAHPS
measures or measures based on administrative data
(non-claims), claims data).).

ADD YOUR CONTENT HERE

☐ Yes
☐ No
☐ Not applicable

n/a

This is not a data entry field.

Enter the number of sites that were evaluated in the
provider workflow analysis.

Numeric field

Select "Not applicable" if the measure does not impose
any burden on providers (e.g., CAHPS measures or
measures based on administrative data (non-claims) or
claims data).

04/05//2023

Subsection
Burden

Row
029

Field Label

*Does the provider
workflow have to be
modified to collect
additional data needed to
report the measure?

Select one.

Guidance

If workflow modifications required moderate to
significant additional data entry from 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, select “Yes.”

☐ Yes
☐ No

ADD YOUR CONTENT HERE

If workflow modifications required no, or limited,
additional data entry from 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 “No.”

2023 CMS MERIT DATA TEMPLATE

04/05//2023

Subsection
Measure Score
Level
(Accountable
Entity Level)
Testing

Row
030

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 CMS Measures
Management System Blueprint
(https://mmshub.cms.gov/measure-lifecycle/measuretesting/evaluation-criteria/scientificacceptability/reliability) Select “Yes” if acceptable
accountable entity-level reliability testing has been
completed as of submission of this form.

☐ Yes
☐ No

ADD YOUR CONTENT HERE

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.
Measure Score
Level
(Accountable
Entity Level)
Testing

031

*Reliability: Type of analysis

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).

☐ 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.

2023 CMS MERIT DATA TEMPLATE

04/05//2023

Subsection
n/a

Row
n/a

Measure Score
Level
(Accountable
Entity Level)
Testing

032

Field Label
If you select “Signal-toNoise” in Row 031, then
Rows 032-035 become
required fields. If you select,
“Random Split-Half
Correlation” in Row 032,
then Rows 036-039 become
required fields.

*Signal-to-Noise: Level of
Analysis

Guidance

ADD YOUR CONTENT HERE
This is not a data entry field.

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 – Individual only
☐ Clinician – Group only
☐ Facility
☐ Health plan
☐ Integrated Delivery System
☐ Population: Community, County or City
☐ Population: Regional and State

n/a

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.

*Signal-to-Noise: Sample

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.

Numeric field

034

*Signal-to-Noise: Median
Statistical result

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.).

Numeric field

035

*Signal-to-Noise:
Interpretation of results

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).

ADD YOUR CONTENT HERE

Measure Score
Level
(Accountable
Entity Level)
Testing

033

Measure Score
Level
(Accountable
Entity Level)
Testing

size

2023 CMS MERIT DATA TEMPLATE

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Subsection
Measure Score
Level
(Accountable
Entity Level)
Testing

Row
036

Field Label

*Random Split-Half

Correlation: Level of Analysis

Guidance
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.
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

037

Measure Score
Level
(Accountability
Entity Level)
Testing

038

Measure Score
Level
(Accountability
Entity Level)
Testing

039

ADD YOUR CONTENT HERE
☐ Accountable Care Organization
☐ Clinician – Individual only
☐ Clinician – Group only
☐ Facility
☐ Health plan
☐ Integrated Delivery System
☐ Population: Community, County or City
☐ Population: Regional and State

*Random Split-Half

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

*Random Split-Half

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

*Random Split-Half

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

Correlation: Sample size

Correlation: Statistical result

Correlation: Interpretation
of results

2023 CMS MERIT DATA TEMPLATE

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Subsection
Measure Score
Level
(Accountability
Entity Level)
Testing

Row
040

Field Label

*Empiric Validity

Guidance
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 CMS Measures
Management System Blueprint
(https://mmshub.cms.gov/measure-lifecycle/measuretesting/evaluation-criteria/scientificacceptability/validity)

☐ Yes
☐ No

ADD YOUR CONTENT HERE

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

Measure Score
Level
(Accountability
Entity Level)
Testing

041

If you select “Yes” in Row
040, then Rows 041-046
become required fields. If
you select “No” in Row 040,
then skip to Row 047.

*Empiric Validity: Statistic
name

2023 CMS MERIT DATA TEMPLATE

n/a

This is not a data entry field.

Indicate the name for the statistic used to assess
accountable entity level validity. Describe whether the
result is a relative risk, odds ratio, relative difference in
scores, etc.

ADD YOUR CONTENT HERE

If more than one test or comparison was conducted,
describe the statistic that most strongly supported the
validity of the measure and provide the full testing
results under the “Methods and findings” question or
as an attachment.

04/05//2023

Subsection
Measure Score
Level
(Accountable
Entity Level)
Testing

Row
042

Field Label

*Empiric Validity: Level of

Analysis

Guidance
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.
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

043

Measure Score
Level
(Accountability
Entity Level)
Testing

044

Measure Score
Level
(Accountability
Entity Level)
Testing

045

*Empiric Validity: Sample

ADD YOUR CONTENT HERE

*Empiric Validity: Statistical
result

Indicate the statistical result. Calculate empiric validity
as the measure is intended to be implemented (e.g.,
after applying minimum denominator requirements,
etc.).

Numeric field

size

If more than one test or comparison was conducted,
provide the result that most strongly supports the
validity of the measure and provide the full testing
results under the “Methods and findings” question or
as an attachment.

*Empiric Validity: Methods

and findings

2023 CMS MERIT DATA TEMPLATE

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 result provided above 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.

ADD YOUR CONTENT HERE

04/05//2023

Subsection
Measure Score
Level
(Accountable
Entity Level)
Testing
Measure Score
Level
(Accountable
Entity Level)
Testing

Row
046

Field Label

*Empiric Validity:

Interpretation of results

047

*Face validity

Guidance
Indicate whether the statistical result affirmed the
hypothesized relationship for the analysis conducted.

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

ADD YOUR CONTENT HERE

☐ 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 (vs. on the survey). Survey item testing results
can be provided in an attachment and described in the
Patient-Reported Data Section.

n/a

Measure Score
Level
(Accountable
Entity Level)
Testing

048

If you select “Yes” in Row
047, then Rows 048-051
become required fields. If
you select “No” in Row 047,
then skip to Row 052.

*Face Validity: Level of

Analysis

n/a

This is not a data entry field.

Select the level of analysis for which experts voted on
face validity. 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.

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.

2023 CMS MERIT DATA TEMPLATE

04/05//2023

Subsection
Measure Score
Level
(Accountable
Entity Level)
Testing
Measure Score
Level
(Accountable
Entity Level)
Testing

Row
049

Field Label

050

*Face validity: Result

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

Measure Score
Level
(Accountable
Entity Level)
Testing

051

Face validity: Interpretation

Briefly explain the interpretation of the result, including
any disagreement with the face validity of the
performance measure.

Free text field

*Face validity: Number of

voting experts and
patients/caregivers

2023 CMS MERIT DATA TEMPLATE

Guidance
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

ADD YOUR CONTENT HERE

04/05//2023

Subsection
Patient/Enco
unter Level
(Data
Element
Level)
Testing

Row
052

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 or denominator
and numerator 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.

n/a

Patient/Enco
unter Level
(Data
Element
Level)
Testing

053

If you select “Yes” in Row
052, then Rows 053-059
become required fields. If
you select “No” in Row 052,
then skip to Row 060.

*Type of Analysis

Note: This section includes tests of both data element
reliability and validity.
n/a

Select all that apply. For more information on
patient/encounter level testing, refer to the CMS
Measures Management System Blueprint
(https://mmshub.cms.gov/measure-lifecycle/measuretesting/evaluation-criteria/scientificacceptability/reliability)

This is not a data entry field.

☐ Agreement between two manual reviewers
☐ Agreement between eCQM and manual reviewer
☐ Agreement between other gold standard and manual
reviewer

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.

2023 CMS MERIT DATA TEMPLATE

04/05//2023

Subsection
Patient/Enco
unter Level
(Data
Element
Level)
Testing
Patient/Enco
unter Level
(Data
Element
Level)
Testing

Row
054

*Sample Size

Field Label

055

*Statistic Name

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.

☐ Percent agreement
☐ Kappa
☐ Correlation coefficient
☐ Sensitivity
☐ Positive Predictive Value

Patient/Enco
unter Level
(Data
Element
Level)
Testing

056

*Statistical Results:

Indicate the single lowest critical data element result of
the statistic selected above. This field is intended to
capture the least reliable or valid data element included
in the measure. Information about all critical data
elements should be provided in the “Interpretation of
results” field.

Numeric field

Individual Data Element

Guidance
Indicate the number of patients/encounters sampled.

Numeric field

ADD YOUR CONTENT HERE

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%

Patient/Enco
unter Level
(Data
Element
Level)
Testing
Patient/Enco
unter Level
(Data
Element
Level)
Testing

057

*Statistical Results: Overall

Denominator

058

*Statistical Results: Overall

Numerator

2023 CMS MERIT DATA TEMPLATE

If not tested at the individual data element level, enter
9999.
After applying denominator exclusions, indicate the
result for the overall denominator of the statistic
selected above. If not tested at the denominator level,
enter 9999.
Indicate the result for the overall numerator of the
statistic selected above. If not tested at the numerator
level, enter 9999.

Numeric field

04/05//2023

Subsection
Patient/Enco
unter Level
(Data
Element
Level)
Testing

Row
059

Field Label

*Interpretation of results

Guidance
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 (e.g., feasibility scorecard), provide the
name of the attachment and location in the
attachment.

ADD YOUR CONTENT HERE
ADD YOUR CONTENT HERE

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.
Subsection
PatientReported
Data

Row
060

n/a

Field Label

*Does the performance

measure use survey or
patient-reported data?
If you select “Yes” in Row
060, then Row 061 becomes
a required field. If you select
“No” in Row 060, then skip
to Row 065.

2023 CMS MERIT DATA TEMPLATE

Guidance
Indicate whether the performance measure utilizes
data from structured surveys or patient-reported tools.
n/a

☐ Yes
☐ No

ADD YOUR CONTENT HERE

This is not a data entry field.

04/05//2023

Subsection
PatientReported
Data

Row
061

Field Label

*Surveys or patient-

reported outcome tools

Guidance
List each survey or patient-reported outcome tool
accepted by the performance measure and 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.

ADD YOUR CONTENT HERE
ADD YOUR CONTENT HERE

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.
PatientReported
Data

062

*Survey level testing

Indicate whether each patient survey or patientreported outcome tool has been validated by a peer
reviewed study or empirical testing. For a list of
acceptable types of testing, please refer to the latest
CMS Blueprint version
(https://mmshub.cms.gov/measure-lifecycle/measuretesting/evaluation-criteria/scientificacceptability/reliability).

☐ Yes
☐ No

Select “Yes” if you can provide relevant testing of the
survey or tool conducted either prior to development of
the performance measure or as part of the
development of the performance measure.

n/a

PatientReported
Data

063

If you select “Yes” in Row
062, then Rows 063-064
become required fields. If
you select “No” in Row 062,
then skip to Row 065.

*Type of testing analysis

2023 CMS MERIT DATA TEMPLATE

Select “No” if any of the surveys or tools included in the
measure have not been validated.
n/a

This is not a data entry field.

☐ Internal Consistency
☐ Construct Validity
☐ Other (enter here):

Select all that apply.

04/05//2023

Subsection
PatientReported
Data

Row
064

Subsection
Measure
Performance

Row
065

Measure
Performance

066

Field Label

*Testing methodology and

results

Field Label

Guidance
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.

*Measure performance type of score

Select one

*Measure performance

Select one

Guidance

score interpretation

2023 CMS MERIT DATA TEMPLATE

ADD YOUR CONTENT HERE
ADD YOUR CONTENT HERE

ADD YOUR CONTENT HERE
☐ Categorical (e.g., yes/no)
☐ Continuous variable (e.g., average)
☐ Count
☐ Frequency Distribution
☐ Non-weighted score/composite scale
☐ Rate
☐ Proportion
☐ Ratio
☐ Weighted score/composite scale
☐ Other (enter here:)
☐ 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

04/05//2023

Subsection
n/a

Row
n/a

Measure
Performance

067

Field Label
If you select “Better quality =
Higher score” or “Better
quality = Lower score” in
Row 066, then Rows 070079 become required fields.
If you select “Better quality =
Score within a defined
interval” in this field, then
Rows 068-079 become
required fields. If you select
“Passing score above a
specified threshold defines
better quality” or “Passing
score below a specified
threshold defines better
quality” in this field, then
Row 067 and Rows 070-079
become required fields.

*Passing score

n/a

Guidance

Provide the value that indicates the passing score for
the performance measure.

ADD YOUR CONTENT HERE
This is not a data entry field

Numeric field

Please enter only one value in the response field and do
not enter a range of values.
Measure
Performance

068

*Lower limit of defined

interval

If unknown or not available, enter 9999.
Provide the lower limit for the performance score’s
defined interval.

Numeric field

For example, if the defined interval is 60 - 120 minutes,
enter the lower limit of 60 here.
Please enter only one value in the response field and do
not enter a range of values.
If unknown or not available, enter 9999.

2023 CMS MERIT DATA TEMPLATE

04/05//2023

Subsection
Measure
Performance

Row
069

Field Label

*Upper limit of defined

interval

Guidance
Provide the upper limit for the performance score’s
defined interval.

Numeric field

ADD YOUR CONTENT HERE

For example, if the defined interval is 60 – 120 minutes,
enter the upper limit of 120 here.
Please enter only one value in the response field and do
not enter a range of values.
Measure
Performance

070

*Number of accountable

entities included in analysis

If unknown or not available, enter 9999.
Provide the number of accountable entities included in
the analysis of the distribution of performance scores
described in "Overall mean performance score" "Overall standard deviation of performance scores."

Numeric field

Please enter a single value and do not enter a range.
Measure
Performance

071

Measure
Performance

072

*Number of accountable

entities: unit

*Overall mean performance

score

If unknown or not available, enter 9999.
Provide the unit of accountable entities included in the
analysis of the distribution of performance scores
described in "Overall mean performance score" "Overall standard deviation of performance scores."
Provide the mean performance score across
accountable entities in the test sample that is relevant
to the intended use of the measure.

ADD YOUR CONTENT HERE

Numeric field

Note: for MIPS 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.
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 mean
performance score in percentage form, without the
symbol. For example, if the mean performance score is
97.9%, enter 97.9 and not 0.979.
If a mean performance score is not available, enter
9999.

2023 CMS MERIT DATA TEMPLATE

04/05//2023

Subsection
Measure
Performance

Row
073

Field Label

*Minimum performance

score

Guidance
Provide the minimum performance score for the testing
sample that is relevant to the intended use of the
measure.

Numeric field

ADD YOUR CONTENT HERE

If this is a proportion measure, provide the minimum
performance score in percentage form, without the
symbol. For example, if the minimum performance
score is 85.6%, enter 85.6 and not 0.856.

Measure
Performance

074

10th percentile

If a minimum performance score is not available, enter
9999.
Provide the performance score at the 10th 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 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
Performance

075

*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.
If a median performance score is not available, enter
9999.

2023 CMS MERIT DATA TEMPLATE

04/05//2023

Subsection
Measure
Performance

Row
076

Field Label
90th percentile

Guidance
Provide the performance score at the 90th percentile
for the testing sample that is relevant to the intended
use of the measure.

Numeric field

ADD YOUR CONTENT HERE

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.

Measure
Performance

077

*Maximum performance

score

If a 90th percentile performance score is not available,
enter 9999.
Provide the maximum performance score for the
testing sample that is relevant to the intended use of
the measure.

Numeric field

If this is a proportion measure, provide the maximum
performance score in percentage form, without the
symbol. For example, if the maximum performance
score is 85.6%, enter 85.6 and not 0.856.

Measure
Performance

078

Measure
Performance

079

*Overall standard deviation

of performance scores

*Is there evidence for
statistically significant gaps
in measure score
performance among select
subpopulations of interest
defined by one or more
social risk factors?

2023 CMS MERIT DATA TEMPLATE

If a maximum performance score is not available, enter
9999.
Provide the standard deviation of performance scores
for the testing sample that is relevant to the intended
use of the measure.
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.

Numeric field
☐ Yes
☐ No
☐ Not tested

04/05//2023

Subsection
Importance

Row
080

Field Label

*Meaningful to Patients.

Was input on the final
performance measure
collected from patients
and/or caregivers?
n/a

n/a

Importance

081

Importance

082

If you select “Yes” in Row
080, then Rows 081 and 082
become required fields. If
you select “No” in Row 080,
then skip to Row 083.

Guidance
Select one. Input from patients and/or caregivers can
include any of the following:
• Patients
• Primary caregivers
• Family
• Other relatives
n/a

☐ Yes
☐ No

This is not a data entry field.

*Denominator: Total

Indicate the total number of patients/caregivers who
responded.

Numeric field

*Numerator: Total number

Indicate the total number of patients/caregivers who
agreed.

Numeric field

number of patients and/or
caregivers who responded
to the question asking
whether information from
the measure (e.g., the
measured outcome or
process) is important to
know about AND can help
improve care for patients in
similar situations or with
similar conditions.
of patients and/or caregivers
who agreed that information
from the measure (e.g., the
measured outcome or
process) is important to
know about AND can help
improve care for patients in
similar situations or with
similar conditions.

2023 CMS MERIT DATA TEMPLATE

ADD YOUR CONTENT HERE

04/05//2023

Subsection
Importance

Row
083

Field Label

*Estimated impact of the

measure: Estimate of annual
denominator size

Importance

n/a

084

n/a

*Were the measured
entities (or others)
consulted on the final
performance measure to
assess whether the measure
is easy to understand AND is
useful for decision-making?

If you select “Yes” in Row
084, then Rows 085-086
become required fields. If
you select “No” in Row 084,
then skip to Row 087.

2023 CMS MERIT DATA TEMPLATE

Guidance
Enter the numerical value of the estimated annual
denominator size across accountable entities eligible to
report the measure. This can be estimated from the
average entity-level denominator in the test sample
multiplied by the approximate number of eligible
entities that may report the measure. If the measure
requires a multi-year denominator, divide the estimate
to report the estimated number of denominator cases
per year rather than for the full denominator period.
If it is not possible to estimate based on the testing
sample and other publicly available information, enter
9999.
Select one. The assessment of whether the measure is
easy to understand AND useful for decision-making may
be obtained from measured entities, or others such as
consumers, purchasers, policy makers, etc., using any of
the following methods:

Numeric field

ADD YOUR CONTENT HERE

☐ Yes
☐ No

• Focus groups
• Structured interviews
• Surveys of potential users
Notes:
• This is separate from face validity testing of the
performance measure.
• The desired threshold is 60% or greater of measured
entities (or others) who respond in agreement that
the information produced by the performance
measure is easy to understand AND useful for
decision-making.
n/a

This is not a data entry field.

04/05//2023

Subsection
Importance

Row
085

Field Label

*Denominator: Total

number of measured
entities (or others) who
responded when asked if
information produced by the
performance measure is
easy to understand AND
useful for decision-making

Importance

086

087

*Numerator: Total number
of measured entities (or
others) who agreed that
information produced by the
performance measure is
easy to understand AND
useful for decision-making

*Estimated impact of the
measure: Estimate of annual
denominator size: unit

2023 CMS MERIT DATA TEMPLATE

Guidance
Enter the total number of measured entities (or others)
who responded when asked if information produced by
the performance measure is easy to understand AND
useful for decision-making.
Notes:
• This is separate from any face validity testing.
• The assessment of understandability and decisionmaking utility of the measure may be obtained from
measured entities, or others such as consumers,
purchasers, policy makers, etc.
• The desired threshold is 60% or greater of measured
entities (or others) who respond in agreement that
the information produced by the performance
measure is easy to understand AND useful for
decision-making.
Enter the total number of measured entities (or others)
who responded in agreement that the information
produced by the performance measure is easy to
understand AND useful for decision-making.
Note:
• This is separate from face validity testing of the
performance measure.
• The assessment of understandability and decisionmaking utility of the measure may be obtained from
measured entities, or others, such as consumers,
purchasers, policy makers, etc.,
• The desired threshold is 60% or greater of those
being measured (or others) who respond in
agreement that the information produced by the
performance measure is easy to understand AND
useful for decision-making.
Indicate the unit (e.g., patients) of the estimate of
annual denominator size.

Numeric field

ADD YOUR CONTENT HERE

Numeric field

Free text field

04/05//2023

Subsection
Background
Information

Row
088

n/a

Previous
Measures

089

n/a

Field Label

*What is the history or

Select one

If you select “New measure
never previously submitted
to the MUC List, reviewed
by Measure Applications
Partnership (MAP)
Workgroup, or used in a
CMS Program” in Row 088,
then skip to Row 101". If
you select “Measure
currently used in a CMS
program being submitted
as-is for a new or different
program” or "Measure
currently used in a CMS
program, but the measure
is undergoing substantial
change” then Rows 097099 become required fields.

n/a

Guidance

background for including
this measure on the
current year MUC List?

*Was this measure

published on a previous
year's Measures Under
Consideration list?
If you select “Yes” in Row
089, then Rows 90-97
become required fields. in
the Previous Measures
section. If you select “No”
in Row 089, then skip to
Row 98.

2023 CMS MERIT DATA TEMPLATE

ADD YOUR CONTENT HERE
☐ New measure never reviewed by Measure
Applications Partnership (MAP) Workgroup, or
used in a CMS program
☐ Submitted previously but not included in MUC
List
☐ Measure previously submitted to MAP, refined,
and resubmitted per MAP recommendation
☐ Measure currently used in a CMS program being
submitted as-is for a new or different program
☐ Measure currently used in a CMS program, but
the measure is undergoing substantial change
This is not a data entry 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.

04/05//2023

Subsection
Previous
Measures

Row
090

Field Label

*In what prior year(s) was

this measure published on
the Measures Under
Consideration List?

2023 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.

ADD YOUR CONTENT HERE
☐ 2011
☐ 2012
☐ 2013
☐ 2014
☐ 2015
☐ 2016
☐ 2017
☐ 2018
☐ 2019
☐ 2020
☐ 2021
☐ 2022
☐ Other (enter here):

04/05//2023

Subsection
Previous
Measures

Row
091

Previous
Measures

092

Previous
Measures

093

Previous
Measures

094

Previous
Measures

095

Previous
Measures

096

Background
Information

097

Field Label

Guidance
List both the year and the associated MUC ID number in
each year. If unknown, enter N/A.

ADD YOUR CONTENT HERE
ADD YOUR CONTENT HERE

List both the year and the associated workgroup name in
each year. Workgroup options: Clinician; Hospital; PostAcute Care/Long-Term Care; Coordinating Committee.
Example: "Clinician, 2014."
List both the year and the associated CMS programs in
each year.

ADD YOUR CONTENT HERE

*What was the MAP
recommendation in each
year?

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.

ADD YOUR CONTENT HERE

Briefly describe the reason(s) if known.

ADD YOUR CONTENT HERE

*MAP report page number

List both the year and the associated MAP report page
number for each year.

ADD YOUR CONTENT HERE

*Range of year(s) this

For example: Hospice Quality Reporting (2012-2018)

ADD YOUR CONTENT HERE

*What was the MUC ID for
the measure in each year?

*List the CMS CBE MAP

workgroup(s) in each year

*What were the programs

that MAP reviewed the
measure for in each year?

*Why was the measure
not recommended by the
MAP workgroups in those
year(s)?

being referenced for each
year

ADD YOUR CONTENT HERE

measure has been used by
CMS Program(s).

2023 CMS MERIT DATA TEMPLATE

04/05//2023

Subsection
Background
Information

Row
098

Field Label

*What other federal

programs are currently
using this measure?

2023 CMS MERIT DATA TEMPLATE

Guidance
Select all that apply. These should be current use
programs only, not programs for the upcoming year’s
submittal.

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-Acquired Condition Reduction Program
☐ Hospital Inpatient Quality Reporting Program
☐ Hospital Outpatient Quality Reporting Program
☐ Hospital Readmissions Reduction Program
☐ Hospital Value-Based Purchasing Program
☐ Inpatient Psychiatric Facility Quality Reporting
Program
☐ Inpatient Rehabilitation Facility Quality Reporting
Program
☐ Long-Term Care Hospital Quality Reporting
Program
☐ Medicare Promoting Interoperability Program for
Eligible Hospitals and Critical Access Hospitals
(CAHs)
☐ Medicare Shared Savings Program
☐ Merit-based Incentive Payment System-Cost
☐ Part C & D Star Rating [Medicare]
☐ 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):

04/05//2023

Subsection
Background
Information

Row
099

Field Label

*How will this measure

align with the same
measure(s) that are
currently used in other
federal programs?

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, NQF#, etc.), if available.

ADD YOUR CONTENT HERE
ADD YOUR CONTENT HERE

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.

2023 CMS MERIT DATA TEMPLATE

04/05//2023

Subsection
Previous
Measures

Row
100

submitted to meet a
statutory requirement, list
the corresponding statute

Subsection
Data
Sources

Row
101

Data
Sources

102

Data
Sources
Data
Sources

Field Label

*If this measure is being

103
104

Field Label

Guidance
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
ADD YOUR CONTENT HERE

Guidance

ADD YOUR CONTENT HERE
☐ Administrative Data (non-claims)
☐ Claims Data
☐ Electronic Clinical Data (non-EHR)
☐ Electronic Health Record
☐ Paper Medical Records
☐ Standardized Patient Assessments
☐ Patient Reported Data and Surveys
☐ Registries
☐ Other (enter here):
☐ Yes
☐ No

*What data sources are
used for the measure?

Select all that apply.

*The current measure
specifications allow for the
utilization of at least one
digital data source.

Select “Yes” if measure data sources include at least one of
the following:
• Administrative Claims
• Administrative Data
• Patient Assessment Instrument (e.g., MDS, LTCH-CARE,
OASIS)
• EHR
• Registry (e.g., QCDR and Qualified Registry and EQRS)

If applicable, specify the
data source
Description of parts related
to each data source

2023 CMS MERIT DATA TEMPLATE

Use the next field to specify or elaborate on the type of
data source, if needed to define your measure.

Select “No” if measure data sources are limited to the
following:
• Chart-Abstracted
• Survey (For example, currently CAHPS, QRS Survey, HOS
are not captured digitally)
• Part B claims measures (MIPS) reported using Quality
Data codes
• Paper Medical Records
Use this field to specify or elaborate on the type of data
source, if needed, to define your measure.
Describe the parts or elements of the measure that are
relevant to the selected data sources

ADD YOUR CONTENT HERE
ADD YOUR CONTENT HERE

04/05//2023

STEWARD
Subsection
Steward
Information

Row
105

*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.084-086 for list choices.
Copy/paste or enter your choices here:

Steward
Information

106

*Measure Steward Contact

Please provide the contact information of the measure
steward.

ADD YOUR CONTENT HERE

Long-Term
Steward
Information

107

*Is the long-term steward

☐ Yes
☐ No

n/a

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

108

If different from Steward above, enter the required contact
information for the Long-Term Measure Steward listed
above

ADD YOUR CONTENT HERE

Submitter
Information
Submitter
Information

109
110

*Primary Submitter Contact
Information

Submitter
Information
n/a

111

Secondary Submitter
Contact Information
If applicable, select from
drop-down menu “Other
MERIT users who will
contribute to this measure”

Information

different than the steward?

n/a

If you select “Yes” in Row
107, then Row 108 becomes
a required field. If you select
“No” in Row 107, then skip
to Row 109.

*Long-Term Measure

Steward Contact
Information
Is primary submitter the
same as steward?

2023 CMS MERIT DATA TEMPLATE

Select “Yes” or “No.”
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.
n/a

This is not a data entry field.

☐ Yes
☐ No
ADD YOUR CONTENT HERE

ADD YOUR CONTENT HERE
This is not a data entry field.

04/05//2023

CHARACTERISTICS
Subsection
General
Characteristics

Row
112

n/a

General
Characteristics

113

General
Characteristics

114

n/a

General
Characteristics

115

Field Label

*Measure Type

If you select “PRO-PM or
Experience of Care” in Row
112, then Row 113
becomes a required field. If
you select “Outcome” or
“PRO-PM or Experience of
Care” in Row 112, then
Row 147 in the Evidence
section becomes a required
field.

Guidance
Select only one type of measure. For definitions, see:
https://mmshub.cms.gov/about-quality/new-tomeasures/types.

n/a

*Assessment of patient

Select one. Indicate whether this measure assesses patient
experience of care.

*Is this measure in the

Select Yes or No. Current measures can be found at
https://cmit.cms.gov/CMIT_public/ListMeasures

experience of care

CMS Measures Inventory
Tool (CMIT)?
If you select “Yes” in Row
114, then Row 115
becomes a required field. If
you select “No” in Row 114,
then skip to Row 116.

*CMIT ID

2023 CMS MERIT DATA TEMPLATE

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.

☐ Yes
☐ No
☐ Yes
☐ No

n/a

This is not a data entry field.

If the measure is currently in CMIT, enter the CMIT ID in the
format #####-X-XXXXXXX. Current measures and CMIT IDs
can be found at
https://cmit.cms.gov/CMIT_public/ListMeasures

ADD YOUR CONTENT HERE

04/05//2023

Subsection
General
Characteristics

Row
116

Field Label
Alternate Measure ID

General
Characteristics

117

*What is the target

General
Characteristics

118

General
Characteristics

119

General
Characteristics

population of the measure?

*What one area of

specialty the measure is
aimed to, or which
specialty is most likely to
report this measure?

*Evidence of performance

gap

120

*Unintended

consequences

2023 CMS MERIT DATA TEMPLATE

Guidance
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.

ADD YOUR CONTENT HERE
ADD YOUR CONTENT HERE

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.

ADD YOUR CONTENT HERE

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.

ADD YOUR CONTENT HERE
See Appendix A.097 for list choices. Copy/paste or
enter your choice(s) here:

ADD YOUR CONTENT HERE

04/05//2023

Subsection
Evidence

Row
121

Field Label

*Type of evidence to

support the measure

n/a

Evidence

122

If you select “Clinical
Guidelines or USPSTF (U.S.
Preventive Services Task
Force) Guidelines” in Row
121, then Rows 122-129
become required fields. If
you select “Systematic
Review” in Row 121, then
Rows 131 and 137-139
become required fields. If
you select “Empirical data”
in Row 121, then Rows 131
and 142-144 become
required fields. If you select
“Grey Literature” in Row
121, then Rows 131 and
145-147 become required
fields.

*Number of clinical
guidelines, including
USPSTF guidelines that
address this topic

2023 CMS MERIT DATA TEMPLATE

Guidance
Select all that apply. Refer to the latest CMS Blueprint
version (https://mmshub.cms.gov/measurelifecycle/measure-conceptualization/informationgathering-overview) and the supplementary material
related to evidence review
(https://mmshub.cms.gov/sites/default/files/Environmenta
l-Scans.pdf) to obtain updated guidance.
n/a

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

Enter a numerical value of ≥1. Count all guidelines that are
relevant to this measure topic including those that offer
contradictory guidance.

Numeric field

This is not a data entry field.

04/05//2023

Subsection
Evidence

Row
123

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
ADD YOUR CONTENT HERE

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 CMS Blueprint
version (https://mmshub.cms.gov/measurelifecycle/measure-conceptualization/informationgathering-overview) and the supplementary material
related to evidence review
(https://mmshub.cms.gov/sites/default/files/Environmenta
l-Scans.pdf).
If there is lengthy text, describe the guidelines in an
evidence attachment, named to clearly indicate the related
form field.

2023 CMS MERIT DATA TEMPLATE

04/05//2023

Subsection
Evidence

Row
124

Field Label

*Name the guideline

developer/entity

Evidence

125

*Publication year

Evidence

126

*Guideline citation

Evidence

127

*Is this an evidence-based

clinical guideline

Evidence

128

*Does the clinical guideline
include a publicly available
evidence summary?

2023 CMS MERIT DATA TEMPLATE

Guidance
If the response to the Number of clinical guidelines,
including USPSTF guidelines, that address this measure
topic is >1, identify the guideline that most closely aligns
with and supports your measure concept. This is now
referred to as the primary clinical guideline.
Spell out the primary clinical guideline entity’s name
followed by the appropriate acronym, if available.
For example: United States Preventive Services Task Force
(USPSTF)
Provide the publication year for the primary clinical
guideline.
Use the 4-digit format (e.g., 2016).
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
There are disparate methods of developing clinical
guidance documents. An evidence-based guideline is one
which uses evidence to inform the development of their
recommendations. The evidence must be reviewed in a
deliberate, systematic manner. To determine this, the
developer must have provided a description of a systematic
search of literature and their search strategy which
includes the dates of the literature covered, databases
consulted, and a screening, review and data extraction
process.
Select “No” for clinical guidelines that are based purely on
expert consensus with or without supplementation with a
narrative literature review (non-systematic).
Evidence-based clinical guidelines should be accompanied
by a publicly available evidence summary. If the guideline
includes an evidence summary, please select “Yes” and
provide a link to the evidence summary in the text box.

ADD YOUR CONTENT HERE
ADD YOUR CONTENT HERE

Numeric field (4-digit year)
☐ Citation (enter here)
☐ URL (enter here)
☐ DOI (enter here)
☐ Not available
☐ Yes
☐ No

☐ Yes (enter URL here:)
☐ No

04/05//2023

Subsection
Evidence

Row
129

Field Label

*Is the selected guideline

statement used to support
an inappropriate use/care
measure?
Evidence

130

*For the guideline
statement that most
closely aligns with the
measure concept, what is
the associated level of
evidence or level of
certainty in the evidence?
*List the guideline
statement that most
closely aligns with the
measure concept.

Evidence

131

Evidence

132

*Is the guideline graded?

n/a

Evidence

133

If you select “Yes” in Row
132, then Rows 133-138
become required fields.

*What evidence grading
system did the guideline
use to describe strength of
recommendation?

2023 CMS MERIT DATA TEMPLATE

Guidance
Select one. Indicate whether the guideline statement
mentioned in “List the guideline statement that most
closely aligns with the measure concept" (row 131) is used
to promote the practice of not performing a specific action,
process or intervention to support an inappropriate use or
inappropriate care measure.
Select the associated level of evidence or certainty of
evidence using the convention used by the guideline
developer.
Select one.

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

☐ Yes
☐ No

ADD YOUR CONTENT HERE

☐ High or similar
☐ Moderate or similar
☐ Low, Very Low or similar
☐ Other (enter here)

ADD YOUR CONTENT HERE

☐ Yes
☐ No

This is not a data entry field.

Select the evidence grading system used by the clinical
guideline. (e.g., GRADE or USPSTF) to describe the guideline
statement’s strength of recommendation.

☐ GRADE method
☐ Modified GRADE
☐ USPSTF
☐ Other (enter here)

04/05//2023

Subsection
Evidence

Evidence

Row
134

135

*List all categories and

Field Label

Guidance
Insert the complete list of grading categories and their
definitions.

ADD YOUR CONTENT HERE
ADD YOUR CONTENT HERE

*For the guideline

Select the associated strength of recommendation using
the convention used by the guideline developer.

☐ 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
ADD YOUR CONTENT HERE

corresponding definitions
for the evidence grading
system used to describe
strength of
recommendation in the
guideline.
statement that most
closely aligns with the
measure concept, what is
the associated strength of
recommendation?

Evidence

136

137

Select one.

*List all categories and

Insert the complete list of grading categories and their
definitions.

*Number of systematic

Insert the number of peer reviewed systematic reviews
that addresses this measure topic. This includes systematic
reviews that address the same intervention/ process/
structure but may have conflicting conclusions.

corresponding definitions
for the evidence grading
system used to describe
level of evidence or level of
certainty in the evidence?
reviews that inform this
measure concept

Numeric field

Enter a numerical value of greater than or equal to 1.

2023 CMS MERIT DATA TEMPLATE

04/05//2023

Subsection
Evidence

Row
138

Field Label

*Briefly summarize the

peer-reviewed systematic
review(s) that inform this
measure concept

Evidence

139

*Peer-reviewed systematic
review citation

Evidence

140

*Peer-reviewed original
research

Evidence

141

*Peer-reviewed original
research citation

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.

ADD YOUR CONTENT HERE
ADD YOUR CONTENT HERE

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

☐ 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.
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.
If more than one article was identified, provide at least one
of the following for one key article:
• Citation
• URL
• DOI

☐ Yes (please provide search strategy in an
attachment; e.g., years searched, keywords and search
terms used, databases used, etc.)
☐ 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.

2023 CMS MERIT DATA TEMPLATE

04/05//2023

Subsection
Evidence

Row
142

Evidence

Field Label

Guidance

*Source of empirical data

Select all that apply

143

*Summarize the empirical
data

144

*Empirical data citation

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. 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

Evidence

145

*Name grey literature

Evidence

146

*Summarize the grey
literature

2023 CMS MERIT DATA TEMPLATE

Provide the complete list of citations with accompanying
DOI or URL in a separate attachment.
If more than one grey literature was identified, provide at
least one of the following for one key piece of evidence:
•
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
☐ Peer-reviewed narrative literature review
☐ Published and publicly available reports (e.g., from
agencies)
☐ Internal data analysis
☐ Other (enter here)
ADD YOUR CONTENT HERE

☐ Citation (enter here:)
☐ URL (enter here:):
☐ DOI (enter here:)
☐ Not available

ADD YOUR CONTENT HERE

04/05//2023

Subsection
Evidence

Row
147

Field Label

*Grey literature citation

Evidence

148

*Does the evidence discuss
a relationship between at
least one process,
structure, or intervention
with the outcome?

Subsection
Risk
Adjustment
and
Stratification

Row
149

Field Label

n/a

Risk
Adjustment
and
Stratification

150

*Was risk adjustment
and/or stratification
considered?

If you select “Yes” in Row
149, then Row 150, 152,
and 161 become required
fields. If you select “No” in
Row 149, then skip to Row
163.

*Was a conceptual model
outlining the pathway
between patient risk
factors, quality of care, and
the outcome of interest
established?

2023 CMS MERIT DATA TEMPLATE

Guidance
If more than one grey literature was identified, provide at
least one of the following for one key piece of evidence:
• Citation
• URL
• DOI

ADD YOUR CONTENT HERE
☐ 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.
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.

☐ Yes
☐ No

Guidance
Select “Yes” if the measure development process included
consideration of risk adjustment and/or stratification, even
if the final measure does not include risk adjustment or
stratification. While risk adjustment is typically only
required for outcome measures, other measure types can
select “Yes” if risk adjustment or stratification was
considered.
Select “No” if neither risk adjustment nor stratification was
considered as part of the measure development process.
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.

ADD YOUR CONTENT HERE
☐ Yes
☐ No

This is not a data entry field.

☐ Yes
☐ No

Select “No” if a conceptual model was not established or
the conceptual model was based solely on expert opinion
or empirical analysis.

04/05//2023

Subsection
n/a

Row
n/a

Risk
Adjustment
and
Stratification
Risk
Adjustment
and
Stratification
n/a

151

Field Label
If you select “Yes” in Row
150, then Row 151
becomes a required field. If
you select “No” in Row 150,
then skip to Row 152.

*Were all key risk factors

identified in the conceptual
model available for testing?
152

*Is the measure risk
adjusted?

n/a

If you select “Yes” in Row
152, then Rows 153-160
become required fields. If
you select “Yes” in Row
152, you are also
encouraged to upload
documentation about your
risk adjustment model as
an attachment. If you select
“No” in Row 152, then skip
to Row 161.

2023 CMS MERIT DATA TEMPLATE

Guidance
n/a

ADD YOUR CONTENT HERE
This is not a data entry field.

If some key risk factors were not available for testing or
inclusion in the risk model/stratification approach, select
“No” and describe the anticipated impact on measure
scores (e.g., magnitude and direction of bias).
Indicate whether the final measure is risk adjusted.

☐ Yes
☐ No (enter here:)

n/a

This is not a data entry field.

☐ Yes
☐ No

04/05//2023

Subsection
Risk
Adjustment
and
Stratification

Row
153

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
CMS Measures Management System Blueprint
(https://www.cms.gov/Medicare/Quality-InitiativesPatient-AssessmentInstruments/MMS/Downloads/Blueprint.pdf).
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 characteristic
☐ 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.

2023 CMS MERIT DATA TEMPLATE

04/05//2023

Subsection
Risk
Adjustment
and
Stratification

Row
n/a

Risk
Adjustment
and
Stratification

154

Risk
Adjustment
and
Stratification

155

Risk
Adjustment
and
Stratification

156

Field Label
If you select “Patient-Level
Demographics” in Row 153,
then Row 154 becomes a
required field. If you select
“Patient-level health status
& clinical conditions” in
Row 153, then Row 155
becomes a required field. If
you select “Patient
functional status” in Row
153, then Row 156
becomes a required field. If
you select “Patient-level
social risk factors” in Row
153, then Row 157
becomes a required field. If
you select “Proxy social risk
factors” in Row 153, then
Row 158 becomes a
required field. If you select
“Patient community
characteristics” in Row 153,
then Row 159 becomes a
required field.

Guidance
n/a

ADD YOUR CONTENT HERE
This is not a data entry field.

*Patient-level

Select all that apply

*Patient-level health status

Select all that apply

*Patient functional status:
please select all that apply

Select all that apply

☐ 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):

demographics: please
select all that apply

& clinical conditions: please
select all that apply

2023 CMS MERIT DATA TEMPLATE

04/05//2023

Subsection
Risk
Adjustment
and
Stratification

Row
157

Risk
Adjustment
and
Stratification

158

Risk
Adjustment
and
Stratification

159

Risk
Adjustment
and
Stratification
Risk
Adjustment
and
Stratification
n/a

Risk
Adjustment
and
Stratification

162

Field Label

ADD YOUR CONTENT HERE

*Patient-level social risk

Guidance
Select all that apply

*Proxy social risk factors:

Select all that apply

☐ Neighborhood Level Income from the Census
☐ Dual Eligibility for Medicare and Medicaid
☐ Other (enter here):

*Patient community

Select all that apply

☐ Percent of Vacant Houses
☐ Crime Rate
☐ Urban/Rural
☐ Other (enter here):

160

*Risk model performance

ADD YOUR CONTENT HERE

161

*Is the measure

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.
Indicate whether the final measure is recommended to be
stratified.
n/a

This is not a data entry field.

Describe the recommended stratification approach
including the data elements used to stratify scores for atrisk subgroups. Demonstrate that there is sufficient sample
size within measured entities to stratify measure scores. If
more room is needed, provide testing results as an
attachment and list the name of the attachment in this
field.

ADD YOUR CONTENT HERE

☐ Income
☐ Education
☐ Wealth
☐ Living Alone
☐ Social Support
☐ Other (enter here):

factors: please select all
that apply

please select all that apply

characteristics: please
select all that apply

recommended to be
stratified?
n/a

If you select “Yes” in Row
161, then Row 162
becomes a required field. If
you select “No” in Row 161
and “No” in Row 152, then
Row 163 becomes a
required field.

*Stratification approach

2023 CMS MERIT DATA TEMPLATE

☐ Yes
☐ No

04/05//2023

Subsection
Risk
Adjustment
and
Stratification

Row
163

Field Label

*Rationale for using

neither risk adjustment nor
stratification

2023 CMS MERIT DATA TEMPLATE

Guidance
Select ALL reasons for not implementing a risk adjustment
model or stratification approach in the measure. For more
information, refer to the CMS Measures Management
System Blueprint Risk Adjustment in Quality Measurement
supplement
(https://mmshub.cms.gov/sites/default/files/RiskAdjustment-in-Quality-Measurement.pdf) and the guidance
on defining stratification schemes
(https://mmshub.cms.gov/measure-lifecycle/measurespecification/develop-specification/stratification)

ADD YOUR CONTENT HERE

☐ 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):
☐ Other (enter here):

04/05//2023

Subsection
Healthcare
Domain

Row
164

Healthcare
Domain

165

Other Priorities

Field Label

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

ADD YOUR CONTENT HERE
☐ Person-Centered Care
☐ Equity
☐ Safety
☐ Affordability and Efficiency
☐ Chronic Conditions
☐ Wellness and Prevention
☐ Seamless Care Coordination
☐ Behavioral Health

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.

☐ Person-Centered Care
☐ Equity
☐ Safety
☐ Affordability and Efficiency
☐ Chronic Conditions
☐ Wellness and Prevention
☐ Seamless Care Coordination
☐ Behavioral Health

*Does this measure

Select one.

*What one Meaningful

Measures 2.0 priority is
most applicable to this
measure?

166

For more information, see:
https://www.cms.gov/meaningful-measures-20-movingmeasure-reduction-modernization

☐ Yes
☐ No

address CMS priorities to
improve maternal health
care and maternal
outcomes?
Subsection
Endorsement
Characteristics

Row
167

Field Label

Endorsement
Characteristics

168

*CBE ID (CMS consensusbased entity, or
endorsement ID)

Endorsement
Characteristics

169

If endorsed: Is the measure
being submitted exactly as
endorsed by the CMS CBE?

*What is the endorsement
status of the measure?

2023 CMS MERIT DATA TEMPLATE

Guidance
Select only one. For information on consensus-based entity
(CMS contractor) 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.

ADD YOUR CONTENT HERE

☐ Endorsed
☐ Endorsement removed
☐ Submitted
☐ Failed endorsement
☐ Never submitted
ADD YOUR CONTENT HERE

☐ Yes
☐ No

04/05//2023

Subsection
n/a

Row
n/a

Endorsement
Characteristics

170

Endorsement
Characteristics

171

Endorsement
Characteristics

172

Endorsement
Characteristics

173

Field Label
If you select “No” in Row
169, then Rows 170-171
become required fields.
If not exactly as endorsed,
specify the locations of the
differences

n/a

Guidance

Indicate which specification fields are different. Select all
that apply

If not exactly as endorsed,
describe the nature of the
differences
If endorsed: Year of most
recent CDP endorsement

Briefly describe the differences

Year of next anticipated
CDP endorsement review

Select one. If you are submitting for initial endorsement,
select the anticipated year.

2023 CMS MERIT DATA TEMPLATE

Select one

ADD YOUR CONTENT HERE
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):
ADD YOUR CONTENT HERE
☐ 2017
☐ 2018
☐ 2019
☐ 2020
☐ 2021
☐ 2022
☐ 2023
☐ 2022
☐ 2023
☐ 2024
☐ 2025
☐ 2026
☐ 2027

04/05//2023

GROUPS
Subsection
n/a

Row
174

Field Label

*Is this measure an

electronic clinical quality
measure (eCQM)?
n/a

n/a

175

If you select “Yes” in Row
174, then Rows 175-177
become required fields. If
you select “No” in Row
174, then skip to Row 178.

*Measure Authoring Tool

(MAT) Number

n/a

176

n/a

177

*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)?
*If eCQM, does any

electronic health record
(EHR) system tested need
to be modified?

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/
n/a

☐ Yes
☐ No

ADD YOUR CONTENT HERE

This is not a data entry field.

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.
Select 'Yes' or 'No'. For additional information on HQMF
standards, see: https://ecqi.healthit.gov/tool/hqmf

ADD YOUR CONTENT HERE

Select “Yes” if any of the EHR systems tested had to modify
how data were entered by providers or stored to facilitate
calculation of the eCQM.

☐ Yes
☐ No

Select “No” if the data needed to calculate the eCQM were
already included in structured fields in the EHR systems
tested and none of them needed to be modified.

RELATED AND COMPETING MEASURES

2023 CMS MERIT DATA TEMPLATE

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Subsection
Similar In-Use
Measures

Row
178

n/a

Related and
Competing
Measures

179

Related and
Competing
Measures

180

Related and
Competing
Measures

181

Field Label

*Is this measure similar

and/or competing with
measure(s) already in a
program?
If you select “Yes” in Row
178, then Rows 179-181
become required fields. If
you select “No” in Row 178,
then skip to Row 182.

Guidance
Select either Yes or No. Consider other measures with
similar purposes.

☐ Yes
☐ No

ADD YOUR CONTENT HERE

n/a

This is not a data entry field.

*Which measure(s) already
in a program is your
measure similar to and/or
competing with?

Identify the other measure(s) including title and any other
unique identifier.

ADD YOUR CONTENT HERE

Describe benefits of this measure, in comparison to
measure(s) already in a program.

ADD YOUR CONTENT HERE

*How will this measure be
distinguished from other
similar and/or competing
measures?

Describe key differences that set this measure apart from
others.

ADD YOUR CONTENT HERE

*How will this measure
add value to the CMS
program?

2023 CMS MERIT DATA TEMPLATE

04/05//2023

ATTACHMENTS
Subsection
N/A

Row
182

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

183

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
184

Field Label
Submitter Comments

Guidance
Any notes, qualifiers, external references, or other
information not specified above.

ADD YOUR CONTENT HERE
ADD YOUR CONTENT HERE

Send any questions to MMSsupport@battelle.org

2023 CMS MERIT DATA TEMPLATE

04/05//2023

Appendix: Lengthy Lists of Choices
A. 084-086

Choices for Measure Steward (084) and Long-Term Measure Steward (if different) (086)

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

2023 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)

04/05//2023

A.097 Choices for Areas of specialty (097)
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
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concerns regarding where to submit your documents, please contact QPP at qpp@cms.hhs.gov

2023 CMS MERIT DATA TEMPLATE

04/05//2023

File Type	application/pdf
File Title	Measures under Consideration 2023 Data Template
Subject	Health, physician, hospital, quailty, measure, efficiency
Author	Centers for Medicare & Medicaid Services
File Modified	2023-06-07
File Created	2023-06-02