CROSSWALK Appendix E: Measures under Consideration 2025 Data Template for Candidate Measures

Appendix E MUC 2025 Data Template for Candidate Measures Crosswalk.pdf

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

CROSSWALK Appendix E: Measures under Consideration 2025 Data Template for Candidate Measures

OMB: 0938-1314

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OMB control number: 0938-1314
Expiration Date: 02/28/2027

CMS Measures Under Consideration (MUC) Entry/Review
Information Tool (MERIT) Data Template Crosswalk
CY 2024 Final Versus CY 2025 Final
Burden Impact: The changes to this form do not reflect policies in the CY 2026 Physician Fee Scheduled
(PFS) Final Rule for the Quality Payment Program. There are no impacts to burden as a result of any changes
reflected here.
Change #1
Location: Title (Page 1)
Reason for Change: Updated date in title of the document.
CY 2024 Final Rule text: Measures Under Consideration Entry/Review and Information Tool 2024 Data
Template for Candidate Measures
CY 2025 Final Rule text: Measures Under Consideration Entry/Review and Information Tool 2025 Data
Template for Candidate Measures
Change #2
Location: Instructions (Page 1)
Reason for Change: Updated instructions for clarity.
CY 2024 Final Rule text:
1. Before accessing the CMS MERIT (Measures Under Consideration Entry/Review and Information Tool)
online system, you are invited to complete the measure template below by entering your candidate
measure information in the column titled “Add Your Content Here.”
2. All rows that have an asterisk symbol * in the Field Label require a response, unless otherwise
indicated in the template.
3. For each row, the “Guidance” column provides details on how to complete the template and what kinds
of data to include. Unless otherwise specified, the character limit for text fields in CMS MERIT is 8000
characters.
4. For check boxes, note whether the field is “select one” or “select all that apply.” You can click on the
box to place or remove the “X.”
5. For all fields, especially Numerator and Denominator, use plain text whenever possible. Please convert
any special symbols, math expressions, or equations to plain text (keyboard alphanumeric, such as + * /).
6. For all free-text fields: Be sure to spell out all abbreviations and define special terms at their first
occurrence.
7. Numeric fields are noted, where applicable, in the “Add Your Content Here” column.
8. Row numbers are for convenience only and do not appear on the CMS MERIT user interface.
9. Send any questions to MMSsupport@battelle.org with the subject line “Pre-Rulemaking”.

CY 2025 Final Rule text:
1. Before accessing the CMS MERIT (Measures Under Consideration Entry/Review and Information Tool)
online system, you are invited to complete the measure template below by entering your candidate
measure information in the column titled “Add Your Content Here.”
2. All rows that have an asterisk symbol * in the Field Label require a response, unless otherwise
indicated in the template.
3. For each row, the “Guidance” column provides details on how to complete the template and what kinds
of data to include. Unless otherwise specified, the character limit for text fields in CMS MERIT is 8000
characters.
4. For check boxes, note whether the field is “select one” or “select all that apply.” You can click on the
box to place or remove the “X.”
5. For all fields, especially Numerator and Denominator, use plain text whenever possible. Please convert
any special symbols, math expressions, or equations to plain text (keyboard alphanumeric, such as + * /).
6. Please ensure that if your measure includes Numerator Exclusions, Denominator Exclusions, or
Denominator Exceptions, they are listed in their designated locations and not solely identified in the
Numerator or Denominator fields. This practice is crucial for maintaining the standardization of the
measure submission process.
7. For all free-text fields: Be sure to spell out all abbreviations and define special terms at their first
occurrence.
8. Numeric fields are noted, where applicable, in the “Add Your Content Here” column.
9. Row numbers are for convenience only and do not appear on the CMS MERIT user interface.
10. Send any questions to MMSsupport@battelle.org with the subject line “Pre-Rulemaking”.
Change #3
Location: Whole document, Footer
Reason for Change: Updated the year and date.
CY 2024 Final Rule text: 2024 CMS MERIT DATA TEMPLATE; 1/31/2024
CY 2025 Final Rule text: 2025 CMS MERIT DATA TEMPLATE; 1/30/2025
Change #4
Location: Steward or Owner section (Pages 2-3)
Reason for Change: Relocation of section to before “Properties” and re-naming of section from “Steward” to
“Steward or Owner”. This affects the row numbering for all sections of the document.
CY 2024 Final Rule text: N/A
CY 2025 Final Rule text: N/A
Change #5
Location: Page 2, Row 001
Reason for Change: Updated Subsection, Row, Field Label, Guidance and Appendix.
CY 2024 Final Rule text:

Subsection
Steward
Information

Row
089

Field Label

*Measure Steward

Guidance
Enter the current Measure Steward. Typically, this is an
organization or other agency/institution/entity name.

ADD YOUR CONTENT HERE
See Appendix A.085 for list
choices.
Copy/paste or enter your choices
here:

Guidance
Enter the current Measure Steward or Owner. Typically,
this is an organization or other agency/institution/entity
name.

ADD YOUR CONTENT HERE
See Appendix A.001 for list
choices.
Copy/paste or enter your choices
here:

CY 2025 Final Rule text:
Subsection
Steward or
Owner
Information

Row
001

Field Label

*Measure Steward or
Owner

Change #6
Location: Page 2, Row 002
Reason for Change: Updated Subsection, Row, Field Label, and Guidance.
CY 2024 Final Rule text:
Subsection
Steward
Information

Row
090

Field Label

*Measure Steward Contact
Information

Guidance
Please provide the contact information of the measure
steward.

ADD YOUR CONTENT HERE
ADD YOUR CONTENT HERE

Guidance
Please provide the contact information of the measure
steward or owner.

ADD YOUR CONTENT HERE
ADD YOUR CONTENT HERE

CY 2025 Final Rule text:
Subsection
Steward or
Owner
Information

Row
002

Field Label

*Measure Steward or
Owner Contact Information

Change #7
Location: Pages 2-3, Rows 003 through 009, and Skip Logic
Reason for Change: Removed long-term steward questions, added partner collaboration and developer
questions, updated Subsections, Rows, Field labels, Guidance, Skip Logic, and Appendix.
CY 2024 Final Rule text:
Subsection
Long-Term
Steward
Information

Row
091

Field Label

n/a

If you select “Yes” in Row
091, then Row 092 becomes
a required field. If you select
“No” in Row 091, then skip
to Row 093.

Long-Term
Steward
Information

092

*Long-Term Measure

Submitter
Information

093

*Is the long-term steward
different than the steward?

Steward Contact
Information
Is primary submitter the
same as steward?

Guidance
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

ADD YOUR CONTENT HERE
☐ Yes
☐ No

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

ADD YOUR CONTENT HERE

Select “Yes” or “No.”

☐ Yes
☐ No

This is not a data entry field.

Subsection
n/a

Row
n/a

Field Label
If you select “No” in Row
093, then Row 094 becomes
a required field. If you select
“Yes” in Row 093, then skip
to Row 095.

Submitter
Information

094

*Primary Submitter Contact

Submitter
Information
n/a

095

Information

n/a

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

Guidance
n/a

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

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 e-mail 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

ADD YOUR CONTENT HERE

Guidance
To answer the question, please confirm if any external
entities such as federal agencies, organizations,
subcontractors, or partners were involved in the
development of the measure. Simply respond with
"Yes" if there was any collaboration, or "No" if the
development was carried out independently by your
team.

ADD YOUR CONTENT HERE
☐ Yes
☐ No

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

CY 2025 Final Rule text:
Subsection
Steward or
Owner
Information

Row
003

Field Label

n/a

If you select “Yes” in Row
003, then Row 004 becomes
a required field. If you select
“No” in Row 003, then skip
to Row 005.

n/a

This is not a data entry field.

Steward or
Owner
Information

004

*List Collaborators in

If yes, please list all federal agencies, organizations,
subcontractors, or partners that participated in the
development of the measure.

Free text field

Measure
Developer
Information

005

Please verify whether the measure developer is the
same entity as the measure steward or owner
mentioned above.

☐ Yes
☐ No

n/a

This is not a data entry field.

Measure
Developer
Information
Submitter
Information

006

ADD YOUR CONTENT HERE

007

Is primary submitter the
same as steward or owner?

If different from Steward or Owner above, enter the
required contact information for the Measure
Developer listed above
Select “Yes” or “No.”

n/a

If you select “No” in Row
007, then Row 008 becomes
a required field. If you select
“Yes” in Row 007, then skip
to Row 009.

*Did another federal agency
or any other organizations,
subcontractors, or partners
participate in developing the
measure?

Measure Development

*Is the Measure Developer
different than the steward
or owner?
If you select “Yes” in Row
005, then Row 006 becomes
a required field. If you select
“No” in Row 005, then skip
to Row 007.

*Measure Developer
Contact Information

n/a

☐ Yes
☐ No
This is not a data entry field.

Subsection
Submitter
Information

Row
008

Submitter
Information
n/a

009

Field Label

*Primary Submitter Contact
Information

n/a

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

Guidance
If different from Steward or Owner 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
e-mail 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

ADD YOUR CONTENT HERE
ADD YOUR CONTENT HERE

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

Change #8
Location: Page 3, Row 010
Reason for Change: Updated Row and Guidance.
CY 2024 Final Rule text:
Subsection
Measure
Information

Row
001

Field Label

*Measure Title

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.

ADD YOUR CONTENT HERE
Free text field

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
Medicare program name should not ordinarily be part
of the measure title, because each measure record
already has a required field that specifies the Medicare
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

ADD YOUR CONTENT HERE
Free text field

CY 2025 Final Rule text:
Subsection
Measure
Information

Row
010

Field Label

*Measure Title

Subsection

Row

Field Label

Guidance
information on measure title, see the Measure
Specification tab on the CMS MMS Hub.

ADD YOUR CONTENT HERE

Change #9
Location: Page 4, Rows 011 through 013 and Skip Logic
Reason for Change: Addition of questions and Skip Logic related to proprietary or licensing aspects of
measure.
CY 2024 Final Rule text: N/A
CY 2025 Final Rule text:
Subsection
Measure
Information

Row
011

Field Label

*Is any part of the measure
or use of the measure
proprietary and/or licensed?

Guidance
Select ‘Yes’ or ‘No’
Indicate whether there are any proprietary components
of the measure such as specifications, algorithms,
and/or software.
n/a

n/a

If you select “Yes” in Row
011, then Rows 012 and 013
become required fields. If
you select “No” in Row 011,
then skip to Row 014.

Measure
Information

012

*Are there any licensing

Select ‘Yes’ or ‘No’

fees associated with the use
of or reporting of this
measure for either CMS or
Measured Entities?

Indicate whether there are any licensing fees associated
with the use or reporting of this measure for either
CMS or the measured entities.

Measure
Information

013

*Proprietary and/or
Licensing Details

If you answered "Yes" to either of the following
questions: "Is any part of the measure or use of the
measure proprietary and/or licensed?" or "Are there
any licensing fees associated with the use of or
reporting of this measure for either CMS or Measured
Entities?" please provide detailed information about
the proprietary components and/or licensing fees
required.

ADD YOUR CONTENT HERE
☐ Yes
☐ No

This is not a data entry field.

☐ Yes
☐ No

Free text field

Change #10
Location: Pages 5-6, Rows 014 to 017 and Skip Logic
Reason for Change: Updated Row, Guidance, and Skip Logic. Addition of questions and logic about
composite, survey or paired measure to align with updated MERIT format for those measures.
CY 2024 Final Rule text:
Subsection
Measure
Information

Row
013

Field Label

*Is the measure a
composite and/or a paired
measure?

Guidance
Select all that apply.
A composite measure contains two or more individual
measures, resulting in a single measure and a single
score. This includes index measures. If this measure is a
composite measure, please enter data pertaining to the
overall composite measure into this form. Please attach
any additional information pertaining to individual
components.

ADD YOUR CONTENT HERE
☐ Yes, this is a composite
measure
☐ Yes, this is a paired measure
☐ No, this is neither a composite
nor a paired measure

Subsection

Row

Field Label

n/a

If you select “Yes, this is a
paired measure” in Row 013,
then Rows 014-015 become
required fields. If you do not
select “Yes, this is a paired
measure” in this field, then
skip to Row 016.

Measure
Information

014

*How many measures are

Measure
Information

015

intended to be paired with
this measure?

*What are the titles of all
measures that should be
paired with this measure?

Guidance
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

ADD YOUR CONTENT HERE

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

CY 2025 Final Rule text:
Subsection
Measure
Information

Row
014

Field Label

*Is the measure a
composite, survey, and/or a
paired measure?

Guidance
Select all that apply.
A composite measure contains two or more individual
measures, resulting in a single measure and a single
score. This includes index measures.
A survey measure refers to a type of performance
measure that is derived from data collected through
surveys.

ADD YOUR CONTENT HERE
☐ Yes, this is a composite
measure
☐ Yes, this is a survey measure
☐ Yes, this is a paired measure
☐ No, this is not a composite,
survey, or a paired measure

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

If you select “Yes, this is a
composite or survey
measure” in Row 014, then
Row 015 becomes a required
field. If you select “Yes, this
is a paired measure” in Row
014, then Rows 016-017
become required fields. If
you select “No, this is not a
composite, survey, or a
paired measure” in Row 014,
then skip to Row 018.

If you choose composite or survey, click save and a
"Component or Survey-Based Measure" tab will
appear at the top of the screen. Navigate to this
screen to answer the component and survey-based
questions.
n/a

This is not a data entry field.

Subsection
Measure
Information

Row
015

Measure
Information

016

Measure
Information

017

n/a

Field Label

*Enter titles of each
component or survey-based
measure

*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?
If you are submitting a
composite or survey
measure, Row 018 in MERIT
will enable you to input
information for each
component or survey-based
measure included in your
submission.

Guidance
Please list each title for each specific component or
survey-based measure.

ADD YOUR CONTENT HERE
Free text field

How many other measures are intended to be paired
with this measure? Do not include this measure in the
count.

Numeric field

Free text field

This is not a data entry field.

Change #11
Location: Page 6, Row 018
Reason for Change: Updated Row and Guidance
CY 2024 Final Rule text:
Subsection
Measure
Information

Row
002

Field Label

*Measure Description

Guidance
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
Free text field

Guidance
Provide a brief description of the measure. For
additional information on measure description, see the
Measure Specification tab on the CMS MMS Hub.

ADD YOUR CONTENT HERE
Free text field

CY 2025 Final Rule text:
Subsection
Measure
Information

Row
018

Field Label

*Measure Description

Change #12
Location: Page 7, Row 019 and Skip Logic
Reason for Change: Updated Row, Field Label, Guidance, and Skip Logic.
CY 2024 Final Rule text:
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

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

Subsection

Row

Field Label

Guidance
guidance as to whether your selection represents
multiple levels of analysis, please contact
MMSSupport@battelle.org. There is functionality
within CMS MERIT to decrease the data entry process
for multiple submissions of the same measure. Please
reach out to MMSSupport@battelle.org
for guidance and support.
If you are submitting for MIPS, there are two choices of
program. Do NOT enter both MIPS-Quality and MIPSCost for the same measure. Choose MIPS-Quality for
measures that pertain to quality and/or efficiency.
Choose MIPS-Cost only for measures that pertain to
cost.

n/a

If you select “Merit-based
Incentive Payment System Quality” in Row 003, then
Row 004 becomes an
optional field. If you do not
select “Merit-based
Incentive Payment System Quality” in Row 003, then
skip to Row 005.

n/a

ADD YOUR CONTENT HERE
☐ Hospital Inpatient Quality
Reporting Program
☐ Hospital Outpatient Quality
Reporting Program
☐ Hospital Readmissions
Reduction Program
☐ Hospital Value-Based
Purchasing Program
☐ Hospital-Acquired Condition
Reduction Program
☐ Inpatient Psychiatric Facility
Quality Reporting Program
☐ Inpatient Rehabilitation Facility
Quality Reporting Program
☐ Long-Term Care (LTC) Hospital
Quality Reporting Program
☐ Medicare Promoting
Interoperability Program
☐ Medicare Shared Savings
Program
☐ Merit-based Incentive Payment
System-Cost
☐ Merit-based Incentive Payment
System-Quality
☐ Part C Star Ratings
☐ Part D Star Ratings
☐ Prospective Payment SystemExempt Cancer Hospital Quality
Reporting Program
☐ Rural Emergency Hospital
Quality Reporting Program
☐ Skilled Nursing Facility Quality
Reporting Program
☐ Skilled Nursing Facility ValueBased Purchasing Program
This is not a data entry field.

CY 2025 Final Rule text:
Subsection
Measure
Information

Row
019

Field Label

*Select the Medicare
program(s) for which the
measure is being submitted.

Subsection

Row

Field Label

Guidance
within CMS MERIT to decrease the data entry process
for multiple submissions of the same measure. Please
reach out to MMSSupport@battelle.org
for guidance and support.
If you are submitting for MIPS, there are two choices of
program. Do NOT enter both MIPS-Quality and MIPSCost for the same measure. Choose MIPS-Quality for
measures that pertain to quality and/or efficiency.
Choose MIPS-Cost only for measures that pertain to
cost.
If you are submitting a measure to the Hospital
Inpatient Quality Reporting Program and your measure
is an electronic Clinical Quality Measure (eCQM), it is
also required to be submitted to the Medicare
Promoting Interoperability Program.

n/a

If you select “Merit-based
Incentive Payment System Quality” in Row 019, then
Row 020 becomes an
optional field. If you do not
select “Merit-based
Incentive Payment System Quality” in Row 019, then
skip to Row 021.

n/a

ADD YOUR CONTENT HERE
☐ Hospital Outpatient Quality
Reporting Program
☐ Hospital Readmissions
Reduction Program
☐
Hospital Value-Based Purchasing
Program
☐ Hospital-Acquired Condition
Reduction Program
☐ Inpatient Psychiatric Facility
Quality Reporting Program
☐ Inpatient Rehabilitation Facility
Quality Reporting Program
☐ Long-Term Care (LTC) Hospital
Quality Reporting Program
☐ Medicare Promoting
Interoperability Program
☐ Medicare Shared Savings
Program
☐ Merit-based Incentive Payment
System-Cost
☐ Merit-based Incentive Payment
System-Quality
☐ Part C Star Ratings
☐ Part D Star Ratings
☐ Prospective Payment SystemExempt Cancer Hospital Quality
Reporting Program
☐ Rural Emergency Hospital
Quality Reporting Program
☐ Skilled Nursing Facility Quality
Reporting Program
☐ Skilled Nursing Facility ValueBased Purchasing Program
This is not a data entry field.

Change #13
Location: Page 8, Row 020
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Measure
Information

Row
004

Field Label
MIPS Quality: Identify any
links with related Cost
measures and Improvement
Activities

Guidance
Where available, provide description of linkages and a
rationale that correlates this MIPS quality measure to
other performance category measures and activities.

ADD YOUR CONTENT HERE
Free text field

CY 2025 Final Rule text:
10

Subsection
Measure
Information

Row
020

Field Label
MIPS Quality: Identify any
links with related Cost
measures and Improvement
Activities

Guidance
Where available, provide description of linkages and a
rationale that correlates this MIPS quality measure to
other performance category measures and activities.

ADD YOUR CONTENT HERE
Free text field

Change #14
Location: Page 8, Row 021 and Skip Logic
Reason for Change: Updated Row, Guidance, and Skip Logic.
CY 2024 Final Rule text:
Subsection
Measure
Information

Row
005

Field Label
*Completed Stage(s) of
Development

Guidance
Select all stages of development that have been
completed. There are five stages in the Measure
Lifecycle: conceptualization; specification; testing;
implementation; and use, continuing evaluation, and
maintenance. Measure conceptualization is the first
stage; however, the stages are not necessarily
sequential. Instead, the stages are iterative and can
occur concurrently.

ADD YOUR CONTENT HERE
☐ Measure Conceptualization
☐ Measure Specification
☐ Measure Testing
☐ Measure Use, Continuing
Evaluation & Maintenance

The measure conceptualization stage initiates
information gathering and business case development.
The measure specification stage involves establishing
the basic elements of the measure, including the
numerator, calculation algorithm, and data source
identification.
The measure testing stage examines the specifications,
usually with a limited number of real settings, to make
sure the measure is scientifically acceptable and
feasible.
Measure specification and measure testing are
iterative.

n/a

If you select only “Measure
Conceptualization” and/or
“Measure Specification” in
Row 005, then Row 006
becomes a required field. If
your selections include
“Measure Testing” or
“Measure Use, Continuing
Evaluation & Maintenance”
in Row 005, then skip to Row
007.

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

This is not a data entry field.

CY 2025 Final Rule text:
Subsection
Measure
Information

Row
021

Field Label
*Completed Stage(s) of
Development

ADD YOUR CONTENT HERE
☐ Measure Conceptualization
☐ Measure Specification
☐ Measure Testing
☐ Measure Use, Continuing
Evaluation & Maintenance

Subsection

Row

Field Label

Guidance
sequential. Instead, the stages are iterative and can
occur concurrently.

ADD YOUR CONTENT HERE

n/a

If you select only “Measure
Conceptualization” and/or
“Measure Specification” in
Row 021, then Row 022
becomes a required field. If
your selections include
“Measure Testing” or
“Measure Use, Continuing
Evaluation & Maintenance”
in Row 021, then skip to Row
023.

For additional information regarding stage of
development, see the Blueprint Measure Lifecycle on
the CMS MMS Hub.
n/a

This is not a data entry field.

Change #15
Location: Page 9, Row 022
Reason for Change: Updated Row and Guidance.
CY 2024 Final Rule text:
Subsection
Measure
Information

Row
006

Field Label

*Stage of Development
Details

Guidance
If testing is not yet completed, describe when testing is
planned (i.e., specific dates), what type of testing is
planned (e.g., alpha, beta) as well as the types of
facilities in which the measure will be tested.

ADD YOUR CONTENT HERE
Free text field

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

CY 2025 Final Rule text:
Subsection
Measure
Information

Row
022

Field Label

*Stage of Development
Details

ADD YOUR CONTENT HERE
Free text field

For additional information, see the Blueprint Measure
Lifecycle on the CMS MMS Hub.

Change #16
Location: Page 9, Row 023
Reason for Change: Updated Row numbers and Guidance.
CY 2024 Final Rule text:
Subsection
Measure
Information

Row
007

Field Label

*Level of Analysis

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.” Please
submit results of individual clinician-level testing in this
form and group-level testing results in an attachment.

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

For submission to the MIPS-Cost program, clinician
group-level testing is sufficient.

CY 2025 Final Rule text:
Subsection
Measure
Information

Row
023

Field Label

*Level of Analysis

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 clinician-individual and
clinician-group levels of analysis, you may select
“Clinician: Individual and Group.” Please submit results
of individual clinician-level testing in this form and
group-level testing results in an attachment.

For submission to the MIPS-Cost program, clinician
group-level testing is sufficient.

Change #17
Location: Page 10, Row 024
Reason for Change: Updated Row and text under “Add Your Content Here”.
CY 2024 Final Rule text:
Subsection
Measure
Information

Row
008

Field Label

*In which setting(s) was this

Guidance

ADD YOUR CONTENT HERE
☐ Ambulatory surgery center
☐ Ambulatory/office-based care
☐ Behavioral health clinic
☐ Community hospital
☐ Dialysis facility
☐ Emergency department
☐ Federally qualified health center
(FQHC)
☐ Health and Drug Plans
☐ Hospital outpatient department
(HOD)
☐ Home health
☐ Hospice
☐ Hospital inpatient acute care
facility
☐ Inpatient psychiatric facility
☐ Inpatient rehabilitation facility
☐ Long-term care hospital
☐ Nursing home
☐ PPS-exempt cancer hospital
☐ Skilled nursing facility
☐ Veterans Health Administration
facility
☐ Not yet tested
☐ Other (enter here):

Guidance

ADD YOUR CONTENT HERE
☐ Ambulatory surgery center
☐ Ambulatory/office-based care
☐ Behavioral health clinic
☐ Birthing Centers
☐ Community hospital
☐ Dialysis facility
☐ Emergency department
☐ Emergency Medical
Services/Ambulance
☐ Federally qualified health center
(FQHC)
☐ Health and Drug Plans
☐ Hospital: critical access
☐ Hospital outpatient department
(HOD)
☐ Home health
☐ Hospice
☐ Hospital inpatient acute care
facility
☐ Inpatient psychiatric facility

Select all that apply.

measure tested?

CY 2025 Final Rule text:
Subsection
Measure
Information

Row
024

Field Label

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

Select all that apply.

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE
☐ 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):

Change #18
Location: Page 10, Row 025 and Skip Logic
Reason for Change: Updated Row and Skip Logic.
CY 2024 Final Rule text:
Subsection
Measure
Information

Row
009

n/a

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 separately reported for this measure
(e.g., 7- and 30-day rate, rates for different procedure
types, etc.)? This does not include index measures,
where component measure scores result in one overall
index score. Note: If “Yes”, please describe one score
only in this form. Submit separate attachments for each
of the other scores.
n/a

ADD YOUR CONTENT HERE
☐ Yes
☐ No

This is not a data entry field.

CY 2025 Final Rule text:
Subsection
Measure
Information

Row
025

n/a

Field Label

*Multiple Scores

If you select “Yes” in Row
025, then Rows 026-028
become required fields. If
you select, “No”, then skip to
Row 029.

This is not a data entry field.

Change #19
Location: Page 11, Row 026
Reason for Change: Updated Row and Guidance.
CY 2024 Final Rule text:
Subsection
Measure
Information

Row
010

Field Label

*Measures with Multiple
Scores: Number of Scores

Guidance
How many measure scores are recommended for this
measure?

ADD YOUR CONTENT HERE
Numeric field

Guidance
How many measure scores are included in this
measure?

ADD YOUR CONTENT HERE
Numeric field

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

ADD YOUR CONTENT HERE
Free text field

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

ADD YOUR CONTENT HERE
Free text field

CY 2025 Final Rule text:
Subsection
Measure
Information

Row
026

Field Label

*Measures with Multiple
Scores: Number of Scores

Change #20
Location: Page 11, Row 27
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Measure
Information

Row
011

Field Label

*Measures with Multiple
Scores: Names of Score
Reported in MERIT Form

CY 2025 Final Rule text:
Subsection
Measure
Information

Row
027

Field Label

*Measures with Multiple
Scores: Names of Score
Reported in MERIT Form

Change #21
Location: Page 11, Row 28
Reason for Change: Updated Row, addition of Composite/Survey Logic.
CY 2024 Final Rule text:
Subsection
Measure
Information

Row
012

Field Label

*Measures with Multiple
Scores: Names of Scores

Guidance
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.

ADD YOUR CONTENT HERE
Free text field

CY 2025 Final Rule text:
Subsection
Measure
Information

Row
028

Field Label

*Measures with Multiple
Scores: Names of Scores

Subsection
n/a

Row
n/a

Field Label
If you are submitting a
composite or survey
measure, Rows 029-034 in
MERIT will enable you to
input information for each
component or survey-based
measure included in your
submission.

Guidance

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

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.

ADD YOUR CONTENT HERE
Free text field

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.

ADD YOUR CONTENT HERE
Free text field

n/a

Change #22
Location: Page 11, Row 029
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Measure
Information

Row
016

Field Label

*Numerator

CY 2025 Final Rule text:
Subsection
Measure
Information

Row
029

Field Label

*Numerator

Change #23
Location: Page 11, Row 030
Reason for Change: Updated Row and Guidance.
CY 2024 Final Rule text:
Subsection
Measure
Information

Row
017

Field Label

*Numerator Exclusions

Guidance
For additional information on exclusions/exceptions,
see: https://mmshub.cms.gov/measurelifecycle/measure-testing/evaluation-criteria/scientificacceptability/exclusions. If not applicable, enter 'N/A.'

ADD YOUR CONTENT HERE
Free text field

Guidance
For additional information on exclusions/exceptions,
see the Measure Testing page on the CMS MMS Hub. If
not applicable, enter 'N/A.'

ADD YOUR CONTENT HERE
Free text field

CY 2025 Final Rule text:
Subsection
Measure
Information

Row
030

Field Label

*Numerator Exclusions

Change #24
Location: Page 11, Row 031
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Measure
Information

Row
018

Field Label

*Denominator

Guidance
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.

ADD YOUR CONTENT HERE
Free text field

CY 2025 Final Rule text:
Subsection
Measure
Information

Row
031

Field Label

*Denominator

Change #25
Location: Page 11, Row 032
Reason for Change: Updated Row and Guidance.
CY 2024 Final Rule text:
Subsection
Measure
Information

Row
019

Field Label

*Denominator Exclusions

ADD YOUR CONTENT HERE
Free text field

Guidance
For additional information on exclusions/exceptions,
see the Measure Testing page on the CMS MMS Hub. If
not applicable, enter 'N/A.'

ADD YOUR CONTENT HERE
Free text field

CY 2025 Final Rule text:
Subsection
Measure
Information

Row
032

Field Label

*Denominator Exclusions

Change #26
Location: Page 11, Row 033
Reason for Change: Updated Row and Guidance.
CY 2024 Final Rule text:
Subsection
Measure
Information

Row
020

Field Label

*Denominator Exceptions

ADD YOUR CONTENT HERE
Free text field

CY 2025 Final Rule text:
Subsection
Measure
Information

Row
033

Field Label

*Denominator Exceptions

Guidance
For additional information on exclusions/exceptions,
see the Measure Testing page on the CMS MMS Hub. If
not applicable, enter 'N/A.'

ADD YOUR CONTENT HERE
Free text field

Guidance
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
Free text field

Change #27
Location: Page 11, Row 034
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Measure
Information

Row
021

Field Label

*Briefly describe the
rationale for the measure

CY 2025 Final Rule text:
Subsection
Measure
Information

Row
034

Field Label

*Briefly describe the
rationale for the measure

Change #28
Location: Page 12, Row 035 and Skip Logic
Reason for Change: Updated Row and Skip Logic.
CY 2024 Final Rule text:
Subsection
Measure
Implementa
tion

Row
022

Field Label

*Feasibility of Data
Elements

Guidance
Select one. Select the extent to which the specified data
elements are available in electronic fields. Electronic
fields should include a designated location and format
for the data in claims, EHRs, registries, etc.
• Select “ALL data elements are in defined fields in
electronic sources” if the data elements needed to
calculate the measure are all available in discrete and
electronically defined fields.
• Select “Some data elements are in defined fields in
electronic sources” if the data elements needed to
calculate the measure are not all available in discrete
and electronically defined fields.
• Select “No data elements are in defined fields in
electronic sources” if none of the data elements
needed to calculate the measure are available in
discrete and electronically defined fields.
• Select “Not applicable" ONLY for CAHPS measures.
• Select “Unable to Determine” ONLY if a feasibility
assessment has not yet been completed.

ADD YOUR CONTENT HERE
☐ ALL data elements are in
defined fields in electronic
sources
☐ Some data elements are in
defined fields in electronic
sources
☐ No data elements are in
defined fields in electronic
sources
☐ Not applicable (applies only for
CAHPS measures)
☐ Unable to determine (applies
only if a feasibility assessment
has not yet been completed)

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

Subsection
n/a

Row
n/a

Field Label
If you select “ALL data
elements are in defined
fields in electronic sources”
or “Some data elements are
in defined fields in electronic
sources in Row 022, then
Row 023 becomes a required
field, otherwise, skip to row
024.

Guidance
n/a

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

CY 2025 Final Rule text:
Subsection
Measure
Implementa
tion

Row
035

Field Label

*Feasibility of Data
Elements

n/a

If you select “ALL data
elements are in defined
fields in electronic sources”
or “Some data elements are
in defined fields in electronic
sources” in Row 035, then
Row 036 becomes a required
field, otherwise, skip to row
037.

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

This is not a data entry field.

Change #29
Location: Page 13, Row 036
Reason for Change: Updated Row and Guidance.
CY 2024 Final Rule text:
Subsection
Measure
Implementa
tion

Row
023

Field Label

*USCDI Data Elements

Guidance
Select one. Indicate the extent to which the data
elements that are in defined fields in electronic sources
align with United States Core Data for Interoperability
(USCDI) v4 or USCDI+ Quality draft standard definitions.

ADD YOUR CONTENT HERE
☐ ALL data elements align with
USCDI/USCDI+ Quality standard
definitions

Subsection

Row

Field Label

Guidance
For more information about USCDI, please refer to the
HealthIT.gov website available at:
https://www.healthit.gov/isa/united-states-core-datainteroperability-uscdi
For more information about USCDI+ Quality, please
refer to the HealthIT.gov website available at:
https://www.healthit.gov/topic/interoperability/uscdiplus

ADD YOUR CONTENT HERE
☐ Some data elements align with
USCDI/USCDI+ Quality standard
definitions
☐ None of the data elements align
with USCDI/USCDI+ Quality
standard definitions
☐ USCDI/USCDI+ Quality
alignment not assessed

CY 2025 Final Rule text:
Subsection
Measure
Implementa
tion

Row
036

Field Label

*USCDI Data Elements

Guidance
Select one. Indicate the extent to which the data
elements that are in defined fields in electronic sources
align with the current version of the United States Core
Data for Interoperability (USCDI) or USCDI+ Quality
draft standard definitions.
For more information about USCDI, please refer to the
HealthIT.gov website.
For more information about USCDI+ Quality, please
refer to the HealthIT.gov website.

ADD YOUR CONTENT HERE
☐ ALL data elements align with
USCDI/USCDI+ Quality standard
definitions
☐ Some data elements align with
USCDI/USCDI+ Quality standard
definitions
☐ None of the data elements align
with USCDI/USCDI+ Quality
standard definitions
☐ USCDI/USCDI+ Quality
alignment not assessed

Change #30
Location: Page 14, Row 37 and Skip Logic
Reason for Change: Updated Row and Skip Logic.
CY 2024 Final Rule text:
Subsection
Measure
Implementa
tion

Row
024

Field Label

*Method of Measure
Calculation

Guidance
Select one. Select the method used to calculate
measure scores for the version of the measure
proposed in this submission form. Please review
guidance before making selections:
• Select “Electronically Derived Administrative Data
(Claims and/or Non-Claims)” if the measure can be
calculated exclusively from administrative data
submitted electronically for billing or other purposes.
• Select “eCQM” if the measure is exclusively specified
and formatted to use data from electronic health
record (EHRs) and/or health information technology
systems, using the Quality Data Model (QDM) to
define the data elements and Clinical Quality
Language (CQL) to express measure logic.
• Select “Other digital method” if the measure does
not meet the definition of an eCQM as described
above, but can be calculated electronically (e.g.,
registry, MDS, OASIS).
• Select “Manual abstraction” if all data elements in
the measure requires manual review of records,
paper-based billing, or manual calculation (e.g.,
CAHPS).
• Select “Combination” if two or more types of data
sources are required to calculate the measure score.
For all other measures that rely on patient surveys
(e.g., PRO-PMs), select the option that best describes

ADD YOUR CONTENT HERE
☐ Electronically Derived
Administrative Data (Claims and/or
Non-Claims)
☐ eCQM
☐ Other digital method
☐ Manual abstraction
☐ Combination

Subsection

Measure
Implementa
tion

Row

n/a

Field Label

If you select "Combination"
in Row 024, then Row 025
becomes a required field;
otherwise, skip to Row 026.

Guidance
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

This is not a data entry field.

CY 2025 Final Rule text:
Subsection
Measure
Implementa
tion

Row
037

Measure
Implementa
tion

n/a

Field Label

*Method of Measure
Calculation

If you select "Combination"
in Row 037, then Row 038
becomes a required field;
otherwise, skip to Row 039.

ADD YOUR CONTENT HERE
☐ Electronically Derived
Administrative Data (Claims and/or
Non-Claims)
☐ eCQM
☐ Other digital method
☐ Manual abstraction
☐ Combination

This is not a data entry field.

Change #31
Location: Page 14, Row 038
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Measure
Implementa
tion

Row
025

Field Label

*Combination measure:
Methods of calculation

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

ADD YOUR CONTENT HERE
☐ Electronically Derived
Administrative Data (Claims
and/or Non-Claims)
☐ eCQM
☐ Other digital method
☐ Manual abstraction

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

ADD YOUR CONTENT HERE
☐ Electronically Derived
Administrative Data (Claims
and/or Non-Claims)
☐ eCQM
☐ Other digital method
☐ Manual abstraction

CY 2025 Final Rule text:
Subsection
Measure
Implementa
tion

Row
038

Field Label

*Combination measure:
Methods of calculation

Change #32
Location: Page 15, Row 039
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Measure
Implementa
tion

Row
026

Field Label

*How is the measure
expected to be reported to
the program?

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)
Claims
Web interface
Other (enter here):

☐
☐
☐
☐
☐

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

CY 2025 Final Rule text:
Subsection
Measure
Implementa
tion

Row
039

Field Label

*How is the measure
expected to be reported to
the program?

Change #33
Location: Page 16, Row 040
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Burden

Row
027

Field Label

Guidance

*Did the provider workflow

Select one.

have to be modified to
collect additional data
needed to report the
measure?

Select “Yes” if workflow modifications impose
moderate to significant additional data entry burden on
a clinician or other provider to collect the data
elements to report the measure because data are not
routinely collected during clinical care, OR EHR
interface changes were necessary.

ADD YOUR CONTENT HERE
☐ Yes
☐ No
☐ Not applicable
☐ Unable to determine

Select “No” if workflow modifications impose no or
limited additional data entry burden on a clinician or
other provider to collect the data elements to report
the measure because data are routinely collected
during the clinical care, AND no EHR interface changes
were necessary.
Select "Not applicable" if the measure imposes no data
entry burden on the clinician or provider because:
A) the measure is calculated by someone other than
the clinician or provider AND uses data that are
routinely generated (i.e., administrative data and
claims), OR
B) the data are collected by someone other than the
clinician or provider (e.g., CAHPS), OR
C) the measure repurposes existing data sets to
calculate a measure score (e.g., HEDIS).
Select "Unable to determine” if a workflow analysis was
not completed and/or it cannot be determined whether
the workflow modifications impose additional data
entry burden to collect data needed to report the
measure.

CY 2025 Final Rule text:
Subsection
Burden

Row
040

Field Label

Guidance

*Did the provider workflow

Select one.

have to be modified to
collect additional data
needed to report the
measure?

ADD YOUR CONTENT HERE
☐ Yes
☐ No
☐ Not applicable
☐ Unable to determine

Subsection

Row

Field Label

Guidance
A) the measure is calculated by someone other than
the clinician or provider AND uses data that are
routinely generated (i.e., administrative data and
claims), OR

ADD YOUR CONTENT HERE

B) the data are collected by someone other than the
clinician or provider (e.g., CAHPS), OR
C) the measure repurposes existing data sets to
calculate a measure score (e.g., HEDIS).
Select "Unable to determine” if a workflow analysis was
not completed and/or it cannot be determined whether
the workflow modifications impose additional data
entry burden to collect data needed to report the
measure.

Change #34
Location: Page 17, Row 041 and Skip Logic
Reason for Change: Updated Row, Guidance, and Skip Logic.
CY 2024 Final Rule text:
Subsection
Groups

Row
028

Field Label

*Is this measure an
electronic clinical quality
measure (eCQM)?

Groups

n/a

If you select “Yes” in Row
028, then Rows 029-031
become required fields. If
you select “No” in Row 028,
then skip to Row 032.

Guidance
Select 'Yes' or 'No'. If your answer is yes, the Measure
Authoring Tool (MAT) ID number must be provided
below. For more information on eCQMs, see:
https://www.emeasuretool.cms.gov/

ADD YOUR CONTENT HERE
☐ Yes
☐ No

n/a

This is not a data entry field.

Guidance
Select 'Yes' or 'No'. If your answer is yes, CMS ID must
be provided below. For more information on eCQMs,
visit the Measure Authoring Development Integrated
Environment (MADiE) website.

ADD YOUR CONTENT HERE
☐ Yes
☐ No

CY 2025 Final Rule text:
Subsection
Groups

Row
041

Field Label

*Is this measure an
electronic clinical quality
measure (eCQM)?

If you select "yes" to this question and are submitting to
the Hospital Inpatient Quality Reporting Program, you
are also required to submit this measure to the
Medicare Promoting Interoperability Program.
Groups

n/a

If you select “Yes” in Row
041, then Rows 042-044
become required fields. If
you select “No” in Row 041,
then skip to Row 045.

n/a

This is not a data entry field.

Change #35
Location: Page 17, Row 042
Reason for Change: Updated Row, Field Label, and Guidance.
CY 2024 Final Rule text:
Subsection
Groups

Row
029

Field Label

*Measure Authoring Tool
(MAT) Number

Guidance
You must attach Bonnie test cases for this measure,
with 100% logic coverage (test cases should be
appended), attestation that value sets are published in
Value Set Authority Center (VSAC), and feasibility
scorecard. If not an eCQM, or if MAT number is not
available, enter 0.

ADD YOUR CONTENT HERE
ADD YOUR CONTENT HERE

Guidance
CMS encourages all submitters to submit both Quality
Data Model (QDM) and Fast Health Interoperability
Resources (FHIR) specifications, where available.

ADD YOUR CONTENT HERE
ADD YOUR CONTENT HERE

CY 2025 Final Rule text:
Subsection
Groups

Row
042

Field Label

*CMS ID found in MADiE

For QDM specifications, you must attach the eCQM
specification exported from MADiE, test cases exported
from MADiE, with 100% coverage/100% passing both
QRDA and Excel format), attestation that value sets are
published in Value Set Authority Center (VSAC), and
feasibility scorecard.
For FHIR specifications, you must attach the MADiE
output of the FHIR specifications using QI-Core 4.1.1 or
QI-Core STU 6, MADiE output of the QI-Core 4.1.1 or QiCore STU 6 compliant test cases (QI-Core version should
align between specification and test cases), and
attestation to value sets published in VSAC. Additional
Feasibility scorecard is not required at this time.
If not an eCQM, or if MAT number is not available,
enter 0.

Change #36
Location: Page 18, Row 043
Reason for Change: Updated Row, Field Label, and Guidance.
CY 2024 Final Rule text:
Subsection
Groups

Row
030

Field Label

*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)?

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

ADD YOUR CONTENT HERE
☐ Yes
☐ No

CY 2025 Final Rule text:
Subsection
Groups

Row
043

Field Label

Guidance
Select 'Yes' or 'No'. For additional information on HQMF
standards, visit the eCQI Resource Centers HQMF page.

ADD YOUR CONTENT HERE
☐ Yes
☐ No

Change #37
Location: Page 18, Row 044 and Composite/Survey Logic
Reason for Change: Updated Row and added Composite/Survey Logic.
CY 2024 Final Rule text:
Subsection
Groups

Row
031

Field Label

*Number of unique EHR
vendors represented in
testing dataset

Guidance
Enter the number of unique EHR vendors represented
in the dataset to demonstrate that measure data
elements are valid and that the measure score can be
accurately calculated across different systems (e.g.,
Epic, Cerner, etc.).

ADD YOUR CONTENT HERE
Numeric field

n/a

This is not a data entry field.

CY 2025 Final Rule text:
Subsection
Groups

Row
044

Field Label

*Number of unique EHR
vendors represented in
testing dataset

n/a

If you are submitting a
composite or survey
measure, Rows 045-063 in
MERIT will enable you to
input information for each
component or survey-based
measure included in your
submission.

Change #38
Location: Page 19, Row 045 and Skip Logic
Reason for Change: Updated Row, Guidance, and Skip Logic.
CY 2024 Final Rule text:
Subsection
Measure
Score Level
(Accountabl
e Entity
Level)
Testing

Row
032

Field Label

*Reliability

Guidance
Indicate whether reliability testing was conducted for
the accountable entity-level measure scores.
Acceptable reliability tests include signal-to-noise (or
inter-unit reliability) or random split-half correlation.
For more information on accountable entity-level
reliability testing, refer to the Blueprint content on the
CMS Measures Management System (MMS) Hub
(https://mmshub.cms.gov/measure-lifecycle/measuretesting/evaluation-criteria/scientificacceptability/reliability).

ADD YOUR CONTENT HERE
☐ Yes
☐ No

Select “Yes” if acceptable accountable entity-level
reliability testing has been completed as of submission
of this form.
Select “No” if you are not able to provide the results of
acceptable accountable entity-level reliability testing in
this submission. If testing results are incomplete, or if
you are submitting a different type of reliability testing,
provide as an attachment.
Note: This section refers to the reliability of the
accountable entity-level measure scores in the final
performance measure. For testing of surveys or patient
reported tools, refer to the Patient-Reported Data
section. Note: for MIPS-Quality submissions, please
provide individual clinician-level results. If the measure
was also tested at the clinician group level, you may
include those results in an attachment.
n/a

n/a

If you select “Yes” in Row
032, then Row 33 becomes a
required field. If you select
“No” in Row 032, then skip
to Row 042.

n/a

This is not a data entry field.

CY 2025 Final Rule text:
Subsection
Measure
Score Level
(Accountabl
e Entity
Level)
Testing

Row
045

Field Label

*Reliability

ADD YOUR CONTENT HERE
☐ Yes
☐ No

n/a

If you select “Yes” in Row
045, then Rows 046-054
becomes required fields. If
you select “No” in Row 045,
then skip to Row 055.

n/a

This is not a data entry field.

Change #39
Location: Page 20, Row 046 and Skip Logic
Reason for Change: Updated Row, Guidance, text under “Add Your Content Here”, and Skip Logic.
CY 2024 Final Rule text:
Subsection
Measure
Score Level
(Accountabl
e Entity
Level)
Testing

Row
033

Field Label

*Reliability: Type of analysis

Guidance
Select all that apply.
Signal-to-noise (or inter-unit reliability) is the precision
attributed to an actual construct versus random
variation (e.g., ratio of between unit variance to total
variance) (Adams J. The reliability of provider profiling:
a tutorial. Santa Monica, CA: RAND; 2009.
http://www.rand.org/pubs/technical_reports/TR653.ht
ml).

ADD YOUR CONTENT HERE
☐ Signal-to-Noise
☐ Random Split-Half Correlation

Random split-half correlation is the agreement between
two measures of the same concept, using data derived
from split samples drawn from the same entity at a
single point in time.

Subsection
n/a

Row
n/a

Field Label
If you select “Signal-toNoise” in Row 033, then
Rows 034-037 become
required fields. If you select,
“Random Split-Half
Correlation” in Row 033,
then Rows 038-041 become
required fields.

Guidance

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

Guidance

ADD YOUR CONTENT HERE
☐ Signal-to-Noise (e.g., BetaBinomial, Mixed Logistic
Regression)
☐ Random Split-Half Correlation

n/a

CY 2025 Final Rule text:
Subsection
Measure
Score Level
(Accountabl
e Entity
Level)
Testing

Row
046

Field Label

*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.).
Random split-half correlation is the agreement between
two measures of the same concept, using data derived
from split samples drawn from the same entity at a
single point in time.

n/a

If you select “Signal-toNoise” in Row 046, then
Rows 047-050 become
required fields. If you select,
“Random Split-Half
Correlation” in Row 046,
then Rows 051-054 become
required fields.

n/a

This is not a data entry field.

Change #40
Location: Page 20, Row 047
Reason for Change: Updated Row and Guidance.
CY 2024 Final Rule text:
Subsection
Measure
Score Level
(Accountable
Entity Level)
Testing

Row
034

Field Label

*Signal-to-Noise: Level of
Analysis

Guidance

ADD YOUR CONTENT HERE

Select the level of analysis at which the signal-tonoise analysis was conducted. If the measure is
specified and intended for use at more than one level,
ensure the results in this section are at the same level
of analysis selected in the Measure Information
section of this form.

☐ Accountable Care Organization
☐ Clinician – Group
☐ Clinician – Individual
☐ Facility
☐ Health plan
☐ Integrated Delivery System
☐ Medicaid program (e.g., Health
Home or 1115)
☐ Population: Community,
County or City
☐ Population: Regional and State

For MIPS-Quality submissions, you must report the
results of individual clinician-level testing. If grouplevel testing is available, you may submit those results
as an attachment.

CY 2025 Final Rule text:
Subsection
Measure
Score Level
(Accountable
Entity Level)
Testing

Row
047

Field Label

Guidance

ADD YOUR CONTENT HERE

* Signal-to-Noise: Level of

Analysis

For MIPS-Quality submissions, you must report the
results of individual clinician-level testing. If grouplevel testing is available, you may submit those results
as an attachment.
For submission to the MIPS-Cost program, clinician
group-level testing is sufficient.

Change #41
Location: Page 20, Row 048
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Measure
Score Level
(Accountable
Entity Level)
Testing

Row
035

Field Label

*Signal-to-Noise: Sample
size

Guidance
Indicate the number of accountable entities sampled
to test the final performance measure. Note that this
field is intended to capture the number of measured
entities and not the number of individual patients or
cases included in the sample.

ADD YOUR CONTENT HERE
Numeric field

CY 2025 Final Rule text:
Subsection
Measure
Score Level
(Accountable
Entity Level)
Testing

Row
048

Field Label

* Signal-to-Noise: Sample
size

ADD YOUR CONTENT HERE
Numeric field

Change #42
Location: Page 21, Row 049
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Measure
Score Level
(Accountable
Entity Level)
Testing

Row
036

Field Label

*Signal-to-Noise: Median
Statistical result

Guidance
Indicate the median result for the signal-to-noise
analysis used to assess accountable entity level
reliability. Results should range from 0.00 to 1.00.
Calculate reliability as the measure is intended to be
implemented (e.g., after applying minimum
denominator requirements, appropriate type of
setting, provider, etc.).

ADD YOUR CONTENT HERE
Numeric field

CY 2025 Final Rule text:
Subsection
Measure
Score Level
(Accountable
Entity Level)
Testing

Row
049

Field Label

* Signal-to-Noise: Median
Statistical result

ADD YOUR CONTENT HERE
Numeric field

Change #43
Location: Page 21, Row 050
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Measure
Score Level
(Accountable
Entity Level)
Testing

Row
037

Field Label

*Signal-to-Noise:
Interpretation of results

Guidance
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
Free text field

CY 2025 Final Rule text:
Subsection
Measure
Score Level
(Accountable
Entity Level)
Testing

Row
050

Field Label

* Signal-to-Noise:
Interpretation of results

ADD YOUR CONTENT HERE
Free text field

Change #44
Location: Page 21, Row 051
Reason for Change: Updated Row and Guidance.
CY 2024 Final Rule text:
Subsection
Measure
Score Level
(Accountable
Entity Level)
Testing

Row
038

Field Label

*Random Split-Half
Correlation: Level of
Analysis

Guidance

ADD YOUR CONTENT HERE

Select the level of analysis at which the random splithalf analysis was conducted. If the measure is
specified and intended for use at more than one
level, ensure the results in this section are at the
same level of analysis selected in the Measure
Information section of this form.

☐ Accountable Care Organization
☐ Clinician – Group
☐ Clinician – Individual
☐ Facility
☐ Health plan
☐ Integrated Delivery System
☐ Medicaid program (e.g., Health
Home or 1115)

For MIPS-Quality submissions, you must report the
results of individual clinician-level testing. If group-

Subsection

Row

Field Label

Guidance
level testing is available, you may submit those
results as an attachment.

ADD YOUR CONTENT HERE
☐ Population: Community,
County or City
☐ Population: Regional and State

CY 2025 Final Rule text:
Subsection
Measure
Score Level
(Accountable
Entity Level)
Testing

Row
051

Field Label

*Random Split-Half
Correlation: Level of
Analysis

Guidance

ADD YOUR CONTENT HERE

For MIPS-Quality submissions, you must report the
results of individual clinician-level testing. If grouplevel testing is available, you may submit those
results as an attachment.
For submission to the MIPS-Cost program, clinician
group-level testing is sufficient.

Change #45
Location: Page 21, Row 052
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Measure Score
Level
(Accountability
Entity Level)
Testing

Row
039

Field Label

*Random Split-Half
Correlation: Sample size

Guidance
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.

ADD YOUR CONTENT HERE
Numeric field

CY 2025 Final Rule text:
Subsection
Measure Score
Level
(Accountability
Entity Level)
Testing

Row
052

Field Label

*Random Split-Half
Correlation: Sample size

ADD YOUR CONTENT HERE
Numeric field

Change #46
Location: Page 22, Row 053
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Measure Score
Level
(Accountability
Entity Level)
Testing

Row
040

Field Label

*Random Split-Half
Correlation: Statistical
result

Guidance
Indicate the statistical result for the random splithalf 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.).

ADD YOUR CONTENT HERE
Numeric field

CY 2025 Final Rule text:
Subsection
Measure Score
Level
(Accountability
Entity Level)
Testing

Row
053

Field Label

*Random Split-Half
Correlation: Statistical
result

ADD YOUR CONTENT HERE
Numeric field

Change #47
Location: Page 22, Row 054
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Measure Score
Level
(Accountability
Entity Level)
Testing

Row
041

Field Label

*Random Split-Half
Correlation: Interpretation
of results

Guidance
Describe the type of statistic and interpretation of
the results (e.g., low, moderate, high). List accepted
thresholds referenced and provide a citation. If
applicable, include the precision of the statistical
result (e.g., 95% confidence interval) and/or an
assessment of statistical significance (e.g., p-value).

ADD YOUR CONTENT HERE
Free text field

CY 2025 Final Rule text:
Subsection
Measure Score
Level
(Accountability
Entity Level)
Testing

Row
054

Field Label

*Random Split-Half
Correlation: Interpretation
of results

ADD YOUR CONTENT HERE
Free text field

Change #48
Location: Page 22, Row 055 and Skip Logic
Reason for Change: Updated Row, Guidance, and Skip Logic.
CY 2024 Final Rule text:
Subsection
Measure Score
Level
(Accountability
Entity Level)
Testing

Row
042

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 Blueprint
content on the CMS MMS Hub
(https://mmshub.cms.gov/measurelifecycle/measure-testing/evaluationcriteria/scientific-acceptability/validity)

ADD YOUR CONTENT HERE
☐ Yes
☐ No

Note: This section refers to the empiric validity of the
accountable entity level measure scores in the final
performance measure. Refer to the Patient-Reported
Data section for testing of surveys or patient reported
tools.
Note: for MIPS-Quality submissions, please provide
individual clinician-level results. If the measure was
also tested at the clinician group level, you may
include those results in an attachment.
n/a

n/a

If you select “Yes” in Row
042, then Rows 043-046
become required fields. If
you select “No” in Row
042, then skip to Row 047.

n/a

This is not a data entry field.

CY 2025 Final Rule text:
Subsection
Measure Score
Level
(Accountability
Entity Level)
Testing

Row
055

Field Label

*Empiric Validity

ADD YOUR CONTENT HERE
☐ Yes
☐ No

Note: This section refers to the empiric validity of the
accountable entity level measure scores in the final
performance measure. Refer to the Patient-Reported
Data section for testing of surveys or patient
reported tools.
Note: for MIPS-Quality submissions, please provide
individual clinician-level results. If the measure was
also tested at the clinician group level, you may
include those results in an attachment.
n/a

n/a

If you select “Yes” in Row
055, then Rows 056-059
become required fields. If
you select “No” in Row 055,
then skip to Row 060.

n/a

This is not a data entry field.

Change #49
Location: Page 23, Row 056
Reason for Change: Updated Row and Guidance.
CY 2024 Final Rule text:
Subsection
Measure
Score Level
(Accountable
Entity Level)
Testing

Row
043

Field Label

*Empiric Validity: Level of
Analysis

Guidance

ADD YOUR CONTENT HERE

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 grouplevel testing is available, you may submit those results
as an attachment.

CY 2025 Final Rule text:
Subsection
Measure
Score Level
(Accountable
Entity Level)
Testing

Row
056

Field Label

*Empiric Validity: Level of
Analysis

Guidance

ADD YOUR CONTENT HERE

Change #50
Location: Page 23, Row 057
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Measure Score
Level
(Accountability
Entity Level)
Testing

Row
044

Field Label

*Empiric Validity: Sample
size

ADD YOUR CONTENT HERE
Numeric field

CY 2025 Final Rule text:
Subsection
Measure Score
Level
(Accountability

Row
057

Field Label

*Empiric Validity: Sample
size

Guidance
Indicate the number of accountable entities sampled
to test the final performance measure. Note that this
field is intended to capture the number of measured

ADD YOUR CONTENT HERE
Numeric field

Subsection

Row

Field Label

Entity Level)
Testing

Guidance

ADD YOUR CONTENT HERE

entities and not the number of individual patients or
cases included in the sample.

Change #51
Location: Page 23, Row 058
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Measure Score
Level
(Accountability
Entity Level)
Testing

Row
045

Field Label

Guidance

*Empiric Validity: Methods

Describe the methods used to assess accountable
entity level validity. Describe the comparison groups
or constructs used to verify the validity of the
measure scores, including hypothesized relationships
(e.g., expected to be positively or negatively
correlated). Describe your findings for each analysis
conducted, including the statistical results and the
strongest and weakest results across analyses. If
applicable, include the precision of the statistical
result(s) (e.g., 95% confidence interval) and/or an
assessment of statistical significance (e.g., p-value). If
methods and results require more space, include as
an attachment.

and findings

ADD YOUR CONTENT HERE
Free text field

CY 2025 Final Rule text:
Subsection
Measure Score
Level
(Accountability
Entity Level)
Testing

Row
058

Field Label

Guidance

*Empiric Validity: Methods

and findings

ADD YOUR CONTENT HERE
Free text field

Change #52
Location: Page 23, Row 059
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Measure
Score Level
(Accountable
Entity Level)
Testing

Row
046

Field Label

*Empiric Validity:
Interpretation of results

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

ADD YOUR CONTENT HERE
☐ Yes
☐ No

CY 2025 Final Rule text:
Subsection
Measure
Score Level
(Accountable
Entity Level)
Testing

Row
059

Field Label

*Empiric Validity:
Interpretation of results

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

ADD YOUR CONTENT HERE
☐ Yes
☐ No

Change #53
Location: Page 24, Row 060 and Skip Logic
Reason for Change: Updated Row and Skip Logic.
CY 2024 Final Rule text:
Subsection
Measure
Score Level
(Accountable
Entity Level)
Testing

Row
047

Field Label

*Face validity

Guidance
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.

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 and is not intended to assess whether
patient-reported surveys or tools have face validity.
Survey item testing results can be provided in an
attachment and described in the Patient-Reported
Data Section.

n/a

If you select “Yes” in Row
047, then Rows 048-050
become required fields. If
you select “No” in Row 047,
then skip to Row 051.

n/a

This is not a data entry field.

CY 2025 Final Rule text:
Subsection
Measure
Score Level
(Accountable
Entity Level)
Testing

Row
060

Field Label

*Face validity

Guidance
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.

ADD YOUR CONTENT HERE
☐ Yes
☐ No

patient-reported surveys or tools have face validity.
Survey item testing results can be provided in an
attachment and described in the Patient-Reported
Data Section.
n/a

n/a

If you select “Yes” in Row
060, then Rows 061-063
become required fields. If
you select “No” in Row 060,
then skip to Row 064.

n/a

This is not a data entry field.

Change #54
Location: Page 24, Row 061
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Measure
Score Level
(Accountable
Entity Level)
Testing

Row
048

Field Label

*Face validity: Total
number of voting experts
and patients/caregivers

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).

ADD YOUR CONTENT HERE
Numeric field

CY 2025 Final Rule text:
Subsection
Measure
Score Level
(Accountable
Entity Level)
Testing

Row
061

Field Label

*Face validity: Total
number of voting experts
and patients/caregivers

ADD YOUR CONTENT HERE
Numeric field

Change #55
Location: Page 24, Row 062
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Measure
Score Level
(Accountable
Entity Level)
Testing

Row
049

Field Label

*Face validity: Number of
experts and
patients/caregivers who
voted in agreement

Guidance
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.

ADD YOUR CONTENT HERE
Numeric field

CY 2025 Final Rule text:
Subsection
Measure
Score Level
(Accountable
Entity Level)
Testing

Row

Field Label

062

*Face validity: Number of
experts and
patients/caregivers who
voted in agreement

ADD YOUR CONTENT HERE
Numeric field

Change #56
Location: Page 25, Row 063
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Measure
Score Level
(Accountable
Entity Level)
Testing

Row

Field Label

050

Face validity: Interpretation

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

ADD YOUR CONTENT HERE
Free text field

CY 2025 Final Rule text:
Subsection
Measure
Score Level
(Accountable
Entity Level)
Testing

Row

Field Label

063

Face validity: Interpretation

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

ADD YOUR CONTENT HERE
Free text field

Change #57
Location: Page 25, Row 064 and Skip Logic
Reason for Change: Updated Row, Guidance, and Skip Logic.
CY 2024 Final Rule text:
Subsection
Patient/Encounter
Level (Data
Element Level)
Testing

Row
051

Field Label

*Patient/Encounter Level
Testing

Guidance
Indicate whether patient/encounter level testing
of the individual data elements in the final
performance measure was conducted (i.e.,
measure of agreement such as kappa or
correlation coefficient). Prior studies of the same
data elements may be submitted.

ADD YOUR CONTENT HERE
☐ Yes
☐ No
☐ Not applicable

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

testing results or a different type of data
element testing, provide as an attachment.
• Select “No” and skip to the Patient-Reported
Data section if data element testing was only
conducted for a survey or patient reported tool
(e.g., internal consistency) rather than data
element agreement for the final performance
measure.
• Select “Not applicable” if the measure relies
entirely on administrative data.

n/a

If you select “Yes” in Row
051, then Rows 052-056
become required fields. If
you select “No” or “Not
applicable” in Row 051,
then skip to Row 057.

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

This is not a data entry field.

CY 2025 Final Rule text:
Subsection
Patient/Encounter
Level (Data
Element Level)
Testing

Row
064

Field Label

*Patient/Encounter Level
Testing

ADD YOUR CONTENT HERE
☐ Yes
☐ No
☐ Not applicable

• Select “Yes” if data element agreement was
assessed at the individual data element level as
of submission of this form.
• Select “No” if you are not able to provide the
results of data element agreement in this
submission. If you are submitting preliminary
testing results or a different type of data
element testing, provide as an attachment.
• Select “No” and skip to the Patient-Reported
Data section if data element testing was only
conducted for a survey or patient reported tool
(e.g., internal consistency) rather than data
element agreement for the final performance
measure.
• Select “Not applicable” if the measure relies
entirely on administrative claims data.

n/a

If you select “Yes” in Row
064, then Rows 065-069
become required fields. If
you select “No” or “Not
applicable” in Row 064,
then skip to Row 070.

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

This is not a data entry field.

Change #58
Location: Page 26, Row 065
Reason for Change: Updated Row and Guidance.
CY 2024 Final Rule text:
Subsection
Patient/Encounter
Level (Data
Element Level)
Testing

Row
052

Field Label

*Type of Analysis

Guidance
Select all that apply. For more information on
patient/encounter level testing, refer to the
Blueprint content on the CMS MMS Hub
(https://mmshub.cms.gov/measurelifecycle/measure-testing/evaluationcriteria/scientific-acceptability/reliability)
Note: This section refers to the patient/encounter
level data elements in the final performance
measure. Refer to the Patient-Reported Data section
for testing of patient/encounter level data elements
in surveys or patient reported tools.

ADD YOUR CONTENT HERE
☐ Agreement between two
manual reviewers
☐ Agreement between eCQM
and manual reviewer
☐ Agreement between other
gold standard and manual
reviewer

CY 2025 Final Rule text:
Subsection
Patient/Encounter
Level (Data
Element Level)
Testing

Row
065

Field Label

*Type of Analysis

Guidance
Select all that apply. For more information on
patient/encounter level testing, refer to the
Blueprint content on the CMS MMS Hub.
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.

ADD YOUR CONTENT HERE
☐ Agreement between two
manual reviewers
☐ Agreement between eCQM
and manual reviewer
☐ Agreement between other
gold standard and manual
reviewer

Change #59
Location: Page 26, Row 066
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Patient/Encounter
Level (Data
Element Level)
Testing

Row
053

Field Label

*Sample Size

Guidance
Indicate the number of patients/encounters
sampled.

ADD YOUR CONTENT HERE
Numeric field

CY 2025 Final Rule text:
Subsection
Patient/Encounter
Level (Data
Element Level)
Testing

Row
066

Field Label

*Sample Size

Guidance
Indicate the number of patients/encounters
sampled.

ADD YOUR CONTENT HERE
Numeric field

Change #60
Location: Page 26, Row 067
Reason for Change: Updated Row and checklist under “Add Your Content Here”.
CY 2024 Final Rule text:
Subsection
Patient/Encounter
Level (Data
Element Level)
Testing

Row
054

Field Label

*Statistic Name

Guidance
Select one. Indicate the statistic used to assess
agreement (e.g., percent agreement, kappa,
positive predictive value, etc.). If more than one
type of statistic was calculated, list the one that
best depicts the reliability and/or validity of the
data elements in your measure. Other statistics
and results should be provided in the
“Interpretation of results” field or provided as an
attachment.

ADD YOUR CONTENT HERE
☐ Percent agreement
☐ Kappa
☐ Correlation coefficient
☐ Sensitivity
☐ Positive Predictive Value

CY 2025 Final Rule text:
Subsection
Patient/Encounter
Level (Data
Element Level)
Testing

Row
067

Field Label

*Statistic Name

ADD YOUR CONTENT HERE
☐ Correlation coefficient
☐ Kappa
☐ Percent agreement
☐ Positive Predictive Value
☐ Sensitivity

Change #61
Location: Page 26, Row 068
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Patient/Encounter
Level (Data
Element Level)
Testing

Row
055

Field Label

*Statistical Results:
Individual Data Element

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

ADD YOUR CONTENT HERE
Numeric field

If providing kappa or a correlation coefficient,
results should be between -1 and 1.
If providing percent agreement, sensitivity, or
positive predictive value, results should be
between 0% and 100%. The percent value should
be entered as a whole number; for example, 70%
would be entered as 70 and NOT 0.7.
If not tested at the individual data element level,
enter 9999.

CY 2025 Final Rule text:
Subsection
Patient/Encounter
Level (Data
Element Level)
Testing

Row
068

Field Label

*Statistical Results:
Individual Data Element

ADD YOUR CONTENT HERE
Numeric field

Change #62
Location: Page 27, Row 069
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Patient/Encounter
Level (Data
Element Level)
Testing

Row
056

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, provide the
name of the attachment and location in the
attachment.

ADD YOUR CONTENT HERE
Free text field

If any data element has low reliability or validity,
describe the anticipated impact and whether it
could introduce bias to measure scores. If there is
variation in reliability or validity scores across test
sites/measured entities, describe how this
variation impacts overall interpretation of the
results.

CY 2025 Final Rule text:
Subsection
Patient/Encounter
Level (Data
Element Level)
Testing

Row
069

Field Label

*Interpretation of results

ADD YOUR CONTENT HERE
Free text field

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

results broken down by test site to demonstrate
whether reliability/validity varied between sites, if
available. If more room is needed and testing
results are included in an attachment, provide the
name of the attachment and location in the
attachment.
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.

Change #63
Location: Page 28, Row 070 and Skip Logic
Reason for Change: Updated Row and Skip Logic.
CY 2024 Final Rule text:
Subsection

Row

PatientReported
Data

057

n/a

Field Label

*Does the performance
measure use survey or
patient-reported data?
If you select “Yes” in Row
057, then Rows 058 and 059
become required fields. If
you select “No” in Row 057,
then skip to Row 060.

Guidance

ADD YOUR CONTENT HERE

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

☐ Yes
☐ No

n/a

This is not a data entry field.

CY 2025 Final Rule text:
Subsection

Row

PatientReported
Data

070

n/a

Field Label

*Does the performance
measure use survey or
patient-reported data?
If you select “Yes” in Row
070, then Rows 071 and 072
become required fields. If
you select “No” in Row 070,
then skip to Row 073.

Guidance

ADD YOUR CONTENT HERE

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

☐ Yes
☐ No

n/a

This is not a data entry field.

Change #64
Location: Page 28, Row 071
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
PatientReported
Data

Row
058

Field Label

*Survey level testing
methodology and results

Guidance
List each survey or patient-reported outcome tool
accepted by the performance measure. Indicate
whether the tool(s) are being used as originally
specified and tested or if modifications are required. If

ADD YOUR CONTENT HERE
Free text field

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

available, provide each survey or tool as a link or
attachment.
Describe the mode(s) of administration available (e.g.,
electronic, phone, mail) and the number of languages
the survey(s) or tool(s) are available in.
Indicate whether any of the surveys or tools is
proprietary requiring licenses or fees for use.
Briefly describe the method used to psychometrically
test or validate the patient survey or patient-reported
outcome tool. (e.g., Cronbach’s alpha, ICC, Pearson
correlation coefficient, Kuder-Richardson test). If the
survey or tool was developed prior to the
development of the performance measure, describe
how the intended use of the survey or tools for the
performance measure aligns with the survey or tool
as originally designed and tested. Indicate whether
the measure uses all components within a tool, or
only parts of the tool. Summarize the statistical
results and briefly describe the interpretation of
results.

CY 2025 Final Rule text:
Subsection
PatientReported
Data

Row
071

Field Label

*Survey level testing
methodology and results

ADD YOUR CONTENT HERE
Free text field

Describe the mode(s) of administration available (e.g.,
electronic, phone, mail) and the number of languages
the survey(s) or tool(s) are available in.
Indicate whether any of the surveys or tools is
proprietary requiring licenses or fees for use.
Briefly describe the method used to psychometrically
test or validate the patient survey or patient-reported
outcome tool. (e.g., Cronbach’s alpha, ICC, Pearson
correlation coefficient, Kuder-Richardson test). If the
survey or tool was developed prior to the
development of the performance measure, describe
how the intended use of the survey or tools for the
performance measure aligns with the survey or tool
as originally designed and tested. Indicate whether
the measure uses all components within a tool, or
only parts of the tool. Summarize the statistical
results and briefly describe the interpretation of
results.

Change #65
Location: Page 29, Row 072 and Composite/Survey Logic
Reason for Change: Updated Row numbers, added Composite/Survey Logic.
CY 2024 Final Rule text:
Subsection
PatientReported
Data

Row
059

Field Label

*Spanish development of
the survey instrument.

Guidance

ADD YOUR CONTENT HERE

Select all that apply. Survey instruments are expected
to be developed in Spanish, in addition to English.

☐ Survey instrument was
developed in Spanish and
validated
☐ Survey instrument was
developed in Spanish but not yet
validated
☐ Working on Spanish version of
survey instrument
☐ There are no plans to develop
a Spanish version of survey
instrument

Guidance

ADD YOUR CONTENT HERE

Select all that apply. Survey instruments are expected
to be developed in Spanish, in addition to English.

n/a

This is not a data entry field.

CY 2025 Final Rule text:
Subsection

Row

PatientReported
Data

072

n/a

Field Label

*Spanish development of
the survey instrument.

If you are submitting a
composite or survey
measure, Rows 073-082 in
MERIT will enable you to
input information for each
component or survey-based
measure included in your
submission.

Change #66
Location: Page 29, Row 073
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Measure
Performance

Row
060

Field Label

*Measure performance type of score

Guidance
Select one. Measure performance score type should
be at the level of accountable entity.

ADD YOUR CONTENT HERE
☐ Categorical (e.g., measured
entity scores yes/no, pass/fail,
or rating scale/score)
☐ Composite scale/non-weighted
score

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE
☐ Composite scale/weighted
score
☐ Continuous variable (e.g.,
average)
☐ Count
☐ Frequency Distribution
☐ Proportion
☐ Rate
☐ Ratio

CY 2025 Final Rule text:
Subsection
Measure
Performance

Row
073

Field Label

*Measure performance type of score

Guidance
Select one. Measure performance score type should
be at the level of accountable entity.

ADD YOUR CONTENT HERE
☐ Categorical (e.g., measured
entity scores yes/no, pass/fail,
or rating scale/score)
☐ Composite scale/non-weighted
score
☐ Composite scale/weighted
score
☐ Continuous variable (e.g.,
average)
☐ Count
☐ Frequency Distribution
☐ Proportion
☐ Rate
☐ Ratio

Change #67
Location: Page 29, Row 074
Reason for Change: Updated Row and text in “Add Your Content Here”.
CY 2024 Final Rule text:
Subsection
Measure
Performance

Row
061

Field Label

*Measure performance

Guidance

ADD YOUR CONTENT 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

Select one

score interpretation

CY 2025 Final Rule text:
Subsection
Measure
Performance

Row
074

Field Label

*Measure performance
score interpretation

Guidance
Select one

ADD YOUR CONTENT HERE
☐ Better performance = Higher
score
☐ Better performance = Lower
score
☐ Better performance = Score
within a defined interval

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE
☐ Passing score above a specified
threshold defines better
performance
☐ Passing score below a specified
threshold defines better
performance

Change #68
Location: Page 29, Row 075
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Measure
Performance

Row
062

Field Label

*Number of accountable
entities included in analysis

Guidance
Provide the number of accountable entities included
in the analysis of the distribution of performance
scores.

ADD YOUR CONTENT HERE
Numeric field

Please enter a single value and do not enter a range.
If unknown or not available, enter 9999.

CY 2025 Final Rule text:
Subsection
Measure
Performance

Row
075

Field Label

*Number of accountable
entities included in analysis

Guidance
Provide the number of accountable entities included
in the analysis of the distribution of performance
scores.

ADD YOUR CONTENT HERE
Numeric field

Please enter a single value and do not enter a range.
If unknown or not available, enter 9999.

Change #69
Location: Page 30, Row 076
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Measure
Performance

Row
063

Field Label

*Number of accountable
entities: unit

Guidance
Provide the unit of accountable entities included in
the analysis of the distribution of performance scores.

ADD YOUR CONTENT HERE
Free text field

CY 2025 Final Rule text:
Subsection
Measure
Performance

Row
076

Field Label

*Number of accountable
entities: unit

Guidance
Provide the unit of accountable entities included in
the analysis of the distribution of performance scores.

ADD YOUR CONTENT HERE
Free text field

Change #70
Location: Page 30, Row 077
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Measure
Performance

Row
064

Field Label

*Number of persons

Guidance
Provide the number of persons included in the
analysis of the distribution of performance scores

ADD YOUR CONTENT HERE
Numeric field

CY 2025 Final Rule text:
Subsection
Measure
Performance

Row
077

Field Label

*Number of persons

Guidance
Provide the number of persons included in the
analysis of the distribution of performance scores

ADD YOUR CONTENT HERE
Numeric field

Change #71
Location: Page 30, Row 078
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Measure
Performance

Row
065

Field Label

*10th percentile

Guidance
Provide the performance score at the 10th percentile
for the testing sample that is relevant to the intended
use of the measure.

ADD YOUR CONTENT HERE
Numeric field

If this is a proportion measure, provide the 10th
percentile score in percentage form, without the
symbol. For example, if the 10th percentile
performance score is 21.2%, enter 21.2 and not 0.212.
If a 10th percentile performance score is not
available, enter 9999.

CY 2025 Final Rule text:
Subsection
Measure
Performance

Row
078

Field Label

*10th percentile

Guidance
Provide the performance score at the 10th percentile
for the testing sample that is relevant to the intended
use of the measure.

ADD YOUR CONTENT HERE
Numeric field

Change #72
Location: Page 30, Row 079
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Measure
Performance

Row
066

Field Label

*50th percentile (median)

Guidance
Provide the median performance score (50th
percentile) for the testing sample that is relevant to
the intended use of the measure.

ADD YOUR CONTENT HERE
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.

CY 2025 Final Rule text:
Subsection
Measure
Performance

Row
079

Field Label

*50th percentile (median)

Guidance
Provide the median performance score (50th
percentile) for the testing sample that is relevant to
the intended use of the measure.

ADD YOUR CONTENT HERE
Numeric field

Change #73
Location: Page 31, Row 080
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Measure
Performance

Row
067

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.

ADD YOUR CONTENT HERE
Numeric field

If this is a proportion measure, provide the 90th
percentile score in percentage form, without the
symbol. For example, if the 90th percentile
performance score is 85.6%, enter 85.6 and not 0.856.

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

If a 90th percentile performance score is not
available, enter 9999.

CY 2025 Final Rule text:
Subsection
Measure
Performance

Row
080

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.

ADD YOUR CONTENT HERE
Numeric field

If this is a proportion measure, provide the 90th
percentile score in percentage form, without the
symbol. For example, if the 90th percentile
performance score is 85.6%, enter 85.6 and not 0.856.
If a 90th percentile performance score is not
available, enter 9999.

Change #74
Location: Page 31, Row 081
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Measure
Performance

Row
068

Field Label

*Additional measure
performance information

Guidance
Provide the following additional measure
performance information, as applicable:

ADD YOUR CONTENT HERE
Free text field

- Mean performance score across accountable
entities in the test sample that is relevant to the
intended use of the measure.
- Minimum and maximum performance score for the
testing sample that is relevant to the intended use of
the measure.
- Standard deviation of performance scores for the
testing sample that is relevant to the intended use of
the measure.
- Passing score for the performance measure.
- Performance score’s defined interval, including
upper and lower limit of the performance score.

CY 2025 Final Rule text:
Subsection
Measure
Performance

Row
081

Field Label

*Additional measure
performance information

Guidance
Provide the following additional measure
performance information, as applicable:

ADD YOUR CONTENT HERE
Free text field

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

- Performance score’s defined interval, including
upper and lower limit of the performance score.

Change #75
Location: Page 31, Row 082
Reason for Change: Updated Row and Guidance.
CY 2024 Final Rule text:
Subsection
Measure
Performance

Row
069

Field Label

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

Guidance
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.

ADD YOUR CONTENT HERE
☐ Yes
☐ No
☐ Not tested

CY 2025 Final Rule text:
Subsection
Measure
Performance

Row
082

Field Label

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

Guidance
Select one. Social risk factors may include age, social,
economic, and geographic factors linguistic and
cultural context, sex, social relationships, residential
and community environments, Medicare/Medicaid
dual eligibility, insurance status (insured/uninsured),
urbanicity/rurality, disability, and health literacy.

ADD YOUR CONTENT HERE
☐ Yes
☐ No
☐ Not tested

Change #76
Location: Page 32, Row 083 and Skip Logic
Reason for Change: Updated Row and Skip Logic.
CY 2024 Final Rule text:
Subsection
Importance

n/a

Row
070

n/a

Field Label

*Meaningful to Patients.
Did the majority of
patients/caregivers
consulted agree that the
measure is meaningful
and/or produces
information that is valuable
to them in making their care
decisions?
If you select “Yes” in Row
070, then Row 071 becomes
a required field. If you select
“No” or “Not evaluated” in
Row 070, then skip to Row
072.

Guidance

ADD YOUR CONTENT HERE

Select one. Patients and/or caregivers can include any
of the following:
• Patients
• Primary caregivers
• Family
• Other relatives

☐ Yes
☐ No
☐ Not evaluated

n/a

This is not a data entry field.

CY 2025 Final Rule text:
Subsection
Importance

n/a

Row
083

n/a

Field Label

*Meaningful to Patients.
Did the majority of
patients/caregivers
consulted agree that the
measure is meaningful
and/or produces
information that is valuable
to them in making their care
decisions?
If you select “Yes” in Row
083, then Row 084 becomes
a required field. If you select
“No” or “Not evaluated” in
Row 083, then skip to Row
085.

Guidance

ADD YOUR CONTENT HERE

Select one. Patients and/or caregivers can include any
of the following:
• Patients
• Primary caregivers
• Family
• Other relatives

☐ Yes
☐ No
☐ Not evaluated

n/a

This is not a data entry field.

Change #77
Location: Page 28, Row 084
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Importance

Row
071

Field Label

*Description of input
collected from
patients/caregivers
consulted

Guidance
Describe the input collected from patient/caregivers
consulted about the measure, including the number
of patients/caregivers consulted and the number who
agreed that the measure is meaningful and produces
information that is valuable in making care decisions.

ADD YOUR CONTENT HERE
Free text field

CY 2025 Final Rule text:
Subsection
Importance

Row
084

Field Label

*Description of input
collected from
patients/caregivers
consulted

ADD YOUR CONTENT HERE
Free text field

Change #78
Location: Page 32, Row 085
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Importance

Row
072

Field Label
Description of input
collected from measured
entities.

Guidance
Describe the input collected from measured entities,
or others such as consumers, purchasers, policy
makers, etc., using any of the following methods:

ADD YOUR CONTENT HERE
Free text field

• Focus groups
• Structured interviews
• Surveys of potential users

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Notes:
• This is separate from face validity testing of the
performance measure.

CY 2025 Final Rule text:
Subsection
Importance

Row
085

Field Label
Description of input
collected from measured
entities.

Guidance
Describe the input collected from measured entities,
or others such as consumers, purchasers, policy
makers, etc., using any of the following methods:

ADD YOUR CONTENT HERE
Free text field

• Focus groups
• Structured interviews
• Surveys of potential users
Notes:
• This is separate from face validity testing of the
performance measure.

Change #79
Location: Pages 33-34, Row 086 and Skip Logic
Reason for Change: Updated Row, Guidance, text in “Add Your Content Here”, and Skip Logic.
CY 2024 Final Rule text:
Subsection
Background
Information

n/a

Row
073

Field Label

*What is the history or
background for including
this measure on the current
year MUC List?

n/a

If you select “New measure
never reviewed by Measure
Applications Partnership
(MAP) Workgroup, or PreRulemaking Measure
Review (PRMR) or used in a
CMS Program” in Row 073,
then skip to Row 078. If you
select “Measure currently
used in a CMS program
being submitted without
substantive changes for a

Guidance
Select one
Note:
•
“CMS program” in the response options refers
only to the Medicare programs that undergo the
Pre-Rulemaking process. A full list of these
programs can be found on the CMS Program
Measure Needs and Priorities report.

n/a

ADD YOUR CONTENT HERE
☐ New measure never reviewed
by Measure Applications
Partnership (MAP) Workgroup,
or Pre-Rulemaking Measure
Review (PRMR) or used in a
CMS program
☐ Submitted previously but not
included in MUC List
☐ Measure previously submitted
to MAP or PRMR, refined, and
resubmitted per MAP or PRMR
recommendation
☐ Measure currently used in a
CMS program being submitted
without substantive changes for
a new or different program
☐ Measure currently used in a
CMS program, but the measure
is undergoing substantive
change
This is not a data entry field.

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Guidance

ADD YOUR CONTENT HERE

new or different program”
or “Measure currently used
in a CMS program, but the
measure is undergoing
substantial change” then
Rows 074-077 become
required fields.

CY 2025 Final Rule text:
Subsection
Background
Information

n/a

Row
086

Field Label

*What is the history or
background for including
this measure on the current
year MUC List?

n/a

If you select “New measure
never reviewed by Measure
Applications Partnership
(MAP) Workgroup, or PreRulemaking Measure
Review (PRMR) or used in a
Medicare Program”,
“Submitted previously but
not included in MUC List” or
“Measure previously
submitted to MAP or PRMR,
refined, and resubmitted
per MAP or PRMR
recommendation” in Row
086, then skip to Row 091. If
you select “Measure
currently used in a Medicare
program being submitted
without substantive
changes for a new or
different program”,
“Measure currently used in
a Medicare program, but

Select one
Note:
•
“Medicare program” in the response options
refers only to the Medicare programs that
undergo the Pre-Rulemaking process. A full list
of these programs can be found on the CMS
Program Measure Needs and Priorities report.

n/a

☐ Measure currently used in a
Medicare program being
submitted without substantive
changes for a new or different
program
☐ Measure currently used in a
Medicare program, but the
measure is undergoing
substantive change
☐ Measure currently used in a
Medicare program, but the
measure is undergoing
substantive changes for a new
or different program
☐ Measure previously submitted
to MAP or PRMR, refined, and
resubmitted per MAP or PRMR
recommendation
☐ New measure never reviewed
by Measure Applications
Partnership (MAP) Workgroup,
or Pre-Rulemaking Measure
Review (PRMR) or used in a
Medicare program
☐ Submitted previously but not
included in MUC List
This is not a data entry field.

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Guidance

ADD YOUR CONTENT HERE

the measure is undergoing
substantial change” or
“Measure currently used in
a Medicare program, but
the measure is undergoing
substantive changes for a
new or different program”
then Rows 087-090 become
required fields.

Change #80
Location: Page 34, Row 087
Reason for Change: Updated Row and Field Label.
CY 2024 Final Rule text:
Subsection
Background
Information

Row
074

Field Label

*Range of year(s) this

Example: Hospice Quality Reporting (2012-2018)

Free text field

measure has been used by
CMS Program(s).

CY 2025 Final Rule text:
Subsection
Background
Information

Row
087

Field Label

*Range of year(s) this

Guidance
Example: Hospice Quality Reporting (2012-2018)

ADD YOUR CONTENT HERE
Free text field

measure has been used by
Medicare Program(s).

Change #81
Location: Page 35, Row 088
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Background
Information

Row
075

Field Label

*What other federal
programs are currently
using this measure?

Guidance

ADD YOUR CONTENT HERE

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

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE
☐ Inpatient Psychiatric Facility
Quality Reporting Program
☐ Inpatient Rehabilitation Facility
Quality Reporting Program
☐ Long-Term Care Hospital
Quality Reporting Program
☐ Medicare Promoting
Interoperability Program
☐ Medicare Shared Savings
Program
☐ Merit-based Incentive Payment
System-Cost
☐ Merit-based Incentive Payment
System-Quality

☐ Part C Star Rating
☐ Part D Star Rating
☐ Prospective Payment SystemExempt Cancer Hospital Quality
Reporting Program
☐ Rural Emergency Hospital
Quality Reporting Program
☐ Skilled Nursing Facility Quality
Reporting Program
☐ Skilled Nursing Facility ValueBased Purchasing Program
☐ Other (enter here):

CY 2025 Final Rule text:
Subsection
Background
Information

Row
088

Field Label

*What other federal
programs are currently
using this measure?

Guidance

ADD YOUR CONTENT HERE

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

☐ Ambulatory Surgical Center
Quality Reporting Program
☐ End-Stage Renal Disease (ESRD)
Quality Incentive Program
☐ Home Health Quality Reporting
Program
☐ Hospice Quality Reporting
Program
☐ Hospital Inpatient Quality
Reporting Program
☐ Hospital Outpatient Quality
Reporting Program
☐ Hospital Readmissions
Reduction Program
☐ Hospital Value-Based
Purchasing Program
☐ Hospital-Acquired Condition
Reduction Program
☐ Inpatient Psychiatric Facility
Quality Reporting Program
☐ Inpatient Rehabilitation Facility
Quality Reporting Program
☐ Long-Term Care Hospital
Quality Reporting Program
☐ Medicare Promoting
Interoperability Program

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE
☐ Medicare Shared Savings
Program
☐ Merit-based Incentive Payment
System-Cost
☐ Merit-based Incentive Payment
System-Quality

Change #82
Location: Page 36, Row 089
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Background
Information

Row
076

Field Label

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

Guidance
Describe how this measure will achieve alignment
with the same measure(s) that are currently used in
other federal programs. Please include the names of
the same measure(s) that are used in other federal
programs and include the corresponding unique
identifier (e.g., federal program ID, CBE#, etc.), if
available.

ADD YOUR CONTENT HERE
Free text field

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.

CY 2025 Final Rule text:
Subsection
Background
Information

Row
089

Field Label

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

ADD YOUR CONTENT HERE
Free text field

Alignment is achieved when a set of measures works
well across care settings or programs to produce
meaningful information without creating extra work

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

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.

Change #83
Location: Page 36, Row 090
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Background
Information

Row
077

Field Label

*If this measure is being
submitted to meet a
statutory requirement, list
the corresponding statute

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
Free text field

CY 2025 Final Rule text:
Subsection
Background
Information

Row
090

Field Label

*If this measure is being
submitted to meet a
statutory requirement, list
the corresponding statute

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
Free text field

Change #84
Location: Page 36, Row 091 and Skip Logic
Reason for Change: Updated Row, Guidance, and Skip Logic.
CY 2024 Final Rule text:
Subsection

Row

Previous
Measures

078

n/a

Field Label

*Was this measure
published on a previous
year’s Measures Under
Consideration List?
If you select “Yes” in Row
078, then Rows 079-085
become required fields. If
you select “No” in Row 078,
then skip to Row 086.

Guidance

ADD YOUR CONTENT HERE

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.

CY 2025 Final Rule text:
Subsection

Row

Previous
Measures

091

n/a

Field Label

*Was this measure
published on a previous
year’s Measures Under
Consideration List?
If you select “Yes” in Row
091, then Rows 092-098
become required fields. If

Guidance

ADD YOUR CONTENT HERE

Select “Yes” or “No.” If yes, you are submitting an
existing measure for expansion into additional
Medicare programs or the measure has substantially
changed since originally published.

☐ Yes
☐ No

n/a

This is not a data entry field.

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

you select “No” in Row 091,
then skip to Row 099.

Change #85
Location: Page 37, Row 092
Reason for Change: Updated Row and text in “Add Your Content Here”.
CY 2024 Final Rule text:
Subsection
Previous
Measures

Row
079

Field Label

*In what prior year(s) was
this measure published on
the Measures Under
Consideration List?

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
☐ 2023

CY 2025 Final Rule text:
Subsection
Previous
Measures

Row
092

Field Label

*In what prior year(s) was
this measure published on
the Measures Under
Consideration List?

ADD YOUR CONTENT HERE
☐ 2011
☐ 2012
☐ 2013
☐ 2014
☐ 2015
☐ 2016
☐ 2017
☐ 2018
☐ 2019
☐ 2020
☐ 2021
☐ 2022
☐ 2023
☐ 2024

Change #86
Location: Page 33, Row 093
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Previous
Measures

Row
080

Field Label

Guidance

*What was the MUC ID for

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

the measure in each year?

ADD YOUR CONTENT HERE
Free text field

CY 2025 Final Rule text:
Subsection
Previous
Measures

Row
093

Field Label

Guidance

*What was the MUC ID for

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

the measure in each year?

ADD YOUR CONTENT HERE
Free text field

Change #87
Location: Page 38, Row 094
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Previous
Measures

Row
081

Field Label

*List the CMS CBE
workgroup(s) (MAP or
PRMR) in each year

Guidance
List both the year and the associated workgroup
name in each year. MAP and PRMR workgroup
options include: Clinician; Hospital; Post-Acute
Care/Long-Term Care; Coordinating Committee.
Example: “Clinician, 2014.”

ADD YOUR CONTENT HERE
Free text field

CY 2025 Final Rule text:
Subsection
Previous
Measures

Row
094

Field Label

*List the CMS CBE
workgroup(s) (MAP or
PRMR) in each year

ADD YOUR CONTENT HERE
Free text field

Change #88
Location: Page 38, Row 095
Reason for Change: Updated Row and Guidance.
CY 2024 Final Rule text:
Subsection
Previous
Measures

Row
082

Field Label

*What were the programs
that MAP or PRMR
reviewed the measure for
in each year?

Guidance
List both the year and the associated CMS programs
in each year.

ADD YOUR CONTENT HERE
Free text field

CY 2025 Final Rule text:
Subsection
Previous
Measures

Row
095

Field Label

*What were the programs
that MAP or PRMR
reviewed the measure for
in each year?

Guidance
List both the year and the associated Medicare
programs in each year.

ADD YOUR CONTENT HERE
Free text field

Change #89
Location: Page 38, Row 096
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Previous
Measures

Row
083

Field Label

*What was the MAP or
PRMR recommendation in
each year?

Guidance
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
Free text field

CY 2025 Final Rule text:
Subsection
Previous
Measures

Row
096

Field Label

*What was the MAP or
PRMR recommendation in
each year?

Guidance
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
Free text field

Change #90
Location: Page 38, Row 097
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Previous
Measures

Row
084

Field Label

*Why was the measure not

Guidance
Briefly describe the reason(s) if known.

ADD YOUR CONTENT HERE
Free text field

recommended by the MAP
or PRMR workgroups in
those year(s)?

CY 2025 Final Rule text:
Subsection
Previous
Measures

Row
097

Field Label

*Why was the measure not

Guidance
Briefly describe the reason(s) if known.

ADD YOUR CONTENT HERE
Free text field

recommended by the MAP
or PRMR workgroups in
those year(s)?

Change #91
Location: Page 38, Row 098
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Previous
Measures

Row
085

Field Label

*MAP or PRMR report page
number being referenced
for each year

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

ADD YOUR CONTENT HERE
Free text field

CY 2025 Final Rule text:
Subsection
Previous
Measures

Row
098

Field Label

*MAP or PRMR report page
number being referenced
for each year

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

ADD YOUR CONTENT HERE
Free text field

Change #92
Location: Page 39, Row 099 and Skip Logic
Reason for Change: Updated Row, Field Label, Guidance, and Skip Logic.
CY 2024 Final Rule text:
Subsection
Data
Sources

Row
086

Field Label

Guidance

*What data sources are

Select all that apply.

used for the measure?

For more information about digital data sources,
please refer to the “Digital Data Sources” section of
the “dQMs - Digital Quality Measures” webpage on
the eCQI Resource Center available at:
https://ecqi.healthit.gov/dqm?qt-tabs_dqm=1

n/a

If your selections in Row
086 only include digital
data sources, then skip to

n/a

ADD YOUR CONTENT HERE
☐ Digital-Administrative systems:
Administrative Data (nonclaims)
☐ Digital-Administrative systems:
Claims Data
☐ Digital-Applications: PatientGenerated Health Data (e.g.,
home blood pressure
monitoring)
☐ Digital-Applications: PatientReported Health Data or Survey
Data (electronic)
☐ Digital-Case Management
Systems
☐ Digital-Clinical Registries
☐ Digital-Electronic Clinical Data
(non-EHR) or Social Needs
Assessments
☐ Digital-Electronic Health
Record (EHR) Data
☐ Digital-Health Information
Exchanges (HIE) Data
☐ Digital-Instrument Data (e.g.,
medical devices and wearables)
☐ Digital-Laboratory Systems
Data
☐ Digital-Patient Portal Data
☐ Digital-Prescription Drug
Monitoring Program Data
☐ Digital-Standardized Patient
Assessment Data (electronic)
☐ Digital-Other (enter here):
☐ Non-Digital-Paper Medical
Records
☐ Non-Digital-Standardized
Patient Assessments (paperbased)
☐ Non-Digital-Patient-Reported
Health Data or Survey Data
(telephonic or paper-based)
☐ Non-Digital-Other (enter here):
This is not a data entry field.

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Guidance

ADD YOUR CONTENT HERE

Row 089. Otherwise, Row
087 becomes a required
field.

CY 2025 Final Rule text:
Subsection
Data
Sources

Row
099

Field Label

*What data sources are

Select all that apply.

used for the measure?

For example, if the measure uses survey data that are
captured both electronically and in paper format,
select the “Applications: Patient-Reported Health
Data or Survey Data (electronic)” from the “Digital
Data Sources” category and “Patient-Reported Health
Data or Survey Data (telephonic or paper-based)”
from the “Non-Digital Data Sources” category.
For more information about digital data sources,
please refer to the “Digital Data Sources” section of
the “dQMs - Digital Quality Measures” webpage on
the eCQI Resource Center.

n/a

If your selections in Row
099 only include digital
data sources, then skip to
Row 102. Otherwise, Row
100 becomes a required
field.

n/a

☐ Digital-Administrative systems:
Administrative Data (nonclaims)
☐ Digital-Administrative systems:
Claims Data
☐ Digital-Applications: PatientGenerated Health Data (e.g.,
home blood pressure
monitoring)
☐ Digital-Applications: PatientReported Health Data or Survey
Data (electronic)
☐ Digital-Case Management
Systems
☐ Digital-Clinical Registries
☐ Digital-Electronic Clinical Data
(non-EHR) or Social Needs
Assessments
☐ Digital-Electronic Health Record
(EHR) Data
☐ Digital-Health Information
Exchanges (HIE) Data
☐ Digital-Instrument Data (e.g.,
medical devices and wearables)
☐ Digital-Laboratory Systems
Data
☐ Digital-Patient Portal Data
☐ Digital-Prescription Drug
Monitoring Program Data
☐ Digital-Standardized Patient
Assessment Data (electronic)
☐ Digital-Other (enter here):
☐ Non-Digital-Paper Medical
Records
☐ Non-Digital-Standardized
Patient Assessments (paperbased)
☐ Non-Digital-Patient-Reported
Health Data or Survey Data
(telephonic or paper-based)
☐ Non-Digital-Other (enter here):
This is not a data entry field.

Change #93
Location: Page 40, Row 100 and Skip Logic
Reason for Change: Updated Row, Field Label, and Skip Logic.
CY 2024 Final Rule text:
Subsection

Row

Data
Sources

087

n/a

Field Label

*Measure version that uses
only digital data sources
If you select “Yes” in Row
087, then skip to Row 089.
Otherwise, Row 088
becomes a required field.

Guidance

ADD YOUR CONTENT HERE

Select one. Indicate whether there is a version of the
measure that uses only digital data sources.

☐ Yes
☐ No

n/a

This is not a data entry field.

CY 2025 Final Rule text:
Subsection

Row

Data
Sources

100

n/a

Field Label

*Because you selected a
non-digital data source, is
there a version of this
measure that only uses
digital data
sources?
If you select “Yes” in Row
100, then skip to Row 102.
Otherwise, Row 101
becomes a required field.

Guidance

ADD YOUR CONTENT HERE

Select one. Indicate whether there is a version of the
measure that uses only digital data sources.

☐ Yes
☐ No

n/a

This is not a data entry field.

Change #94
Location: Page 40, Row 101
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Data
Sources

Row
088

Field Label

*Path to Digital Format

Guidance
Select one. Indicate whether there is a viable path for
the measure to be transitioned to an exclusively
digital format.

ADD YOUR CONTENT HERE
☐ Yes
☐ No

CY 2025 Final Rule text:
Subsection
Data
Sources

Row
101

Field Label

*Path to Digital Format

Guidance
Select one. Indicate whether there is a viable path for
the measure to be transitioned to an exclusively
digital format.

ADD YOUR CONTENT HERE
☐ Yes
☐ No

Change #95
Location: Page 41, Row 102 and Skip Logic
Reason for Change: Updated Row, Guidance, and Skip Logic.
CY 2024 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE
☐ Cost/Resource Use
☐ Efficiency
☐ Intermediate Outcome
☐ Outcome
☐ PRO-PM or Patient Experience
of Care
☐ Process
☐ Structure
This is not a data entry field.

General
Characteristics

096

*Measure Type

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

n/a

If you select “PRO-PM or
Patient Experience of Care”
in Row 096, then Row 097
and Row 122 become
required fields. If not, then
skip to Row 098. If you
select “Outcome” in Row
096, then Row 122
becomes a required field.

n/a

CY 2025 Final Rule text:
Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE
☐ Cost/Resource Use
☐ Efficiency
☐ Intermediate Outcome
☐ Outcome
☐ PRO-PM or Patient Experience
of Care
☐ Process
☐ Structure
This is not a data entry field.

General
Characteristics

102

*Measure Type

Select only one type of measure. For definitions, visit
the “About Quality Measurement” page on the CMS
MMS Hub.

n/a

If you select “PRO-PM or
Patient Experience of Care”
in Row 102, then Row 103
and Row 128 become
required fields. If not, then
skip to Row 104. If you
select “Outcome” in Row
102, then Row 128
becomes a required field.

n/a

Change #96
Location: Page 41, Row 103
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
General
Characteristics

Row
097

Field Label

*Assessment of patient
experience of care

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

ADD YOUR CONTENT HERE
☐ Yes
☐ No

CY 2025 Final Rule text:
Subsection
General
Characteristics

Row
103

Field Label

*Assessment of patient
experience of care

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

ADD YOUR CONTENT HERE
☐ Yes
☐ No

Change #97
Location: Page 41, Row 104 and Skip Logic
Reason for Change: Updated Row, Guidance, and Skip Logic.
CY 2024 Final Rule text:
Subsection

Row

General
Characteristics

098

n/a

Field Label

*Is this measure in the
CMS Measures Inventory
Tool (CMIT)?
If you select “Yes” in Row
098, then Row 099
becomes a required field. If
you select “No” in Row
098, then skip to Row 100.

Guidance

ADD YOUR CONTENT HERE

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

☐ Yes
☐ No

n/a

This is not a data entry field.

CY 2025 Final Rule text:
Subsection

Row

General
Characteristics

104

n/a

Field Label

*Is this measure in the
CMS Measures Inventory
Tool (CMIT)?
If you select “Yes” in Row
104, then Row 105
becomes a required field. If
you select “No” in Row 104,
then skip to Row 106.

Guidance

ADD YOUR CONTENT HERE

Select Yes or No. Current measures can be found at
the CMS Measure Inventory Tool (CMIT) website.

☐ Yes
☐ No

n/a

This is not a data entry field.

Change #98
Location: Page 41, Row 105
Reason for Change: Updated Row and Guidance.
CY 2024 Final Rule text:
Subsection
General
Characteristics

Row
099

Field Label

*CMIT ID

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

ADD YOUR CONTENT HERE
ADD YOUR CONTENT HERE

CY 2025 Final Rule text:
Subsection
General
Characteristics

Row
105

Field Label

*CMIT ID

Guidance
If the measure is currently in CMIT, enter the CMIT ID
in the format #####-##-X-PRGM. Current measures

ADD YOUR CONTENT HERE
ADD YOUR CONTENT HERE

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

and CMIT IDs can be found at the CMS Measure
Inventory Tool (CMIT) website.

Change #99
Location: Page 42, Row 106
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
General
Characteristics

Row
100

Field Label
Alternate Measure ID

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 consensusbased entity (endorsement) ID, CMIT ID, or previous
year MUC ID in this field.

ADD YOUR CONTENT HERE
ADD YOUR CONTENT HERE

CY 2025 Final Rule text:
Subsection
General
Characteristics

Row
106

Field Label
Alternate Measure ID

ADD YOUR CONTENT HERE
ADD YOUR CONTENT HERE

Change #100
Location: Page 42, Row 107
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
General
Characteristics

Row
101

Field Label

*What is the target
population of the
measure?

Guidance
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.

ADD YOUR CONTENT HERE
Free text field

CY 2025 Final Rule text:
Subsection
General
Characteristics

Row
107

Field Label

*What is the target
population of the
measure?

Guidance
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.

ADD YOUR CONTENT HERE
Free text field

Change #101
Location: Page 42, Row 108 and Composite/Survey Logic
Reason for Change: Updated Row, text under “Add Your Content Here” and added Composite/Survey Logic.
CY 2024 Final Rule text:
Subsection
General
Characteristics

Row
102

Field Label

*What one area of

Guidance
Select the ONE most applicable area of specialty.

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

ADD YOUR CONTENT HERE
See Appendix A.098 for list
choices. Copy/paste or enter
your choice(s) here:

CY 2025 Final Rule text:
Subsection

Row

General
Characteristics

108

n/a

Field Label

*What one area of
specialty the measure is
aimed to, or which
specialty is most likely to
report this measure?
If you are submitting a
composite or survey
measure, Row 109 in
MERIT will enable you to
input information for each
component or surveybased measure included in
your submission.

Guidance

ADD YOUR CONTENT HERE

Select the ONE most applicable area of specialty.

See Appendix A.108 for list
choices. Copy/paste or enter
your choice(s) here:

n/a

This is not a data entry field.

Change #102
Location: Page 42, Row 109
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
General
Characteristics

Row
103

Field Label

Guidance

*Evidence of performance

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.

gap

ADD YOUR CONTENT HERE
Free text field

If you have lengthy text add the evidence as an
attachment, named to clearly indicate the related
form field.

CY 2025 Final Rule text:
Subsection
General
Characteristics

Row
109

Field Label

Guidance

*Evidence of performance

gap

ADD YOUR CONTENT HERE
Free text field

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

implementation of the measure would be
meaningful.
If you have lengthy text add the evidence as an
attachment, named to clearly indicate the related
form field.

Change #103
Location: Page 42, Row 110
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
General
Characteristics

Row
104

Field Label

*Unintended
consequences

Guidance
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
Free text field

CY 2025 Final Rule text:
Subsection
General
Characteristics

Row
110

Field Label

*Unintended
consequences

ADD YOUR CONTENT HERE
Free text field

Change #104
Location: Page 43, Row 111 and Skip Logic
Reason for Change: Updated Row, Guidance, text under “Add Your Content Here”, Skip Logic, and added
Composite/Survey Logic.
CY 2024 Final Rule text:
Subsection
Evidence

Row
105

Field Label

*Type of evidence to
support the measure

n/a

If you select “Clinical
Guidelines or USPSTF (U.S.
Preventive Services Task
Force) Guidelines” in Row
105, then Rows 106-113

Guidance
Select all that apply. Refer to the Blueprint content on
the CMS MMS Hub
(https://mmshub.cms.gov/measurelifecycle/measure-conceptualization/informationgathering-overview) and the Environmental Scan
supplemental material
(https://mmshub.cms.gov/tools-and-resources/mmssupplemental-materials) 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
This is not a data entry field.

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Guidance

ADD YOUR CONTENT HERE

become required fields. If
you select “Peer-Reviewed
Systematic Review” in Row
105, then Rows 114 and
115 become required fields.
If you select “PeerReviewed Original
Research” in Row 105, then
Rows 116 and 117 become
required fields. If you select
“Empirical data” in Row
105, then Rows 118 and
119 become required fields.
If you select “Grey
Literature” in Row 105, then
Rows 120 and 121 become
required fields.

CY 2025 Final Rule text:
Subsection
Evidence

Row
111

Field Label

*Type of evidence to
support the measure

n/a

If you select “Clinical
Guidelines or USPSTF (U.S.
Preventive Services Task
Force) Guidelines” in Row
111, then Rows 112-119
become required fields. If
you select “Peer-Reviewed
Systematic Review” in Row
111, then Rows 120 and
121 become required fields.
If you select “PeerReviewed Original
Research” in Row 111, then
Rows 122 and 123 become
required fields. If you select
“Empirical data” in Row
111, then Rows 124 and
125 become required fields.
If you select “Grey
Literature” in Row 111, then
Rows 126 and 127 become
required fields.
If you are submitting a
composite or survey
measure, Rows 112-142 in
MERIT will enable you to
input information for each
component or survey-based

Select all that apply. Refer to the Blueprint content on
the CMS MMS Hub and the Environmental Scan
supplemental material to obtain updated guidance.

☐ Clinical Guidelines or USPSTF
(U.S. Preventive Services Task
Force) Guidelines
☐ Empirical data
☐ Grey Literature
☐ Peer-Reviewed Original
Research
☐ Peer-Reviewed Systematic
Review

n/a

This is not a data entry field.

n/a

This is not a data entry field.

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Guidance

ADD YOUR CONTENT HERE

measure included in your
submission.

Change #105
Location: Page 44, Row 112
Reason for Change: Updated Row and Guidance.
CY 2024 Final Rule text:
Subsection
Evidence

Row
106

Field Label

*Outline the clinical
guideline(s) supporting this
measure

Provide a detailed description of which guideline(s)
support the measure and indicate for each, whether
they are evidence-based or consensus-based.

Free text field

Summarize the meaning/rationale of the guideline
statements that are being referenced, their relation to
the measure concept and how they support the
measure whether directly or indirectly, and how the
guideline statement(s) relate to the measure’s
intended accountable entity. Describe the body of
evidence that supports the statement(s) by describing
the quantity, quality and consistency of the studies
that are pertinent to the guideline
statements/sentence. Quantity of studies represent
the number of studies and not the number of
publications associated with a study. If the statement
is advised by 3 publications reporting outcomes from
the same RCT at 3 different time points, this is
considered a single study and not 3 studies.
If referencing a standard norm which may or may not
be driven by evidence, provide the description and
rationale for this norm or threshold as reasoned by
the guideline panel.
If this is an outcome measure or PRO-PM, indicate
how the evidence supports or demonstrates a link
between at least one process, structure, or
intervention and the outcome.
Document the criteria used to assess the quality of
the clinical guidelines such as those proposed by the
Institute of Medicine or ECRI Guideline’s Trust (see
the Information Gathering Overview on the CMS
MMS Hub (https://mmshub.cms.gov/measurelifecycle/measure-conceptualization/informationgathering-overview) and the Environmental Scan
supplemental material section addressing evidence
review (https://mmshub.cms.gov/tools-andresources/mms-supplemental-materials).
If there is lengthy text, describe the guidelines in an
evidence attachment.

CY 2025 Final Rule text:
Subsection
Evidence

Row
112

Field Label

*Outline the clinical
guideline(s) supporting this
measure

Guidance
Provide a detailed description of which guideline(s)
support the measure and indicate for each, whether
they are evidence-based or consensus-based.

ADD YOUR CONTENT HERE
Free text field

Summarize the meaning/rationale of the guideline
statements that are being referenced, their relation to
the measure concept and how they support the
measure whether directly or indirectly, and how the
guideline statement(s) relate to the measure’s
intended accountable entity. Describe the body of
evidence that supports the statement(s) by describing
the quantity, quality and consistency of the studies
that are pertinent to the guideline
statements/sentence. Quantity of studies represent
the number of studies and not the number of
publications associated with a study. If the statement
is advised by 3 publications reporting outcomes from
the same RCT at 3 different time points, this is
considered a single study and not 3 studies.
If referencing a standard norm which may or may not
be driven by evidence, provide the description and
rationale for this norm or threshold as reasoned by
the guideline panel.
If this is an outcome measure or PRO-PM, indicate
how the evidence supports or demonstrates a link
between at least one process, structure, or
intervention and the outcome.
Document the criteria used to assess the quality of
the clinical guidelines such as those proposed by the
Institute of Medicine or ECRI Guideline’s Trust (see
the Information Gathering Overview on the CMS
MMS Hub and the Environmental Scan supplemental
material section addressing evidence review).
If there is lengthy text, describe the guidelines in an
evidence attachment.

Change #106
Location: Page 45, Row 113
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Evidence

Row
107

Field Label

*Guideline citation

Guidance
Provide any of the following:
• Full citation for the primary clinical guideline in any
established citation style (e.g., AMA, APA, Chicago,
Vancouver, etc.)
• URL
• DOI or ISBN for clinical guideline document

ADD YOUR CONTENT HERE
☐ Citation (enter here)
☐ URL (enter here)
☐ DOI (enter here)
☐ Not available

CY 2025 Final Rule text:
Subsection
Evidence

Row
113

Field Label

*Guideline citation

ADD YOUR CONTENT HERE
☐ Citation (enter here)
☐ URL (enter here)
☐ DOI (enter here)
☐ Not available

Change #107
Location: Page 45, Row 114
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Evidence

Row
108

Field Label

*List the guideline
statement that most closely
aligns with the measure
concept.

Guidance
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.

ADD YOUR CONTENT HERE
Free text field

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.

CY 2025 Final Rule text:
Subsection
Evidence

Row
114

Field Label

*List the guideline
statement that most closely
aligns with the measure
concept.

ADD YOUR CONTENT HERE
Free text field

Change #108
Location: Page 45, Row 115 and Skip Logic
Reason for Change: Updated Row and Skip Logic.
CY 2024 Final Rule text:
Subsection

Row

Field Label

Evidence

109

*Is the guideline graded?

n/a

If you select “Yes” in Row
109, then Rows 110-111,
and 113 become required
fields.

Guidance
A graded guideline is one which explicitly provides
evidence rating and recommendation grading
conventions in the document itself. Grades are usually
found next to each recommendation statement.
Select one.
n/a

ADD YOUR CONTENT HERE
☐ Yes
☐ No

This is not a data entry field.

CY 2025 Final Rule text:
Subsection

Row

Field Label

Evidence

115

*Is the guideline graded?

n/a

If you select “Yes” in Row
115, then Rows 116-117,
and 119 become required
fields.

ADD YOUR CONTENT HERE
☐ Yes
☐ No

This is not a data entry field.

Change #109
Location: Page 45, Row 116
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Evidence

Row
110

Field Label

*List evidence grading
system used and all
categories and
corresponding definitions
for the evidence grading
system used to describe
strength of
recommendation in the
guideline.

Guidance
Insert the complete list of evidence grading systems,
grading categories, and category definitions used by
the clinical guideline (e.g., GRADE or USPSTF) to
describe the guideline statement’s strength of
recommendation.

ADD YOUR CONTENT HERE
Free text field

If there is lengthy text, include details in a separate
evidence attachment.

CY 2025 Final Rule text:
Subsection
Evidence

Row
116

Field Label

*List evidence grading
system used and all
categories and
corresponding definitions

Guidance
Insert the complete list of evidence grading systems,
grading categories, and category definitions used by
the clinical guideline (e.g., GRADE or USPSTF) to

ADD YOUR CONTENT HERE
Free text field

Subsection

Row

Field Label
for the evidence grading
system used to describe
strength of
recommendation in the
guideline.

Guidance

ADD YOUR CONTENT HERE

describe the guideline statement’s strength of
recommendation.
If there is lengthy text, include details in a separate
evidence attachment.

Change #110
Location: Page 46, Row 117 and Skip Logic
Reason for Change: Updated Row and Skip Logic.
CY 2024 Final Rule text:
Subsection
Evidence

Row
111

Field Label

*For the guideline
statement that most closely
aligns with the measure
concept, what is the
associated strength of
recommendation?

n/a

If you select “USPSTF Grade
D, Moderate or high
certainty that the service
has no net benefit or harm
outweighs benefit” in Row
111, then Row 112 becomes
a becomes a required field;
otherwise, skip to Row 113.

Guidance

ADD YOUR CONTENT HERE

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
This is not a data entry field.

Select one.

n/a

CY 2025 Final Rule text:
Subsection
Evidence

Row
117

Field Label

*For the guideline
statement that most closely
aligns with the measure
concept, what is the
associated strength of
recommendation?

n/a

If you select “USPSTF Grade
D, Moderate or high
certainty that the service
has no net benefit or harm

Guidance

ADD YOUR CONTENT HERE

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

Select one.

n/a

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Guidance

ADD YOUR CONTENT HERE

outweighs benefit” in Row
117, then Row 118 becomes
a becomes a required field;
otherwise, skip to Row 119.

Change #111
Location: Page 46, Row 118
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Evidence

Row
112

Field Label

*Is the selected guideline
statement used to support
an inappropriate use/care
measure?

Select one. Indicate whether the guideline statement
mentioned in “List the guideline statement that most
closely aligns with the measure concept” is used to
promote the practice of not performing a specific
action, process or intervention to support an
inappropriate use or inappropriate care measure.

☐ Yes
☐ No

CY 2025 Final Rule text:
Subsection
Evidence

Row
118

Field Label

*Is the selected guideline
statement used to support
an inappropriate use/care
measure?

Guidance
Select one. Indicate whether the guideline statement
mentioned in “List the guideline statement that most
closely aligns with the measure concept” is used to
promote the practice of not performing a specific
action, process or intervention to support an
inappropriate use or inappropriate care measure.

ADD YOUR CONTENT HERE
☐ Yes
☐ No

Change #112
Location: Page 46, Row119
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Evidence

Row
113

Field Label

*List all categories and
corresponding definitions
for the evidence grading
system used to describe
level of evidence or level of
certainty in the evidence.

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

ADD YOUR CONTENT HERE
Free text field

CY 2025 Final Rule text:
Subsection
Evidence

Row
119

Field Label

*List all categories and
corresponding definitions
for the evidence grading
system used to describe
level of evidence or level of
certainty in the evidence.

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

ADD YOUR CONTENT HERE
Free text field

Change #113
Location: Page 47, Row 120
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Evidence

Row
114

Field Label

*Briefly summarize the
peer-reviewed systematic
review(s) that inform this
measure concept

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
Free text field

If there is lengthy text, submit details via an evidence
attachment.

CY 2025 Final Rule text:
Subsection
Evidence

Row
120

Field Label

*Briefly summarize the
peer-reviewed systematic
review(s) that inform this
measure concept

ADD YOUR CONTENT HERE
Free text field

If there is lengthy text, submit details via an evidence
attachment.

Change #114
Location: Page 47, Row 121
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Evidence

Row
115

Field Label

*Peer-reviewed systematic
review citation

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

ADD YOUR CONTENT HERE
☐ 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.

CY 2025 Final Rule text:
Subsection
Evidence

Row
121

Field Label

*Peer-reviewed systematic
review citation

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

ADD YOUR CONTENT HERE
☐ 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.

Change #115
Location: Page 47, Row 122
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Evidence

Row
116

Field Label

*Peer-reviewed original
research

Guidance
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.

ADD YOUR CONTENT HERE
☐ Yes
☐ No

If “Yes,” please provide documentation of the search
strategy in an attachment (e.g., years searched,
keywords and search terms used, databases used,
etc.).

CY 2025 Final Rule text:
Subsection
Evidence

Row
122

Field Label

*Peer-reviewed original
research

ADD YOUR CONTENT HERE
☐ Yes
☐ No

If “Yes,” please provide documentation of the search
strategy in an attachment (e.g., years searched,
keywords and search terms used, databases used,
etc.).

Change #116
Location: Page 47, Row 123
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Evidence

Row
117

Field Label

*Peer-reviewed original
research citation

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

ADD YOUR CONTENT HERE
☐ 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.

CY 2025 Final Rule text:
Subsection
Evidence

Row
123

Field Label

*Peer-reviewed original
research citation

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

ADD YOUR CONTENT HERE
☐ 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.

Change #117
Location: Page 48, Row 124
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Evidence

Row
118

Field Label

*Summarize the empirical
data

Guidance
Provide a summary of the empirical data and how it
informs this measure concept. Describe the
limitations of the data. If this is an outcome measure
or PRO-PM, indicate how the evidence supports or
demonstrates a link between at least one process,
structure, or intervention with the outcome. Describe
the source of the empirical data (e.g., peer-reviewed
narrative literature review, published and publicly
available reports, internal data analysis, etc.).

ADD YOUR CONTENT HERE
Free text field

If there is lengthy text, include details in a separate
evidence attachment.

CY 2025 Final Rule text:
Subsection
Evidence

Row
124

Field Label

*Summarize the empirical
data

ADD YOUR CONTENT HERE
Free text field

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

structure, or intervention with the outcome. Describe
the source of the empirical data (e.g., peer-reviewed
narrative literature review, published and publicly
available reports, internal data analysis, etc.).
If there is lengthy text, include details in a separate
evidence attachment.

Change #118
Location: Page 48, Row 125
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Evidence

Row
119

Field Label

*Empirical data citation

Guidance
If more than one empirical data was identified,
provide at least one of the following for one key
empirical data:
• 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.

CY 2025 Final Rule text:
Subsection
Evidence

Row
125

Field Label

*Empirical data citation

Guidance
If more than one empirical data was identified,
provide at least one of the following for one key
empirical data:
• 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.

Change #119
Location: Page 48, Row 126
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Evidence

Row
120

Field Label

*Summarize the grey
literature

Guidance
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
ADD YOUR CONTENT HERE

Provide the complete list of citations with
accompanying DOI or URL in a separate attachment.

CY 2025 Final Rule text:
Subsection
Evidence

Row
126

Field Label

*Summarize the grey
literature

ADD YOUR CONTENT HERE
ADD YOUR CONTENT HERE

Provide the complete list of citations with
accompanying DOI or URL in a separate attachment.

Change #120
Location: Page 48, Row 127
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Evidence

Row
121

Field Label

*Grey literature citation

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.

CY 2025 Final Rule text:
Subsection
Evidence

Row
127

Field Label

*Grey literature citation

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.

Change #121
Location: Page 49, Row 128
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Evidence

Row
122

Field Label

Guidance

*Does the evidence discuss

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.

a relationship between at
least one process,
structure, or intervention
with the outcome?

ADD YOUR CONTENT HERE
☐ Yes
☐ No

CY 2025 Final Rule text:
Subsection
Evidence

Row
128

Field Label

Guidance

*Does the evidence discuss

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.

a relationship between at
least one process,
structure, or intervention
with the outcome?

ADD YOUR CONTENT HERE
☐ Yes
☐ No

Change #122
Location: Page 49, Row 129 and Skip Logic
Reason for Change: Updated Row and Skip Logic.
CY 2024 Final Rule text:
Subsection

Row

Risk
Adjustment
and
Stratification

123

n/a

Field Label

*Is the measure risk
adjusted?

If you select “Yes” in Row
123, then Row 124 becomes
a become required field. If
you select “No” in Row 123,
then skip to Row 134.

Guidance
Indicate whether the final measure is risk adjusted.
Note that if you select “Yes,” you are encouraged to
upload documentation about the risk adjustment
model as an attachment.
n/a

ADD YOUR CONTENT HERE
☐ Yes
☐ No

This is not a data entry field.

CY 2025 Final Rule text:
Subsection

Row

Risk
Adjustment
and
Stratification

129

n/a

Field Label

*Is the measure risk
adjusted?

If you select “Yes” in Row
129, then Row 130 becomes
a become required field. If
you select “No” in Row 129,
then skip to Row 140.

Guidance
Indicate whether the final measure is risk adjusted.
Note that if you select “Yes,” you are encouraged to
upload documentation about the risk adjustment
model as an attachment.
n/a

ADD YOUR CONTENT HERE
☐ Yes
☐ No

This is not a data entry field.

Change #123
Location: Page 49, Row 130 and Skip Logic
Reason for Change: Updated Row and Skip Logic.
CY 2024 Final Rule text:
Subsection
Risk
Adjustment
and
Stratification

Row
124

Field Label

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

ADD YOUR CONTENT HERE
☐ Yes
☐ No

Subsection

n/a

Row

n/a

Field Label

If you select “Yes” in Row
124, then Row 125 becomes
a required field. If you select
“No” in Row 124, then skip
to Row 126.

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

ADD YOUR CONTENT HERE

This is not a data entry field.

CY 2025 Final Rule text:
Subsection
Risk
Adjustment
and
Stratification

n/a

Row
130

Field Label

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

n/a

If you select “Yes” in Row
130, then Row 131 becomes
a required field. If you select
“No” in Row 130, then skip
to Row 132.

Guidance
Select “Yes” if a conceptual model was established
based on a review of published literature. The
conceptual model can be supplemented by other
sources of information such as expert opinion or
empirical analysis.
Select “No” if a conceptual model was not established
or the conceptual model was based solely on expert
opinion or empirical analysis.
n/a

ADD YOUR CONTENT HERE
☐ Yes
☐ No

This is not a data entry field.

Change #124
Location: Page 49, Row 131
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Risk
Adjustment
and
Stratification

Row
125

Field Label

*Were all key risk factors
identified in the conceptual
model available for testing?

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

ADD YOUR CONTENT HERE
☐ Yes
☐ No (enter here:)

CY 2025 Final Rule text:
Subsection
Risk
Adjustment
and
Stratification

Row
131

Field Label

*Were all key risk factors
identified in the conceptual
model available for testing?

ADD YOUR CONTENT HERE
☐ Yes
☐ No (enter here:)

Change #125
Location: Pages 50-51, Row 132 and Skip Logic
Reason for Change: Updated Row, Guidance, text under “Add Your Content Here”, and Skip Logic.
CY 2024 Final Rule text:
Subsection
Risk
Adjustment
and
Stratification

Row
126

Field Label
Risk adjustment variable
types

Guidance
Select ALL risk adjustment variable types that are
included in your final risk model. For more
information on how to select risk factors for
accountability measures, refer to the Blueprint
content on the CMS MMS Hub
(https://mmshub.cms.gov/measurelifecycle/measure-specification/data-protocol/riskadjustment).
Select “Patient-level demographics” if the measure
uses information related to each patient’s age, sex,
race/ethnicity, etc.

ADD YOUR CONTENT HERE
☐ Patient-level demographics
☐ Patient-level health status &
clinical conditions
☐ Patient functional status
☐ Patient-level social risk factors
☐ Proxy social risk factors
☐ Patient community
characteristics
☐ Other (enter here):

Select “Patient-level health status & clinical
conditions” if the measure uses information specific
to each individual patient about their health status
prior to the start of care (e.g., case-mix adjustment).
Select “Patient functional status” if the measure uses
information specific to each individual patient’s
functional status prior to the start of care (e.g., body
function, ability to perform activities of daily living,
etc.)
Select “Patient-level social risk factors” if the measure
uses patient-reported information related to their
individual social risks (e.g., income, living alone, etc.).
Select “Proxy social risk factors” if the measure uses
data related to characteristics of the people in the
patient’s community (e.g., neighborhood level income
from the census).
Select “Patient community characteristics” if the
measure uses information about the patient’s
community (e.g., percent of vacant houses, crime
rate).

Risk
Adjustment
and
Stratification

n/a

If you select “Patient-Level
Demographics” in Row 126,
then Row 127 becomes a
required field. If you select
“Patient-level health status
& clinical conditions” in
Row 126, then Row 128
becomes a required field. If
you select “Patient
functional status” in Row
126, then Row 129 becomes
a required field. If you select

Select “Other” if the risk factor is related to the
healthcare provider, health system, or other factor
that is not related to the patient.
n/a

This is not a data entry field.

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Guidance

ADD YOUR CONTENT HERE

“Patient-level social risk
factors” in Row 126, then
Row 130 becomes a
required field. If you select
“Proxy social risk factors” in
Row 126, then Row 131
becomes a required field. If
you select “Patient
community characteristics”
in Row 126, then Row 132
becomes a required field.

CY 2025 Final Rule text:
Subsection
Risk
Adjustment
and
Stratification

Row
132

Field Label
Risk adjustment variable
types

Select ALL risk adjustment variable types that are
included in your final risk model. For more
information on how to select risk factors for
accountability measures, refer to the Blueprint
content on the CMS MMS Hub.
Select “Patient-level demographics” if the measure
uses information related to each patient’s age, sex,
social, economic, and geographic factors, etc.

☐ Patient community
characteristics
☐ Patient functional status
☐ Patient-level demographics
☐ Patient-level health status &
clinical conditions
☐ Patient-level social risk factors
☐ Proxy social risk factors
☐ Other (enter here):

Risk
Adjustment
and
Stratification

n/a

If you select “Patient-level
demographics” in Row 132,
then Row 133 becomes a
required field. If you select
“Patient-level health status
& clinical conditions” in
Row 132, then Row 134

Select “Other” if the risk factor is related to the
healthcare provider, health system, or other factor
that is not related to the patient.
n/a

This is not a data entry field.

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

becomes a required field. If
you select “Patient
functional status” in Row
132, then Row 135 becomes
a required field. If you select
“Patient-level social risk
factors” in Row 132, then
Row 136 becomes a
required field. If you select
“Proxy social risk factors” in
Row 132, then Row 137
becomes a required field. If
you select “Patient
community characteristics”
in Row 132, then Row 138
becomes a required field.

Change #126
Location: Page 51, Row 133
Reason for Change: Updated Row and text under “Add Your Content Here”.
CY 2024 Final Rule text:
Subsection
Risk
Adjustment
and
Stratification

Row
127

Field Label

*Patient-level

Guidance

ADD YOUR CONTENT HERE
☐ Age
☐ Sex
☐ Gender
☐ Race/ethnicity
☐ Other (enter here):

Select all that apply

demographics: please
select all that apply

CY 2025 Final Rule text:
Subsection
Risk
Adjustment
and
Stratification

Row
133

Field Label

*Patient-level

Guidance

ADD YOUR CONTENT HERE
☐ Age
☐ Social, Economic, and
Geographic Factors
☐ Sex
☐ Other (enter here):

Select all that apply

demographics: please
select all that apply

Change #127
Location: Page 51, Row 134
Reason for Change: Updated Row and text under “Add Your Content Here”.
CY 2024 Final Rule text:
Subsection
Risk
Adjustment
and
Stratification

Row
128

Field Label

*Patient-level health status
& clinical conditions: please
select all that apply

Guidance
Select all that apply

ADD YOUR CONTENT HERE
☐ Case-Mix Adjustment
☐ Severity of Illness
☐ Comorbidities
☐ Health behaviors/health
choices
☐ Other (enter here):

CY 2025 Final Rule text:
Subsection
Risk
Adjustment
and
Stratification

Row
134

Field Label

*Patient-level health status

Guidance

ADD YOUR CONTENT HERE
☐ Case-Mix Adjustment
☐ Comorbidities
☐ Health behaviors/health
choices
☐ Severity of Illness
☐ Other (enter here):

Select all that apply

& clinical conditions: please
select all that apply

Change #128
Location: Page 51, Row 135
Reason for Change: Updated Row and text under “Add Your Content Here”.
CY 2024 Final Rule text:
Subsection
Risk
Adjustment
and
Stratification

Row
129

Field Label

*Patient functional status:

Guidance

ADD YOUR CONTENT HERE
☐ Body Function
☐ Ability to perform activities of
daily living
☐ Other (enter here):

Select all that apply

please select all that apply

CY 2025 Final Rule text:
Subsection
Risk
Adjustment
and
Stratification

Row
135

Field Label

*Patient functional status:

Guidance

ADD YOUR CONTENT HERE
☐ Ability to perform activities of
daily living
☐ Body Function
☐ Other (enter here):

Select all that apply

please select all that apply

Change #129
Location: Page 52, Row 136
Reason for Change: Updated Row and text under “Add Your Content Here”.
CY 2024 Final Rule text:
Subsection
Risk
Adjustment
and
Stratification

Row
130

Field Label

*Patient-level social risk

Guidance

ADD YOUR CONTENT HERE
☐ Income
☐ Education
☐ Wealth
☐ Living Alone
☐ Social Support
☐ Other (enter here):

Select all that apply

factors: please select all
that apply

CY 2025 Final Rule text:
Subsection
Risk
Adjustment
and
Stratification

Row
136

Field Label

*Patient-level social risk
factors: please select all
that apply

Guidance
Select all that apply

ADD YOUR CONTENT HERE
☐ Education
☐ Income
☐ Living Alone
☐ Social Support
☐ Wealth
☐ Other (enter here):

Change #130
Location: Page 52, Row 137
Reason for Change: Updated Row and text under “Add Your Content Here”.
CY 2024 Final Rule text:
Subsection
Risk
Adjustment
and
Stratification

Row
131

Field Label

*Proxy social risk factors:

Guidance

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

Select all that apply

please select all that apply

CY 2025 Final Rule text:
Subsection
Risk
Adjustment
and
Stratification

Row
137

Field Label

*Proxy social risk factors:

Guidance

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

Select all that apply

please select all that apply

Change #131
Location: Page 52, Row 138
Reason for Change: Updated Row and text under “Add Your Content Here”.
CY 2024 Final Rule text:
Subsection
Risk
Adjustment
and
Stratification

Row
132

Field Label

*Patient community

Guidance

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

Select all that apply

characteristics: please
select all that apply

CY 2025 Final Rule text:
Subsection
Risk
Adjustment
and
Stratification

Row
138

Field Label

*Patient community

Guidance

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

Select all that apply

characteristics: please
select all that apply

Change #132
Location: Page 52, Row 139
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Risk
Adjustment
and
Stratification

Row
133

Field Label

*Risk model performance

Guidance
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.

ADD YOUR CONTENT HERE
Free text field

CY 2025 Final Rule text:
Subsection
Risk
Adjustment
and
Stratification

Row
139

Field Label

*Risk model performance

ADD YOUR CONTENT HERE
Free text field

Change #133
Location: Pages 52-53, Row 140 and Skip Logic
Reason for Change: Updated Row, Guidance, text under “Add Your Content Here”, and Skip Logic.
CY 2024 Final Rule text:
Subsection
Risk
Adjustment
and
Stratification

n/a

Row
134

Field Label

*Is the measure
recommended to be
stratified based on
evidence from testing
and/or literature?

n/a

If you select a “Yes”
response in Row 134, then
Row 135 becomes a
required field. If you select a
“No” response in Row 134
AND selected a “No”
response in Row 123, then
Row 136 becomes a
required field. Otherwise
skip to Row 137.

Guidance

ADD YOUR CONTENT HERE

Select one. Indicate whether the final measure is
recommended to be stratified. Indicate whether the
recommended stratification is intended to address an
equity gap.

☐ Yes, the measure is
recommended to be stratified to
address an equity gap
☐ Yes, the measure is
recommended to be stratified for
reasons unrelated to an equity
gap
☐ Yes, the measure is
recommended to be stratified
both to address an equity gap
AND for other reasons ☐ No, the
measure is not recommended to
be stratified

Health equity elements for stratification include
sociodemographic data such as race, ethnicity, tribal
sovereignty, language, geography, sex, sexual
orientation and gender identity (SOGI), language,
income, and disability status, as well as social
determinants of health (SDOH) featured in the
Healthy People 2030 SDOH Framework across five
domains: economic stability, education access and
quality, health care access and quality, neighborhood
and built environment, and social and community
context.
For more information about health equity elements,
please refer to the Equity Data Standardization page
on the CMS MMS Hub and the CMS Office of Minority
Heath white paper titled “The Path Forward:
Improving Data to Advance Health Equity Solutions,”
available at: https://mmshub.cms.gov/aboutquality/quality-at-CMS/goals/cms-focus-on-healthequity/equity-data-standardization.
n/a

This is not a data entry field.

CY 2025 Final Rule text:
Subsection
Risk
Adjustment
and
Stratification

Row
140

Field Label

*Is the measure
recommended to be
stratified based on
evidence from testing
and/or literature?

Guidance
Select one. Indicate whether the final measure is
recommended to be stratified. Indicate whether the
recommended stratification is intended to address
the closing of care gaps.
Elements for stratification to address the closing of
care gaps includes sociodemographic data such as
language, sex, disability status, tribal sovereignty, and
social, economic, and geographic factors, as well as
social determinants of health (SDOH) featured in the
Healthy People 2030 SDOH Framework across five
domains: economic stability, education access and
quality, health care access and quality, neighborhood
and built environment, and social and community
context.

ADD YOUR CONTENT HERE
☐ Yes, the measure is
recommended to be stratified to
address a gap in care
☐ Yes, the measure is
recommended to be stratified for
reasons unrelated to a gap in care
☐ Yes, the measure is
recommended to be stratified
both to address a gap in care AND
for other reasons
☐ No, the measure is not
recommended to be stratified

For more information about elements related to
closing care gaps, please refer to the Standardizing
Data to Close the Care Gap page on the CMS MMS
Hub.
n/a

n/a

If you select a “Yes”
response in Row 140, then
Row 141 becomes a
required field. If you select a
“No” response in Row 140
AND selected a “No”
response in Row 129, then
Row 142 becomes a
required field. Otherwise
skip to Row 143.

n/a

This is not a data entry field.

Change #134
Location: Page 53, Row 141
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Risk
Adjustment
and
Stratification

Row
135

Field Label

*Stratification approach

Guidance
Describe the recommended stratification approach
including the data elements used to stratify scores for
subgroups. Demonstrate that there is sufficient
sample size within measured entities to stratify
measure scores.

ADD YOUR CONTENT HERE
Free text field

Indicate whether the recommendation to stratify the
measure is based on evidence from testing and/or the
literature.
If findings from testing informed the recommendation
to stratify the measure, summarize the findings
indicating that stratification would improve
interpretation of measure results. If more room is
needed, provide testing results as an attachment and
list the name of the attachment in this field.

If evidence from the literature informed the
recommendation to stratify the measure, provide
citations supporting your stratification approach.

CY 2025 Final Rule text:
Subsection
Risk
Adjustment
and
Stratification

Row
141

Field Label

*Stratification approach

ADD YOUR CONTENT HERE
Free text field

Change #135
Location: Page 53, Line 142
Reason for Change: Updated Row, Guidance, and text under “Add Your Content Here”.
CY 2024 Final Rule text:
Subsection
Risk
Adjustment
and
Stratification

Row
136

Field Label

*Rationale for using
neither risk adjustment nor
stratification

Guidance

ADD YOUR CONTENT HERE

Select ALL reasons for not implementing a risk
adjustment model or stratification approach in the
measure. For more information, refer to the Risk
Adjustment in Quality Measurement supplemental
material on the CMS MMS Hub
(https://mmshub.cms.gov/tools-and-resources/mmssupplemental-materials) and the guidance on defining
stratification schemes
(https://mmshub.cms.gov/measurelifecycle/measure-specification/developspecification/stratification)

☐ Addressed through exclusions
(e.g., process measures)
☐ Risk adjustment not
appropriate based on conceptual
or empirical rationale (enter
here):
☐ Data were not available to
evaluate risk adjustment or
stratification (enter here):
☐ Risk adjustment and
stratification were not considered
during development or testing
☐ Other (enter here):

Guidance

ADD YOUR CONTENT HERE

CY 2025 Final Rule text:
Subsection
Risk
Adjustment
and
Stratification

Row
142

Field Label

*Rationale for using
neither risk adjustment nor
stratification

Select ALL reasons for not implementing a risk
adjustment model or stratification approach in the
measure. For more information, refer to the Risk
Adjustment in Quality Measurement supplemental

☐ Addressed through exclusions
☐ Data were not available to
evaluate risk adjustment or
stratification (enter here):

Subsection

Row

Field Label

Guidance
material on the CMS MMS Hub and the guidance on
defining stratification schemes.

ADD YOUR CONTENT HERE
☐ Risk adjustment and
stratification were not considered
during development or testing
☐ Risk adjustment not
appropriate based on conceptual
or empirical rationale (enter
here):
☐ Other (enter here):

Change #136
Location: Page 54, Row 143
Reason for Change: Updated Row, Field Label, Guidance, and text under “Add Your Content Here”.
CY 2024 Final Rule text:
Subsection
Healthcare
Domain

Row
137

Field Label

*What one Meaningful
Measures 2.0 priority is
most applicable to this
measure?

Guidance
Select the ONE most applicable Meaningful Measures
2.0 priority. For more information, see:
https://www.cms.gov/meaningful-measures-20moving-measure-reduction-modernization

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

CY 2025 Final Rule text:
Subsection
Healthcare
Domain

Row
143

Field Label

*What one Meaningful
Measures 2.0 domain is
most applicable to this
measure?

Guidance

ADD YOUR CONTENT HERE

Select the ONE most applicable Meaningful Measures
2.0 domain.

☐ Behavioral Health
☐ Chronic Conditions and Related
Acute Events
☐ Closing Gaps of Care
☐ Person-Centered Care
☐ Safety
☐ Seamless Care Coordination
☐ Value, Affordability, and
Efficiency
☐ Wellness and Prevention

Change #137
Location: Page 54, Row 144
Reason for Change: Updated Row, Field Label, Guidance, and text under “Add Your Content Here”.
CY 2024 Final Rule text:
Subsection
Healthcare
Domain

Row
138

Field Label
What, if any, additional
Meaningful Measures 2.0
priorities apply to this
measure?

Guidance
Select up to two additional Meaningful Measures 2.0
priorities that apply to this measure.
For more information, see:
https://www.cms.gov/meaningful-measures-20moving-measure-reduction-modernization

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

☐ Behavioral Health

CY 2025 Final Rule text:
Subsection
Healthcare
Domain

Row
144

Field Label
What, if any, additional
Meaningful Measures 2.0
domain apply to this
measure?

Guidance
Select up to two additional Meaningful Measures 2.0
domain that apply to this measure.

ADD YOUR CONTENT HERE
☐ Behavioral Health
☐ Chronic Conditions and Related
Acute Events
☐ Closing Gaps of Care
☐ Person-Centered Care
☐ Safety
☐ Seamless Care Coordination
☐ Value, Affordability, and
Efficiency
☐ Wellness and Prevention

Change #138
Location: Page 54, Row 145
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Other
Priorities

Row
139

Field Label

*Does this measure

Guidance

ADD YOUR CONTENT HERE
☐ Yes
☐ No

Select one.

address CMS priorities to
improve maternal health
care or maternal
outcomes?

CY 2025 Final Rule text:
Subsection
Other
Priorities

Row
145

Field Label

*Does this measure

Guidance

ADD YOUR CONTENT HERE
☐ Yes
☐ No

Select one.

address CMS priorities to
improve maternal health
care or maternal
outcomes?

Change #139
Location: Page 54, Row 146
Reason for Change: Updated Row and Guidance.
CY 2024 Final Rule text:
Subsection
Endorsement
Characteristics

Row
140

Field Label

Guidance

*What is the endorsement

Select only one. For information on consensus-based
entity (CBE) endorsement, measure ID, and other
information, refer to: https://p4qm.org/

status of the measure?

ADD YOUR CONTENT HERE
☐ Endorsed
☐ Endorsed with conditions
☐ Endorsement removed
☐ Submitted
☐ Failed endorsement or
decision to not endorse
☐ Never submitted

CY 2025 Final Rule text:
Subsection
Endorsement
Characteristics

Row
146

Field Label

Guidance

*What is the endorsement

Select only one. For information on consensus-based
entity (CBE) endorsement, measure ID, and other
information, refer to the PQM Webpage.

status of the measure?

ADD YOUR CONTENT HERE
☐ Endorsed
☐ Endorsed with conditions
☐ Endorsement removed
☐ Submitted
☐ Failed endorsement or
decision to not endorse
☐ Never submitted

Change #140
Location: Page 54, Row 147
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Endorsement
Characteristics

Row
141

Field Label

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

Guidance
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.

ADD YOUR CONTENT HERE
ADD YOUR CONTENT HERE

CY 2025 Final Rule text:
Subsection
Endorsement
Characteristics

Row
147

Field Label

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

ADD YOUR CONTENT HERE
ADD YOUR CONTENT HERE

Change #141
Location: Page 54, Row 148 and Skip Logic
Reason for Change: Updated Row and Skip Logic.
CY 2024 Final Rule text:
Subsection

Row

Endorsement
Characteristics

142

n/a

Field Label
If endorsed: Is the measure
being submitted exactly as
endorsed by the CMS CBE?
If you select “No” in Row
142, then Rows 143-144
become required fields.

Guidance
Select 'Yes' or 'No'. Note that 'Yes' should only be
selected if the submission is an EXACT match to the
CBE-endorsed measure.
n/a

ADD YOUR CONTENT HERE
☐ Yes
☐ No
This is not a data entry field.

CY 2025 Final Rule text:
Subsection
Endorsement
Characteristics

Row
148

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

Guidance
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
☐ Yes
☐ No

Subsection
n/a

Row
n/a

Field Label
If you select “No” in Row
148, then Rows 149-150
become required fields.

Guidance
n/a

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

Change #142
Location: Page 55, Row 149
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Endorsement
Characteristics

Row
143

Field Label
If not exactly as endorsed,
specify the locations of the
differences

Guidance
Indicate which specification fields are different.
Select all that apply

ADD YOUR CONTENT HERE
☐ 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):

CY 2025 Final Rule text:
Subsection
Endorsement
Characteristics

Row
149

Field Label
If not exactly as endorsed,
specify the locations of the
differences

Guidance
Indicate which specification fields are different.
Select all that apply

Change #143
Location: Page 55, Row 150
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Endorsement
Characteristics

Row
144

Field Label
If not exactly as endorsed,
describe the nature of the
differences

Guidance
Briefly describe the differences

ADD YOUR CONTENT HERE
Free text field

CY 2025 Final Rule text:
97

Subsection
Endorsement
Characteristics

Row
150

Field Label
If not exactly as endorsed,
describe the nature of the
differences

Guidance
Briefly describe the differences

ADD YOUR CONTENT HERE
Free text field

Change #144
Location: Page 55, Row 151
Reason for Change: Updated Row and text under “Add Your Content Here”.
CY 2024 Final Rule text:
Subsection
Endorsement
Characteristics

Row
145

Field Label
If endorsed: Year of most
recent CBE endorsement

Guidance

ADD YOUR CONTENT HERE
☐ 2017
☐ 2018
☐ 2019
☐ 2020
☐ 2021
☐ 2022
☐ 2023

Select one

CY 2025 Final Rule text:
Subsection
Endorsement
Characteristics

Row
151

Field Label
If endorsed: Year of most
recent CBE endorsement

Guidance

ADD YOUR CONTENT HERE
☐ 2017
☐ 2018
☐ 2019
☐ 2020
☐ 2021
☐ 2022
☐ 2023
☐ 2024

Select one

Change #145
Location: Page 55, Row 152
Reason for Change: Updated Row and text under “Add Your Content Here”.
CY 2024 Final Rule text:
Subsection
Endorsement
Characteristics

Row
146

Field Label
Year of next anticipated
CBE endorsement review

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

ADD YOUR CONTENT HERE
☐ 2024
☐ 2025
☐ 2026
☐ 2027
☐ 2028

CY 2025 Final Rule text:
Subsection
Endorsement
Characteristics

Row
152

Field Label
Year of next anticipated
CBE endorsement review

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

ADD YOUR CONTENT HERE
☐ 2025
☐ 2026
☐ 2027
☐ 2028
☐ 2029

Change #146
Location: Page 56, Row 153 and Skip Logic
Reason for Change: Updated Row and Skip Logic.
CY 2024 Final Rule text:
Subsection

Row

Related and
Competing
Measures

147

n/a

Field Label

Guidance

*Is this measure related to

Select either Yes or No. Consider other measures with
related purposes.

☐ Yes
☐ No

n/a

This is not a data entry field.

and/or competing with
measure(s) already in a
program?
If you select “Yes” in Row
147, then Rows 148-150
become required fields. If
you select “No” in Row 147,
then skip to Row 151.

ADD YOUR CONTENT HERE

CY 2025 Final Rule text:
Subsection

Row

Related and
Competing
Measures

153

n/a

Field Label

Guidance

*Is this measure related to

Select either Yes or No. Consider other measures with
related purposes.

☐ Yes
☐ No

n/a

This is not a data entry field.

and/or competing with
measure(s) already in a
program?
If you select “Yes” in Row
153, then Rows 154-156
become required fields. If
you select “No” in Row 153,
then skip to Row 157.

ADD YOUR CONTENT HERE

Change #147
Location: Page 56, Row 154
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Related and
Competing
Measures

Row
148

Field Label

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

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

ADD YOUR CONTENT HERE
Free text field

CY 2025 Final Rule text:
Subsection
Related and
Competing
Measures

Row
154

Field Label

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

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

ADD YOUR CONTENT HERE
Free text field

Change #148
Location: Page 56, Row 155
Reason for Change: Updated Row, Field Label, and Guidance.
CY 2024 Final Rule text:
Subsection
Related and
Competing
Measures

Row
149

Field Label

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

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

ADD YOUR CONTENT HERE
Free text field

CY 2025 Final Rule text:
Subsection
Related and
Competing
Measures

Row
155

Field Label

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

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

ADD YOUR CONTENT HERE
Free text field

In your response, please also consider distribution of
measure impact, benefits, and burdens across
program entities and populations (Appropriateness of
Scale) as well as potential near and long term impacts
of measure implementation (Time to Value
Realization).

Change #149
Location: Page 56, Row 156
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
Related and
Competing
Measures

Row
150

Field Label

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

Guidance
Describe key differences that set this measure apart
from others.

ADD YOUR CONTENT HERE
Free text field

CY 2025 Final Rule text:
Subsection
Related and
Competing
Measures

Row
156

Field Label

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

Guidance
Describe key differences that set this measure apart
from others.

ADD YOUR CONTENT HERE
Free text field

100

Change #150
Location: Page 56, Row 157
Reason for Change: Updated Row and Guidance.
CY 2024 Final Rule text:
Subsection
Related and
Competing
Measures

Row
151

Field Label

*Universal Foundation
Measure

Guidance
Select one. Indicate whether this measure is a
Universal Foundation quality measure.
To be considered a Universal Foundation quality
measure, the submitted measure’s population must
align with the population of the existing Universal
Foundation measure (i.e., adult and/or pediatric).

ADD YOUR CONTENT HERE
☐ Measure is a Universal
Foundation quality measure
(populations must align)
☐ Measure is not a Universal
Foundation quality measure

Please refer to the “Aligning Quality Measures Across
CMS – the Universal Foundation” webpage for more
information about Universal Foundation of quality
measures available at: https://www.cms.gov/aligningquality-measures-across-cms-universal-foundation

CY 2025 Final Rule text:
Subsection
Related and
Competing
Measures

Row
157

Field Label

*Universal Foundation
Measure

ADD YOUR CONTENT HERE
☐ Measure is a Universal
Foundation quality measure
(populations must align)
☐ Measure is not a Universal
Foundation quality measure

Please refer to the “Aligning Quality Measures Across
CMS – the Universal Foundation” webpage for more
information about Universal Foundation of quality
measures.

Change #151
Location: Page 57, Row 158
Reason for Change: Updated Row, Guidance, and text under “Add Your Content Here”.
CY 2024 Final Rule text:
Subsection
N/A

Row
152

Field Label
Attachment(s)

Guidance
You are encouraged to attach the measure
information form (MIF) if available. This is a detailed
description of the measure used by the CMS
consensus-based entity (CBE) during endorsement
proceedings. If a MIF is not available, comprehensive
measure methodology documents are encouraged.

ADD YOUR CONTENT HERE
ADD YOUR CONTENT HERE

101

Subsection

Row

Field Label

Guidance

ADD YOUR CONTENT HERE

Patient-AssessmentInstruments/QualityMeasures/Pre-Rulemaking
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
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.

CY 2025 Final Rule text:
Subsection
N/A

Row
158

Field Label
Attachment(s)

Guidance

ADD YOUR CONTENT HERE

You are encouraged to attach the Measure
Information and Justification Form (MIJF) if available.
The MIJF is a guide for documenting specifications
and measure development information when
submitting contracted measure deliverables to CMS.
Previously, the recommended form included the
Measure Information Form (MIF), which was
combined with the Measure Justification Form (MJF)
into a single form. For all future measure submissions,
CMS prefers the MIJF. However, if a submitter already
has a MIF from last year's submission, that would be
accepted. If a MIJF is not available, comprehensive
measure methodology documents are encouraged.

☐ Alternative Level Testing
Results
☐ eCQM Materials
(Specifications, Test Cases, Value
Sets, Feasibility Scorecard)
☐ Measure Information and
Justification Form (MIJF)
☐ Measure Information Form
(MIF)
☐ MIPS Peer Reviewed Journal
Article Template
☐ Risk Adjusted Materials
☐ Other (Please specify:)

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.
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
If eCQM, you must attach the eCQM specifications
exported from MADiE, test cases exported from
MADiE with 100% coverage/100% passing (both
QRDA and Excel format), attestation that value sets
are published in VSAC, and feasibility scorecard.

102

Change #152
Location: Page 57, Row 159
Reason for Change: Updated Row and Guidance.
CY 2024 Final Rule text:
Subsection
N/A

Row
153

Field Label
MIPS Peer Reviewed
Journal Article Template

Guidance
Select Yes or No. For those submitting measures to
MIPS program, enter “Yes.” Attach your completed
Peer Reviewed Journal Article Template.

ADD YOUR CONTENT HERE
☐ Yes
☐ No

CY 2025 Final Rule text:
Subsection
N/A

Row
159

Field Label
MIPS Peer Reviewed
Journal Article Template

Guidance
Select Yes or No. For those submitting quality
measures to MIPS program, enter “Yes.” Attach your
completed Peer Reviewed Journal Article Template.

ADD YOUR CONTENT HERE
☐ Yes
☐ No

Change #153
Location: Page 58, Row 160
Reason for Change: Updated Row.
CY 2024 Final Rule text:
Subsection
N/A

Row
154

Field Label
Submitter Comments

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

ADD YOUR CONTENT HERE
Free text field

CY 2025 Final Rule text:
Subsection
N/A

Row
160

Field Label
Submitter Comments

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

ADD YOUR CONTENT HERE
Free text field

Change #154
Location: Page 59, Appendix A.001
Reason for Change: Updated Title
CY 2024 Final Rule text:
Subsection
Appendix

Title

A. 085 Choices for Measure Steward and Long-Term Measure Steward (if different)

CY 2025 Final Rule text:
Subsection
Appendix

Title

A.001 Choices for Measure Steward or Owner and Long-Term Measure Steward or Owner (if different)

103

Change #155
Location: Page 60, Appendix A.108
Reason for Change: Updated Title
CY 2024 Final Rule text:
Subsection
Appendix

Title

A.098 Choices for Areas of specialty

CY 2025 Final Rule text:
Subsection
Appendix

Title

A.108 Choices for Areas of specialty

According to the Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.), no persons are
required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0938-1314
(Expiration date: 2/28/2027). This information collection is the tool for measure developers to
submit their clinical quality measures for consideration by CMS. The time required to
complete this information collection is estimated to average 3.5 hours per response, including
the time to review instructions, search existing data resources, gather the data needed, to
review and complete the information collection. This information collection is voluntary and all
information collected will be kept private in accordance with regulations at 45 CFR 155.260,
Privacy and Security of Personally Identifiable Information. Pursuant to this regulation, CMS
may only use or disclose personally identifiable information to the extent that such
information is necessary to carry out their statutory and regulatory mandated functions. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving
this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance
Officer, Mail Stop C4-26-05, Baltimore, MD 21244-1850. If you have questions or concerns
regarding where to submit your documents, please contact QPP at qpp@cms.hhs.gov.
Under the Privacy Act of 1974 (5 U.S.C. 552a) any personally identifying information
obtained will be kept private to the extent of the law.

104

File Type	application/pdf
File Title	MUC Data Template Crosswalk CY 2024 Final Versus CY 2025 Final
Keywords	MUC, Data Template, Crosswalk, 2024, 2025
Author	Centers for Medicare & Medicaid Services (CMS)
File Modified	2025:08:25 11:15:38-04:00
File Created	2025:05:23 10:54:50-04:00