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MIPS Measures & Activities Supported in PY 2019

Quality ID NQF Measure Title Measure Description NQS Domain
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001 0059 Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Intermediate Outcome Yes Family Medicine, Internal Medicine, Nephrology, Preventative Medicine
Quality ID NQF Measure Title Measure Description NQS Domain
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005 0081
Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Cardiology, Family Medicine, Hospitalists, Internal Medicine
Quality ID NQF Measure Title Measure Description NQS Domain
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006 0067 Coronary Artery Disease (CAD): Antiplatelet Therapy Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12 month period who were prescribed aspirin or clopidogrel Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Cardiology, Family Medicine, Internal Medicine, Skilled Nursing Facility
Quality ID NQF Measure Title Measure Description NQS Domain
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007 0070
Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%) Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12-month period who also have a prior MI or a current or prior LVEF < 40% who were prescribed beta-blocker therapy Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Cardiology, Family Medicine, Internal Medicine, Skilled Nursing Facility
Quality ID NQF Measure Title Measure Description NQS Domain
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008 0083 Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Cardiology, Family Medicine, Hospitalists, Internal Medicine, Skilled Nursing Facility
Quality ID NQF Measure Title Measure Description NQS Domain
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012 0086 Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more office visits within 12 months Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Ophthalmology
Quality ID NQF Measure Title Measure Description NQS Domain
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014 0087 Age-Related Macular Degeneration (AMD): Dilated Macular Examination Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or geographic atrophy or hemorrhage AND the level of macular degeneration severity during one or more office visits within the 12 month performance period Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Ophthalmology
Quality ID NQF Measure Title Measure Description NQS Domain
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019 0089 Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months Communication and Care Coordination 
Measure Type High Priority Specialty Measure Sets
Process Yes Ophthalmology
Quality ID NQF Measure Title Measure Description NQS Domain
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021 0268 Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second-Generation Cephalosporin Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second-generation cephalosporin prophylactic antibiotic who had an order for a first OR second-generation cephalosporin for antimicrobial prophylaxis Patient Safety
Measure Type High Priority Specialty Measure Sets
Process Yes General Surgery, Neurosurgery, Orthopedic Surgery, Otolaryngology, Plastic Surgery, Thoracic Surgery, Vascular Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
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023 N/A Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) Percentage of surgical patients aged 18 years and older undergoing procedures for which venous thromboembolism (VTE) prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time Patient Safety
Measure Type High Priority Specialty Measure Sets
Process Yes General Surgery, Neurosurgery, Orthopedic Surgery, Otolaryngology, Plastic Surgery, Thoracic Surgery, Urology, Vascular Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
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024 N/A Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older Percentage of patients aged 50 years and older treated for a fracture with documentation of communication, between the physician treating the fracture and the physician or other clinician managing the patient’s on-going care, that a fracture occurred and that the patient was or should be considered for osteoporosis treatment or testing. This measure is submitted by the physician who treats the fracture and who therefore is held accountable for the communication Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Process Yes Family Medicine, Internal Medicine, Orthopedic Surgery, Preventative Medicine, Rheumatology
Quality ID NQF Measure Title Measure Description NQS Domain
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039 0046 Screening for Osteoporosis for Women Aged 65-85 Years of Age Percentage of female patients aged 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) to check for osteoporosis Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Family Medicine, Geriatrics, Internal Medicine, Preventative Medicine, Rheumatology
Quality ID NQF Measure Title Measure Description NQS Domain
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044 0236 Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery Percentage of isolated Coronary Artery Bypass Graft (CABG) surgeries for patients aged 18 years and older who received a beta-blocker within 24 hours prior to surgical incision Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Anesthesiology
Quality ID NQF Measure Title Measure Description NQS Domain
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046 0097 Medication Reconciliation Post-Discharge The percentage of discharges from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years and older of age seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record
This measure is reported as three rates stratified by age group:
• Submission Criteria 1: 18-64 years of age
• Submission Criteria 2: 65 years and older
• Total Rate: All patients 18 years of age and older
Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Process Yes General Surgery, Geriatrics, Nephrology, Orthopedic Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
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047 0326 Advance Care Plan Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Process Yes Cardiology, Family Medicine, Gastroenterology, General Surgery, Geriatrics, Hospitalists, Internal Medicine, Nephrology, Neurology, Obstetrics/Gynecology, Oncology, Orthopedic Surgery, Otolaryngology, Physical Medicine, Preventative Medicine, Rheumatology, Skilled Nursey Facility, Thoracic Surgery, Urology, Vascular Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
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048 N/A Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older  Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Family Medicine, Internal Medicine, Obstetrics/Gynecology, Preventative Medicine, Urology
Quality ID NQF Measure Title Measure Description NQS Domain
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050 N/A Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months Person and Caregiver-Centered Experience and Outcomes
Measure Type High Priority Specialty Measure Sets
Process Yes Family Medicine, Geriatrics, Internal Medicine, Obstetrics/Gynecology, Urology
Quality ID NQF Measure Title Measure Description NQS Domain
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051 0091 Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation Percentage of patients aged 18 years and older with a diagnosis of COPD who had spirometry results documented Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No N/A
Quality ID NQF Measure Title Measure Description NQS Domain
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052 0102 Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy Percentage of patients aged 18 years and older with a diagnosis of COPD (FEV1/FVC < 70%) and who have an FEV1 less than 60% predicted and have symptoms who were prescribed a long-acting inhaled bronchodilator Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No N/A
Quality ID NQF Measure Title Measure Description NQS Domain
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065 0069 Appropriate Treatment for Children with Upper Respiratory Infection (URI) Percentage of children 3 months - 18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode Efficiency and Cost Reduction
Measure Type High Priority Specialty Measure Sets
Process Yes Family Medicine, Otolaryngology, Pediatrics, Urgent Care
Quality ID NQF Measure Title Measure Description NQS Domain
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066 N/A Appropriate Testing for Children with Pharyngitis Percentage of children 3-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode Efficiency and Cost Reduction
Measure Type High Priority Specialty Measure Sets
Process Yes Emergency Medicine, Family Medicine, Pediatrics, Urgent Care
Quality ID NQF Measure Title Measure Description NQS Domain
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067 0377 Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow  Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) or an acute leukemia who had baseline cytogenetic testing performed on bone marrow Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No N/A
Quality ID NQF Measure Title Measure Description NQS Domain
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068 0378 Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) who are receiving erythropoietin therapy with documentation of iron stores within 60 days prior to initiating erythropoietin therapy Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No N/A
Quality ID NQF Measure Title Measure Description NQS Domain
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069 N/A Hematology: Multiple Myeloma: Treatment with Bisphosphonates  Percentage of patients aged 18 years and older with a diagnosis of multiple myeloma, not in remission, who were prescribed or received intravenous bisphosphonate therapy within the 12-month reporting period Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No N/A
Quality ID NQF Measure Title Measure Description NQS Domain
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070 N/A Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry Percentage of patients aged 18 years and older, seen within a 12-month reporting period, with a diagnosis of chronic lymphocytic leukemia (CLL) made at any time during or prior to the reporting period who had baseline flow cytometry studies performed and documented in the chart Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No N/A
Quality ID NQF Measure Title Measure Description NQS Domain
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076 2726 Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections  Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed Patient Safety
Measure Type High Priority Specialty Measure Sets
Process Yes Anesthesiology, Hospitalists, Interventional Radiology
Quality ID NQF Measure Title Measure Description NQS Domain
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091 0653 Acute Otitis Externa (AOE): Topical Therapy Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process Yes Emergency Medicine, Family Medicine, Internal Medicine, Otolaryngology, Pediatrics, Urgent Care
Quality ID NQF Measure Title Measure Description NQS Domain
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093 0654 Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy Efficiency and Cost Reduction
Measure Type High Priority Specialty Measure Sets
Process Yes Emergency Medicine, Family Medicine, Internal Medicine, Otolaryngology, Pediatrics, Urgent Care
Quality ID NQF Measure Title Measure Description NQS Domain
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102 0389 Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer Efficiency and Cost Reduction
Measure Type High Priority Specialty Measure Sets
Process Yes Oncology, Radiation Oncology, Urology
Quality ID NQF Measure Title Measure Description NQS Domain
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104 0390 Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate Cancer  Percentage of patients, regardless of age, with a diagnosis of prostate cancer at high or very high risk of recurrence receiving external beam radiotherapy to the prostate who were prescribed androgen deprivation therapy in combination with external beam radiotherapy to the prostate  Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Urology
Quality ID NQF Measure Title Measure Description NQS Domain
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109 N/A Osteoarthritis (OA): Function and Pain Assessment  Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain Person and Caregiver-Centered Experience and Outcomes
Measure Type High Priority Specialty Measure Sets
Process Yes Family Medicine, Orthopedic Surgery, Physical Medicine, Preventative Medicine
Quality ID NQF Measure Title Measure Description NQS Domain
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110 0041 Preventive Care and Screening: Influenza Immunization Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization Community/Population Health
Measure Type High Priority Specialty Measure Sets
Process No Allergy/Immunology, Family Medicine, Geriatrics, Infectious Disease, Internal Medicine, Nephrology, Obstetrics/Gynecology, Oncology, Otolaryngology, Pediatrics, Preventative Medicine, Rheumatology, Skilled Nursing Facility
Quality ID NQF Measure Title Measure Description NQS Domain
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111 0043 Pneumococcal Vaccination Status for Older Adults Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine Community/Population Health
Measure Type High Priority Specialty Measure Sets
Process No Allergy/Immunology, Family Medicine, Geriatrics, Infectious Disease, Internal Medicine, Nephrology, Obstetrics/Gynecology, Oncology, Otolaryngology, Pediatrics, Preventative Medicine, Rheumatology
Quality ID NQF Measure Title Measure Description NQS Domain
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112 2372 Breast Cancer Screening Percentage of women 50 - 74 years of age who had a mammogram to screen for breast cancer Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Family Medicine, Obstetrics/Gynecology, Preventative Medicine
Quality ID NQF Measure Title Measure Description NQS Domain
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113 0034 Colorectal Cancer Screening Percentage of patients 50-75 years of age who had appropriate screening for colorectal cancer Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Family Medicine, Preventative Medicine
Quality ID NQF Measure Title Measure Description NQS Domain
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116 0058 Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis The percentage of adults 18–64 years of age with a diagnosis of acute bronchitis who were not prescribed or dispensed an antibiotic prescription Efficiency and Cost Reduction
Measure Type High Priority Specialty Measure Sets
Process Yes Emergency Medicine, Family Medicine, Internal Medicine, Preventative Medicine, Urgent Care
Quality ID NQF Measure Title Measure Description NQS Domain
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117 0055 Diabetes: Eye Exam Percentage of patients 18 - 75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal or dilated eye exam (no evidence of retinopathy) in the 12 months prior to the measurement period Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Family Medicine, Internal Medicine, Ophthalmology
Quality ID NQF Measure Title Measure Description NQS Domain
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118 0066 Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%) Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Cardiology, Skilled Nursing Facility
Quality ID NQF Measure Title Measure Description NQS Domain
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119 0062 Diabetes: Medical Attention for Nephropathy The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Family Medicine, Internal Medicine, Nephrology, Podiatry, Preventative Medicine
Quality ID NQF Measure Title Measure Description NQS Domain
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126 0417 Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 months Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Family Medicine, Internal Medicine, Podiatry, Preventative Medicine
Quality ID NQF Measure Title Measure Description NQS Domain
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127 0416 Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Podiatry
Quality ID NQF Measure Title Measure Description NQS Domain
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128 0421 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter

Normal Parameters: Age 18 years and older BMI => 18.5 and < 25 kg/m2
Community/Population Health
Measure Type High Priority Specialty Measure Sets
Process No Cardiology, Family Medicine, Gastroenterology, General Surgery, Internal Medicine, Mental/Behavioral Health, Obstetrics/Gynecology, Orthopedic Surgery, Otolaryngology, Physical Medicine, Physical Therapy/Occupational Therapy, Podiatry, Preventative Medicine, Rheumatology, Urology, Vascular Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
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130 0419 Documentation of Current Medications in the Medical Record Percentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration Patient Safety
Measure Type High Priority Specialty Measure Sets
Process Yes Allergy/Immunology, Cardiology, Dermatology, Family Medicine, Gastroenterology, General Surgery, Geriatrics, Hospitalists, Infectious Disease, Internal Medicine, Mental/Behavioral Health, Nephrology, Neurology, Neurosurgical, Obstetrics/Gynecology, Oncology, Ophthalmology, Orthopedic Surgery, Otolaryngology, Physical Medicine, Physical Therapy/Occupational Therapy, Plastic Surgery, Preventative Medicine, Rheumatology, Thoracic Surgery, Urgent Care, Urology, Vascular Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
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131 0420 Pain Assessment and Follow-Up Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Process Yes Geriatrics, Orthopedic Surgery, Physical Medicine, Physical Therapy/Occupational Therapy, Rheumatology, Urgent Care, Urology
Quality ID NQF Measure Title Measure Description NQS Domain
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134 0418 Preventive Care and Screening: Screening for Depression and Follow-Up Plan Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen Community/Population Health
Measure Type High Priority Specialty Measure Sets
Process No Family Medicine, Internal Medicine, Mental/Behavioral Health, Neurology, Orthopedic Surgery, Pediatrics, Preventative Medicine
Quality ID NQF Measure Title Measure Description NQS Domain
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137 N/A Melanoma: Continuity of Care – Recall System Percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered, at least once within a 12 month period, into a recall system that includes:
• A target date for the next complete physical skin exam, AND
• A process to follow up with patients who either did not make an appointment within the specified timeframe or who missed a scheduled appointment
Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Structure Yes Dermatology
Quality ID NQF Measure Title Measure Description NQS Domain
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138 N/A Melanoma: Coordination of Care Percentage of patient visits, regardless of age, with a new occurrence of melanoma that have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Process Yes Dermatology
Quality ID NQF Measure Title Measure Description NQS Domain
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141 0563 Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 15% from the pre-intervention level) OR if the most recent IOP was not reduced by at least 15% from the pre-intervention level, a plan of care was documented within the 12 month performance period Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Outcome Yes Ophthalmology
Quality ID NQF Measure Title Measure Description NQS Domain
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143 0384 Oncology: Medical and Radiation – Pain Intensity Quantified Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified Person and Caregiver-Centered Experience and Outcomes
Measure Type High Priority Specialty Measure Sets
Process Yes Oncology, Radiation Oncology
Quality ID NQF Measure Title Measure Description NQS Domain
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144 0383 Oncology: Medical and Radiation – Plan of Care for Moderate to Severe Pain Percentage of patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having moderate to severe pain with a plan of care to address pain documented on or before the date of the second visit with a clinician Person and Caregiver-Centered Experience and Outcomes
Measure Type High Priority Specialty Measure Sets
Process Yes Oncology, Radiation Oncology
Quality ID NQF Measure Title Measure Description NQS Domain
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145 N/A Radiology: Exposure Dose Indices or Exposure Time and Number of Images Reported for Procedures Using Fluoroscopy Final reports for procedures using fluoroscopy that document radiation exposure indices, or exposure time and number of fluorographic images (if radiation exposure indices are not available) Patient Safety
Measure Type High Priority Specialty Measure Sets
Process Yes Diagnostic Radiology, Interventional Radiology
Quality ID NQF Measure Title Measure Description NQS Domain
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146 0508 Radiology: Inappropriate Use of “Probably Benign” Assessment Category in Screening Mammograms Percentage of final reports for screening mammograms that are classified as “probably benign” Efficiency and Cost Reduction
Measure Type High Priority Specialty Measure Sets
Process Yes Diagnostic Radiology
Quality ID NQF Measure Title Measure Description NQS Domain
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147 N/A Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy Percentage of final reports for all patients, regardless of age, undergoing bone scintigraphy that include physician documentation of correlation with existing relevant imaging studies (e.g., x-ray, Magnetic Resonance Imaging (MRI), Computed Tomography (CT), etc.) that were performed Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Process Yes Diagnostic Radiology
Quality ID NQF Measure Title Measure Description NQS Domain
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154 0101 Falls: Risk Assessment Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months Patient Safety
Measure Type High Priority Specialty Measure Sets
Process Yes Family Medicine, Internal Medicine, Neurology, Orthopedic Surgery, Otolaryngology, Physical Medicine, Podiatry, Preventative Medicine, Skilled Nursing Facility
Quality ID NQF Measure Title Measure Description NQS Domain
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155 0101 Falls: Plan of Care Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Process Yes Family Medicine, Internal Medicine, Neurology, Orthopedic Surgery, Otolaryngology, Physical Medicine, Podiatry, Preventative Medicine, Skilled Nursing Facility
Quality ID NQF Measure Title Measure Description NQS Domain
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164 0129 Coronary Artery Bypass Graft (CABG): Prolonged Intubation Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation > 24 hours Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Outcome Yes Thoracic Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
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165 0130 Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate Percentage of patients aged 18 years and older undergoing isolated CABG surgery who, within 30 days postoperatively, develop deep sternal wound infection involving muscle, bone, and/or mediastinum requiring operative intervention Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Outcome Yes Thoracic Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
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166 0131 Coronary Artery Bypass Graft (CABG): Stroke Percentage of patients aged 18 years and older undergoing isolated CABG surgery who have a postoperative stroke (i.e., any confirmed neurological deficit of abrupt onset caused by a disturbance in blood supply to the brain) that did not resolve within 24 hours Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Outcome Yes Thoracic Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
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167 0114 Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure Percentage of patients aged 18 years and older undergoing isolated CABG surgery (without pre-existing renal failure) who develop postoperative renal failure or require dialysis Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Outcome Yes Thoracic Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
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168 0115 Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require a return to the operating room (OR) during the current hospitalization for mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction, or other cardiac reason Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Outcome Yes Thoracic Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
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176 N/A Rheumatoid Arthritis (RA): Tuberculosis Screening   Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have documentation of a tuberculosis (TB) screening performed and results interpreted within 12 months prior to receiving a first course of therapy using a  biologic disease-modifying anti-rheumatic drug (DMARD) Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Rheumatology
Quality ID NQF Measure Title Measure Description NQS Domain
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177 N/A Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment of disease activity at ≥50% of encounters for RA for each patient during the measurement year Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Rheumatology
Quality ID NQF Measure Title Measure Description NQS Domain
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178 N/A Rheumatoid Arthritis (RA): Functional Status Assessment Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) for whom a functional status assessment was performed at least once within 12 months Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Orthopedic Surgery, Rheumatology
Quality ID NQF Measure Title Measure Description NQS Domain
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179 N/A Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease prognosis at least once within 12 months Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Orthopedic Surgery, Rheumatology
Quality ID NQF Measure Title Measure Description NQS Domain
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180 N/A Rheumatoid Arthritis (RA): Glucocorticoid Management Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone ≥ 10 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Orthopedic Surgery, Rheumatology
Quality ID NQF Measure Title Measure Description NQS Domain
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181 N/A Elder Maltreatment Screen and Follow-Up Plan Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening tool on the date of encounter AND a documented follow-up plan on the date of the positive screen Patient Safety
Measure Type High Priority Specialty Measure Sets
Process Yes Family Medicine, Geriatrics, Internal Medicine, Mental/Behavioral Health, Neurology, Skilled Nursing Facility
Quality ID NQF Measure Title Measure Description NQS Domain
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182 2624 Functional Outcome Assessment Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Process Yes Nephrology, Physical Medicine, Physical Therapy/Occupational Therapy
Quality ID NQF Measure Title Measure Description NQS Domain
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185 0659 Colonoscopy Interval for Patients with a History of Adenomatous Polyps
– Avoidance of Inappropriate Use 
Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior adenomatous polyp(s) in previous colonoscopy findings, which had an interval of 3 or more years since their last colonoscopy Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Process Yes Gastroenterology
Quality ID NQF Measure Title Measure Description NQS Domain
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187 N/A Stroke and Stroke Rehabilitation: Thrombolytic Therapy Percentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who arrive at the hospital within two hours of time last known well and for whom IV t-PA was initiated within three hours of time last known well Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Emergency Medicine, Neurosurgical
Quality ID NQF Measure Title Measure Description NQS Domain
+
191 0565 Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following the cataract surgery Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Outcome Yes Ophthalmology
Quality ID NQF Measure Title Measure Description NQS Domain
+
192 0564 Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and had any of a specified list of surgical procedures in the 30 days following cataract surgery which would indicate the occurrence of any of the following major complications: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence Patient Safety
Measure Type High Priority Specialty Measure Sets
Outcome Yes Ophthalmology
Quality ID NQF Measure Title Measure Description NQS Domain
+
195 0507 Radiology: Stenosis Measurement in Carotid Imaging Reports Percentage of final reports for carotid imaging studies (neck magnetic resonance angiography [MRA], neck computed tomography angiography [CTA], neck duplex ultrasound, carotid angiogram) performed that include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Diagnostic Radiology
Quality ID NQF Measure Title Measure Description NQS Domain
+
205 0409 HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia, gonorrhea, and syphilis screenings were performed at least once since the diagnosis of HIV infection Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Infectious Disease, Pediatrics
Quality ID NQF Measure Title Measure Description NQS Domain
+
217 0422 Functional Status Change for Patients with Knee Impairments A patient-reported outcome measure of risk-adjusted change in functional status for patients aged 14 years+ with knee impairments. The change in functional status (FS) is assessed using the Knee FS patient-reported outcome measure (PROM) (©Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey) Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Patient Reported Outcome Yes Physical Therapy/Occupational Therapy
Quality ID NQF Measure Title Measure Description NQS Domain
+
218 0423 Functional Status Change for Patients with Hip Impairments A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with hip impairments. The change in functional status (FS) is assessed using the Hip FS patient-reported outcome measure (PROM) (©Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey) Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Patient Reported Outcome Yes Physical Therapy/Occupational Therapy
Quality ID NQF Measure Title Measure Description NQS Domain
+
219 0424 Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with foot, ankle and lower leg impairments. The change in functional status (FS) assessed using the Foot/Ankle FS patient-reported outcome measure (PROM) (©Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey) Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Patient Reported Outcome Yes Physical Therapy/Occupational Therapy
Quality ID NQF Measure Title Measure Description NQS Domain
+
220 0425 Functional Status Change for Patients with Low Back Impairments A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with low back impairments. The change in functional status (FS) is assessed using the Low Back FS patient-reported outcome measure (PROM) (©Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level by to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey) Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Patient Reported Outcome Yes Physical Therapy/Occupational Therapy
Quality ID NQF Measure Title Measure Description NQS Domain
+
221 0426 Functional Status Change for Patients with Shoulder Impairments A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with shoulder impairments. The change in functional status (FS) is assessed using the Shoulder FS patient-reported outcome measure (PROM) (©Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey) Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Patient Reported Outcome Yes Physical Therapy/Occupational Therapy
Quality ID NQF Measure Title Measure Description NQS Domain
+
222 0427 Functional Status Change for Patients with Elbow, Wrist or Hand Impairments A patient-reported outcome measure of risk-adjusted change in functional status (FS) for patients 14 years+ with elbow, wrist or hand impairments. The change in FS is assessed using the Elbow/Wrist/Hand FS patient-reported outcome measure (PROM) (©Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey) Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Patient Reported Outcome Yes Physical Therapy/Occupational Therapy
Quality ID NQF Measure Title Measure Description NQS Domain
+
223 0428 Functional Status Change for Patients with General Orthopedic Impairments A patient-reported outcome measure of risk-adjusted change in functional status (FS) for patients aged 14 years+ with general orthopedic impairments (neck, cranium, mandible, thoracic spine, ribs or other general orthopedic impairment). The change in FS is assessed using the General Orthopedic FS PROM (patient reported outcome measure) (©Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey) Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Patient Reported Outcome Yes Physical Therapy/Occupational Therapy
Quality ID NQF Measure Title Measure Description NQS Domain
+
225 0509 Radiology: Reminder System for Screening Mammograms Percentage of patients undergoing a screening mammogram whose information is entered into a reminder system with a target due date for the next mammogram Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Structure Yes Diagnostic Radiology
Quality ID NQF Measure Title Measure Description NQS Domain
+
226 0028 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user Community/Population Health
Measure Type High Priority Specialty Measure Sets
Process No Allergy/Immunology, Cardiology, Dermatology, Family Medicine, Gastroenterology, General Surgery, Internal Medicine, Mental/Behavioral Health, Neurology, Neurosurgical, Obstetrics/Gynecology, Ophthalmology, Orthopedic Surgery, Otolaryngology, Physical Medicine, Plastic Surgery, Podiatry, Preventative Medicine, Rheumatology, Thoracic Surgery, Urgent Care, Urology, Vascular Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
+
236 0018 Controlling High Blood Pressure Percentage of patients 18 - 85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (< 140/90 mmHg) during the measurement period Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
 Intermediate Outcome Yes Cardiology, Family Medicine, Internal Medicine, Obstetrics/Gynecology, Rheumatology, Vascular Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
+
238 0022 Use of High-Risk Medications in the Elderly Percentage of patients 65 years of age and older who were ordered high-risk medications. Two rates are submitted.
1) Percentage of patients who were ordered at least one high-risk medication
2) Percentage of patients who were ordered at least two of the same high-risk medication
Patient Safety
Measure Type High Priority Specialty Measure Sets
Process Yes Allergy/Immunology, Cardiology, Family Medicine, Geriatrics, Internal Medicine, Rheumatology
Quality ID NQF Measure Title Measure Description NQS Domain
+
243 0643 Cardiac Rehabilitation Patient Referral from an Outpatient Setting   Percentage of patients evaluated in an outpatient setting who within the previous 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the qualifying event/diagnosis who were referred to a CR program Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Process Yes Cardiology, Family Medicine, Internal Medicine 
Quality ID NQF Measure Title Measure Description NQS Domain
+
249 1854 Barrett’s Esophagus  Percentage of esophageal biopsy reports that document the presence of Barrett’s mucosa that also include a statement about dysplasia Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Pathology
Quality ID NQF Measure Title Measure Description NQS Domain
+
250 1853 Radical Prostatectomy Pathology Reporting Percentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin status Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Oncology, Pathology
Quality ID NQF Measure Title Measure Description NQS Domain
+
254 N/A Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain Percentage of pregnant female patients aged 14 to 50 who present to the emergency department (ED) with a chief complaint of abdominal pain or vaginal bleeding who receive a trans-abdominal or trans-vaginal ultrasound to determine pregnancy location Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Emergency Medicine
Quality ID NQF Measure Title Measure Description NQS Domain
+
255 N/A Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure  Percentage of Rh-negative pregnant women aged 14-50 years at risk of fetal blood exposure who receive Rh- Immunoglobulin (Rhogam) in the emergency department (ED) Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Emergency Medicine
Quality ID NQF Measure Title Measure Description NQS Domain
+
258 N/A Rate of Open Repair of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7)  Percent of patients undergoing open repair of small or moderate sized non-ruptured infrarenal abdominal aortic aneurysms who do not experience a major complication (discharge to home no later than post-operative day #7) Patient Safety
Measure Type High Priority Specialty Measure Sets
Outcome Yes Vascular Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
+
259 N/A Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post Operative Day #2)  Percent of patients undergoing endovascular repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) that do not experience a major complication (discharged to home no later than post-operative day #2) Patient Safety
Measure Type High Priority Specialty Measure Sets
Outcome Yes Vascular Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
+
260 N/A Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2) Percent of asymptomatic patients undergoing CEA who are discharged to home no later than post-operative day #2 Patient Safety
Measure Type High Priority Specialty Measure Sets
Outcome Yes Vascular Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
+
261 N/A Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness  Percentage of patients aged birth and older referred to a physician (preferably a physician specially trained in disorders of the ear) for an otologic evaluation subsequent to an audiologic evaluation after presenting with acute or chronic dizziness Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Process Yes N/A
Quality ID NQF Measure Title Measure Description NQS Domain
+
262 N/A Image Confirmation of Successful Excision of Image-Localized Breast Lesion Image confirmation of lesion(s) targeted for image guided excisional biopsy or image guided partial mastectomy in patients with nonpalpable, image-detected breast lesion(s). Lesions may include: microcalcifications, mammographic or sonographic mass or architectural distortion, focal suspicious abnormalities on magnetic resonance imaging (MRI) or other breast imaging amenable to localization such as positron emission tomography (PET) mammography, or a biopsy marker demarcating site of confirmed pathology as established by previous core biopsy Patient Safety
Measure Type High Priority Specialty Measure Sets
Process Yes N/A
Quality ID NQF Measure Title Measure Description NQS Domain
+
264 N/A Sentinel Lymph Node Biopsy for Invasive Breast Cancer The percentage of clinically node negative (clinical stage T1N0M0 or T2N0M0) breast cancer patients before or after neoadjuvant systemic therapy, who undergo a sentinel lymph node (SLN) procedure Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No General Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
+
265 N/A Biopsy Follow-Up Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Process Yes Dermatology, Obstetrics/Gynecology, Otolaryngology, Urology
Quality ID NQF Measure Title Measure Description NQS Domain
+
268 N/A Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy All female patients of childbearing potential (12 - 44 years old) diagnosed with epilepsy who were counseled or referred for counseling for how epilepsy and its treatment may affect contraception OR pregnancy at least once a year Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Neurology
Quality ID NQF Measure Title Measure Description NQS Domain
+
271 N/A Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury–Bone Loss Assessment Percentage of patients regardless of age with an inflammatory bowel disease encounter who were prescribed prednisone equivalents greater than or equal to 10 mg/day for 60 or greater consecutive days or a single prescription equating to 600 mg prednisone or greater for all fills and were documented for risk of bone loss once during the reporting year or the previous calendar year. Individuals who received an assessment for bone loss during the year prior and current year are considered adequately screened to prevent overuse of X-ray assessment
Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Gastroenterology
Quality ID NQF Measure Title Measure Description NQS Domain
+
275 N/A Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy Percentage of patients with a diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status assessed and results interpreted prior to initiating anti-TNF (tumor necrosis factor) therapy Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Gastroenterology
Quality ID NQF Measure Title Measure Description NQS Domain
+
277 N/A Sleep Apnea: Severity Assessment at Initial Diagnosis Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) measured at the time of initial diagnosis Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Internal Medicine, Otolaryngology
Quality ID NQF Measure Title Measure Description NQS Domain
+
279 N/A Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea who were prescribed positive airway pressure therapy who had documentation that adherence to positive airway pressure therapy was objectively measured Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Internal Medicine, Otolaryngology
Quality ID NQF Measure Title Measure Description NQS Domain
+
282 N/A Dementia: Functional Status Assessment Percentage of patients with dementia for whom an assessment of functional status* was performed at least once in the last 12 months
Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Geriatrics, Mental/Behavioral Health, Neurology
Quality ID NQF Measure Title Measure Description NQS Domain
+
283 N/A Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management
Percentage of patients with dementia for whom there was a documented screening for behavioral and psychiatric symptoms, including depression, and for whom, if symptoms screening was positive, there was also documentation of recommendations for management in the last 12 months
Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process Yes Geriatrics, Mental/Behavioral Health, Neurology
Quality ID NQF Measure Title Measure Description NQS Domain
+
286 N/A Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia Percentage of patients with dementia or their caregiver(s) for whom there was a documented safety concerns screening in two domains of risk: 1) dangerousness to self or others and 2) environmental risks; and if safety concerns screening was positive in the last 12 months, there was documentation of mitigation recommendations, including but not limited to referral to other resources


Patient Safety
Measure Type High Priority Specialty Measure Sets
Process Yes Geriatrics, Mental/Behavioral Health, Neurology
Quality ID NQF Measure Title Measure Description NQS Domain
+
288 N/A Dementia: Education and Support of Caregivers for Patients with Dementia Percentage of patients with dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND were referred to additional resources for support in the last 12 months Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Process Yes Geriatrics, Mental/Behavioral Health, Neurology
Quality ID NQF Measure Title Measure Description NQS Domain
+
290 N/A Parkinson’s Disease: Psychiatric Symptoms Assessment for Patients with Parkinson’s Disease Percentage of all patients with a diagnosis of Parkinson’s Disease [PD] who were assessed for psychiatric symptoms in the past 12 months

Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Neurology
Quality ID NQF Measure Title Measure Description NQS Domain
+
291 N/A Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment for Patients with Parkinson's Disease Percentage of all patients with a diagnosis of Parkinson’s Disease [PD] who were assessed for cognitive impairment or dysfunction in the past 12 months
Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Neurology
Quality ID NQF Measure Title Measure Description NQS Domain
+
293 N/A Parkinson’s Disease: Rehabilitative Therapy Options Percentage of all patients with a diagnosis of Parkinson’s Disease (or caregiver(s), as appropriate) who had rehabilitative therapy options (i.e., physical, occupational, and speech therapy) discussed in the past 12 months
Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Process Yes Neurology
Quality ID NQF Measure Title Measure Description NQS Domain
+
303 N/A Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery Percentage of patients aged 18 years and older who had cataract surgery and had improvement in visual function achieved within 90 days following the cataract surgery, based on completing a pre-operative and post-operative visual function survey  Person and Caregiver-Centered Experience and Outcomes
Measure Type High Priority Specialty Measure Sets
Patient Reported Outcome Yes Ophthalmology
Quality ID NQF Measure Title Measure Description NQS Domain
+
304 N/A Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery Percentage of patients aged 18 years and older who had cataract surgery and were satisfied with their care within 90 days following the cataract surgery, based on completion of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey Person and Caregiver-Centered Experience and Outcomes
Measure Type High Priority Specialty Measure Sets
Patient Engagement/Experience Yes N/A
Quality ID NQF Measure Title Measure Description NQS Domain
+
317 N/A Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated Community/Population Health
Measure Type High Priority Specialty Measure Sets
Process No Allergy/Immunology, Cardiology, Dermatology, Emergency Medicine, Family Medicine, Gastroenterology, General Surgery, Internal Medicine, Mental/Behavioral Health Nephrology, Neurology, Obstetrics/Gynecology, Oncology, Orthopedic Surgery, Otolaryngology, Physical Medicine, Plastic Surgery, Preventative Medicine, Rheumatology, Skilled Nursing Facility, Thoracic Surgery, Urgent Care, Urology, Vascular Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
+
320 0658 Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients Percentage of patients aged 50 to 75 years of age receiving a  screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Process Yes Gastroenterology
Quality ID NQF Measure Title Measure Description NQS Domain
+
322 N/A Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients Percentage of stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), or cardiac magnetic resonance (CMR) performed in low-risk surgery patients 18 years or older for preoperative evaluation during the 12-month submission period Efficiency and Cost Reduction
Measure Type High Priority Specialty Measure Sets
Efficiency Yes Cardiology
Quality ID NQF Measure Title Measure Description NQS Domain
+
323 N/A Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI) Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in patients aged 18 years and older routinely after percutaneous coronary intervention (PCI), with reference to timing of test after PCI and symptom status Efficiency and Cost Reduction
Measure Type High Priority Specialty Measure Sets
Efficiency Yes Cardiology
Quality ID NQF Measure Title Measure Description NQS Domain
+
324 N/A Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in asymptomatic, low coronary heart disease (CHD) risk patients 18 years and older for initial detection and risk assessment Efficiency and Cost Reduction
Measure Type High Priority Specialty Measure Sets
Efficiency Yes Cardiology
Quality ID NQF Measure Title Measure Description NQS Domain
+
325 N/A Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions  Percentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Renal Disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Process Yes Mental/Behavioral Health
Quality ID NQF Measure Title Measure Description NQS Domain
+
326 1525 Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy  Percentage of patients aged 18 years and older with nonvalvular atrial fibrillation (AF) or atrial flutter who were prescribed warfarin OR another FDA-approved oral anticoagulant drug for the prevention of thromboembolism during the measurement period Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Cardiology, Family Medicine, Internal Medicine, Skilled Nursing Facility
Quality ID NQF Measure Title Measure Description NQS Domain
+
328 1667 Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level < 10g/dL Percentage of calendar months within a 12-month period during which patients aged 17 years and younger with a diagnosis of End Stage Renal Disease (ESRD) receiving hemodialysis or peritoneal dialysis have a hemoglobin level < 10 g/dL Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
 Intermediate Outcome Yes Nephrology
Quality ID NQF Measure Title Measure Description NQS Domain
+
329 N/A Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis  Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) who initiate maintenance hemodialysis during the measurement period, whose mode of vascular access is a catheter at the time maintenance hemodialysis is initiated Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Outcome Yes N/A
Quality ID NQF Measure Title Measure Description NQS Domain
+
330 N/A Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) receiving maintenance hemodialysis for greater than or equal to 90 days whose mode of vascular access is a catheter Patient Safety
Measure Type High Priority Specialty Measure Sets
Outcome Yes Nephrology
Quality ID NQF Measure Title Measure Description NQS Domain
+
331 N/A Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)  Percentage of patients, aged 18 years and older, with a diagnosis of acute viral sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms Efficiency and Cost Reduction
Measure Type High Priority Specialty Measure Sets
Process Yes Emergency Medicine, Family Medicine, Internal Medicine, Otolaryngology, Urgent Care
Quality ID NQF Measure Title Measure Description NQS Domain
+
332 N/A Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use) Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosis Efficiency and Cost Reduction
Measure Type High Priority Specialty Measure Sets
Process Yes Emergency Medicine, Family Medicine, Internal Medicine, Otolaryngology, Urgent Care
Quality ID NQF Measure Title Measure Description NQS Domain
+
333 N/A Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse)  Percentage of patients aged 18 years and older, with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis Efficiency and Cost Reduction
Measure Type High Priority Specialty Measure Sets
Efficiency Yes Emergency Medicine, Family Medicine, Internal Medicine, Otolaryngology, Urgent Care
Quality ID NQF Measure Title Measure Description NQS Domain
+
335 N/A Maternity Care: Elective Delivery or Early Induction Without Medical Indication at > 37 and < 39 Weeks (Overuse) Percentage of patients, regardless of age, who gave birth during a 12-month period who delivered a live singleton at > 37 and < 39 weeks of gestation completed who had elective deliveries or early inductions without medical indication Patient Safety
Measure Type High Priority Specialty Measure Sets
Outcome Yes N/A
Quality ID NQF Measure Title Measure Description NQS Domain
+
336 N/A Maternity Care: Post-Partum Follow-Up and Care Coordination Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for post-partum care within 8 weeks of giving birth who received a breast feeding evaluation and education, post-partum depression screening, post-partum glucose screening for gestational diabetes patients, and family and contraceptive planning Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Process Yes N/A
Quality ID NQF Measure Title Measure Description NQS Domain
+
337 N/A Psoriasis: Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis on a Biological Immune Response Modifier
Percentage of patients, regardless of age, with psoriasis, psoriatic arthritis and rheumatoid arthritis on a biological immune response modifier whose providers are ensuring active tuberculosis prevention either through yearly negative standard tuberculosis screening tests or are reviewing the patient’s history to determine if they have had appropriate management for a recent or prior positive test Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Dermatology, Family Medicine, Internal Medicine
Quality ID NQF Measure Title Measure Description NQS Domain
+
338 2082 HIV Viral Load Suppression The percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Outcome Yes Allergy/Immunology, Family Medicine, Infectious Disease, Internal Medicine
Quality ID NQF Measure Title Measure Description NQS Domain
+
340 2079 HIV Medical Visit Frequency  Percentage of patients, regardless of age with a diagnosis of HIV who had at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical visits Efficiency and Cost Reduction
Measure Type High Priority Specialty Measure Sets
Process Yes Allergy/Immunology, Infectious Disease
Quality ID NQF Measure Title Measure Description NQS Domain
+
342 N/A Pain Brought Under Control Within 48 Hours Patients aged 18 and older who report being uncomfortable because of pain at the initial assessment (after admission to palliative care services) who report pain was brought to a comfortable level within 48 hours Person and Caregiver-Centered Experience and Outcomes
Measure Type High Priority Specialty Measure Sets
Outcome Yes Family Medicine, Internal Medicine
Quality ID NQF Measure Title Measure Description NQS Domain
+
343 N/A Screening Colonoscopy Adenoma Detection Rate  The percentage of patients age 50 years or older with at least one conventional adenoma or colorectal cancer detected during screening colonoscopy Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Outcome Yes Gastroenterology
Quality ID NQF Measure Title Measure Description NQS Domain
+
344 N/A Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)  Percent of asymptomatic patients undergoing CAS who are discharged to home no later than post-operative day #2 Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Outcome Yes Cardiology, Vascular Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
+
345 1543 Rate of Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS) Who Are Stroke Free or Discharged Alive Percent of asymptomatic patients undergoing CAS who are stroke free while in the hospital or discharged alive following surgery
Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Outcome Yes Cardiology, Neurosurgical, Vascular Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
+
346 1540 Rate of Asymptomatic Patients Undergoing Carotid Endarterectomy (CEA) Who Are Stroke Free or Discharged Alive Percent of asymptomatic patients undergoing CEA who are stroke free or discharged alive following surgery Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Outcome Yes Neurosurgical, Vascular Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
+
347 1534 Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) Who Are Discharged Alive Percent of patients undergoing endovascular repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) who are discharged alive
Patient Safety
Measure Type High Priority Specialty Measure Sets
Outcome Yes Vascular Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
+
348 N/A HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate Patients with physician-specific risk-standardized rates of procedural complications following the first time implantation of an ICD Patient Safety
Measure Type High Priority Specialty Measure Sets
Outcome Yes Electro-physiology Cardiac Specialist
Quality ID NQF Measure Title Measure Description NQS Domain
+
350 N/A Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy Percentage of patients regardless of age undergoing a total knee replacement with documented shared decision-making with discussion of conservative (non-surgical) therapy (e.g. nonsteroidal anti-inflammatory drug (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Process Yes Orthopedic Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
+
351 N/A Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation  Percentage of patients regardless of age undergoing a total knee replacement who are evaluated for the presence or absence of venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure (e.g. history of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), Myocardial Infarction (MI), Arrhythmia and Stroke) Patient Safety
Measure Type High Priority Specialty Measure Sets
Process Yes Orthopedic Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
+
352 N/A Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet Percentage of patients regardless of age undergoing a total knee replacement who had the prophylactic antibiotic completely infused prior to the inflation of the proximal tourniquet Patient Safety
Measure Type High Priority Specialty Measure Sets
Process Yes Orthopedic Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
+
353 N/A Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report Percentage of patients regardless of age undergoing a total knee replacement whose operative report identifies the prosthetic implant specifications including the prosthetic implant manufacturer, the brand name of the prosthetic implant and the size of each prosthetic implant Patient Safety
Measure Type High Priority Specialty Measure Sets
Process Yes Orthopedic Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
+
354 N/A Anastomotic Leak Intervention Percentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery Patient Safety
Measure Type High Priority Specialty Measure Sets
Outcome Yes N/A
Quality ID NQF Measure Title Measure Description NQS Domain
+
355 N/A Unplanned Reoperation within the 30 Day Postoperative Period Percentage of patients aged 18 years and older who had any unplanned reoperation within the 30 day postoperative period Patient Safety
Measure Type High Priority Specialty Measure Sets
Outcome Yes General Surgery, Plastic Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
+
356 N/A Unplanned Hospital Readmission within 30 Days of Principal Procedure Percentage of patients aged 18 years and older who had an unplanned hospital readmission within 30 days of principal procedure Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Outcome Yes General Surgery, Plastic Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
+
357 N/A Surgical Site Infection (SSI) Percentage of patients aged 18 years and older who had a surgical site infection (SSI) Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Outcome Yes General Surgery, Otolaryngology, Plastic Surgery, Vascular Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
+
358 N/A Patient-Centered Surgical Risk Assessment and Communication Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon Person and Caregiver-Centered Experience and Outcomes
Measure Type High Priority Specialty Measure Sets
Process Yes General Surgery, Orthopedic Surgery, Otolaryngology, Plastic Surgery, Thoracic Surgery, Urology, Vascular Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
+
360 N/A Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies  Percentage of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion studies) imaging reports for all patients, regardless of age, that document a count of known previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion) studies that the patient has received in the 12-month period prior to the current study Patient Safety
Measure Type High Priority Specialty Measure Sets
Process Yes Diagnostic Radiology
Quality ID NQF Measure Title Measure Description NQS Domain
+
361 N/A Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry  Percentage of total computed tomography (CT) studies performed for all patients, regardless of age, that are submitted to a radiation dose index registry that is capable of collecting at a minimum selected data elements Patient Safety
Measure Type High Priority Specialty Measure Sets
Structure Yes Diagnostic Radiology
Quality ID NQF Measure Title Measure Description NQS Domain
+
362 N/A Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison Purposes Percentage of final reports for computed tomography (CT) studies performed for all patients, regardless of age, which document that Digital Imaging and Communications in Medicine (DICOM) format image data are available to non-affiliated external healthcare facilities or entities on a secure, media free, reciprocally searchable basis with patient authorization for at least a 12-month period after the study Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Structure Yes Diagnostic Radiology
Quality ID NQF Measure Title Measure Description NQS Domain
+
364 N/A Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines  Percentage of final reports for CT imaging studies with a finding of an incidental pulmonary nodule for patients aged 35 years and older that contain an impression or conclusion that includes a recommended interval and modality for follow-up (e.g., type of imaging or biopsy) or for no follow-up, and source of recommendations (e.g., guidelines such as Fleischner Society, American Lung Association, American College of Chest Physicians) Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Process Yes Diagnostic Radiology
Quality ID NQF Measure Title Measure Description NQS Domain
+
370 0710e Depression Remission at Twelve Months The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Outcome Yes Family Medicine, Geriatrics, Internal Medicine, Mental/Behavioral Health
Quality ID NQF Measure Title Measure Description NQS Domain
+
374 N/A Closing the Referral Loop: Receipt of Specialist Report Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Process Yes Allergy/Immunology, Cardiology, Dermatology, Family Medicine, Gastroenterology, General Surgery, Internal Medicine, Interventional Radiology, Mental/Behavioral Health, Neurology, Obstetrics/Gynecology, Oncology, Ophthalmology, Orthopedic Surgery, Otolaryngology, Physical Medicine, Preventative Medicine, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
+
383 1879 Adherence to Antipsychotic Medications For Individuals with Schizophrenia Percentage of individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months) Patient Safety
Measure Type High Priority Specialty Measure Sets
Intermediate Outcome Yes Family Medicine, Internal Medicine, Mental/Behavioral Health
Quality ID NQF Measure Title Measure Description NQS Domain
+
384 N/A Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment who did not require a return to the operating room within 90 days of surgery Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Outcome Yes Ophthalmology
Quality ID NQF Measure Title Measure Description NQS Domain
+
385 N/A Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment and achieved an improvement in their visual acuity, from their preoperative level, within 90 days of surgery in the operative eye Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Outcome Yes Ophthalmology
Quality ID NQF Measure Title Measure Description NQS Domain
+
386 N/A Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences Percentage of patients diagnosed with Amyotrophic Lateral Sclerosis (ALS) who were offered assistance in planning for end of life issues (e.g. advance directives, invasive ventilation, hospice) at least once annually Person and Caregiver-Centered Experience and Outcomes
Measure Type High Priority Specialty Measure Sets
Process Yes Neurology
Quality ID NQF Measure Title Measure Description NQS Domain
+
387 N/A Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users  Percentage of patients, regardless of age, who are active injection drug users who received screening for HCV infection within the 12-month reporting period Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Family Medicine, Internal Medicine
Quality ID NQF Measure Title Measure Description NQS Domain
+
388 N/A Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy)  Percentage of patients aged 18 years and older who had cataract surgery performed and had an unplanned rupture of the posterior capsule requiring vitrectomy Patient Safety
Measure Type High Priority Specialty Measure Sets
Outcome Yes Ophthalmology
Quality ID NQF Measure Title Measure Description NQS Domain
+
389 N/A Cataract Surgery: Difference Between Planned and Final Refraction  Percentage of patients aged 18 years and older who had cataract surgery performed and who achieved a final refraction within +/- 1.0 diopters of their planned (target) refraction Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Outcome Yes Ophthalmology
Quality ID NQF Measure Title Measure Description NQS Domain
+
390 N/A Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options Percentage of patients aged 18 years and older with a diagnosis of hepatitis C with whom a physician or other qualified healthcare professional reviewed the range of treatment options appropriate to their genotype and demonstrated a shared decision making approach with the patient. To meet the measure, there must be documentation in the patient record of a discussion between the physician or other qualified healthcare professional and the patient that includes all of the following: treatment choices appropriate to genotype, risks and benefits, evidence of effectiveness, and patient preferences toward treatment
Person and Caregiver-Centered Experience and Outcomes
Measure Type High Priority Specialty Measure Sets
Process Yes Gastroenterology
Quality ID NQF Measure Title Measure Description NQS Domain
+
391 0576 Follow-Up After Hospitalization for Mental Illness (FUH) The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had a follow-up visit with a mental health practitioner. Two rates are submitted:
• The percentage of discharges for which the patient received follow-up within 30 days of discharge.
• The percentage of discharges for which the patient received follow-up within 7 days of discharge.
Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Process Yes Mental/Behavioral Health, Pediatrics
Quality ID NQF Measure Title Measure Description NQS Domain
+
392 2474 HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation. This measure is submitted as four rates stratified by age and gender:
• Submission Age Criteria 1: Females 18-64 years of age
• Submission Age Criteria 2: Males 18-64 years of age
• Submission Age Criteria 3: Females 65 years of age and older
• Submission Age Criteria 4: Males 65 years of age and older
Patient Safety
Measure Type High Priority Specialty Measure Sets
Outcome Yes Electro-physiology Cardiac Specialist
Quality ID NQF Measure Title Measure Description NQS Domain
+
393 N/A HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision  Infection rate following CIED device implantation, replacement, or revision
Patient Safety
Measure Type High Priority Specialty Measure Sets
Outcome Yes Electro-physiology Cardiac Specialist
Quality ID NQF Measure Title Measure Description NQS Domain
+
394 1407 Immunizations for Adolescents The percentage of adolescents 13 years of age who had the recommended immunizations by their 13th birthday Community/Population Health
Measure Type High Priority Specialty Measure Sets
Process No Family Medicine, Pediatrics
Quality ID NQF Measure Title Measure Description NQS Domain
+
395 N/A Lung Cancer Reporting (Biopsy/Cytology Specimens)  Pathology reports based on biopsy and/or cytology specimens with a diagnosis of primary non-small cell lung cancer classified into specific histologic type or classified as NSCLC-NOS with an explanation included in the pathology report Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Process Yes Pathology
Quality ID NQF Measure Title Measure Description NQS Domain
+
396 N/A Lung Cancer Reporting (Resection Specimens) Pathology reports based on resection specimens with a diagnosis of primary lung carcinoma that include the pT category, pN category and for non-small cell lung cancer, histologic type Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Process Yes Pathology
Quality ID NQF Measure Title Measure Description NQS Domain
+
397 N/A Melanoma Reporting Pathology reports for primary malignant cutaneous melanoma that include the pT category and a statement on thickness, ulceration and mitotic rate Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Process Yes Pathology
Quality ID NQF Measure Title Measure Description NQS Domain
+
398 N/A Optimal Asthma Control  Composite measure of the percentage of pediatric and adult patients whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools and not at risk for exacerbation Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Outcome Yes Family Medicine, Internal Medicine, Otolaryngology, Pediatrics
Quality ID NQF Measure Title Measure Description NQS Domain
+
400 3059 One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945-1965 who received one-time screening for hepatitis C virus (HCV) infection Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Family Medicine, Internal Medicine, Nephrology
Quality ID NQF Measure Title Measure Description NQS Domain
+
401 N/A Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12 month submission period Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Family Medicine, Gastroenterology, Internal Medicine
Quality ID NQF Measure Title Measure Description NQS Domain
+
402 N/A Tobacco Use and Help with Quitting Among Adolescents The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user Community/Population Health
Measure Type High Priority Specialty Measure Sets
Process No Allergy/Immunology, Cardiology, Dermatology, Family Medicine, Gastroenterology, General Surgery, Internal Medicine, Mental/Behavioral Health, Neurology, Obstetrics/Gynecology, Oncology, Orthopedic Surgery, Otolaryngology, Pediatrics, Physical Medicine, Preventative Medicine, Rheumatology, Thoracic Surgery, Urgent Care, Vascular Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
+
403 N/A Adult Kidney Disease: Referral to Hospice Percentage of patients aged 18 years and older with a diagnosis of ESRD who withdraw from hemodialysis or peritoneal dialysis who are referred to hospice care Person and Caregiver-Centered Experience and Outcomes
Measure Type High Priority Specialty Measure Sets
Process Yes Nephrology
Quality ID NQF Measure Title Measure Description NQS Domain
+
404 N/A Anesthesiology Smoking Abstinence The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Intermediate Outcome Yes Anesthesiology
Quality ID NQF Measure Title Measure Description NQS Domain
+
405 N/A Appropriate Follow-up Imaging for Incidental Abdominal Lesions Percentage of final reports for abdominal imaging studies for patients aged 18 years and older with one or more of the following noted incidentally with follow-up imaging recommended
• Liver lesion < 0.5 cm
• Cystic kidney lesion < 1.0 cm
• Adrenal lesion < 1.0 cm
Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process Yes Diagnostic Radiology
Quality ID NQF Measure Title Measure Description NQS Domain
+
406 N/A Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients Percentage of final reports for computed tomography (CT), CT angiography (CTA) or magnetic resonance imaging (MRI) or magnetic resonance angiogram (MRA) studies of the chest or neck for patients aged 18 years and older with no known thyroid disease with a thyroid nodule < 1.0 cm noted incidentally with follow-up imaging recommended Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process Yes Diagnostic Radiology
Quality ID NQF Measure Title Measure Description NQS Domain
+
407 N/A Appropriate Treatment of Methicillin-Susceptible Staphylococcus Aureus (MSSA) Bacteremia Percentage of patients with sepsis due to MSSA bacteremia who received beta-lactam antibiotic (e.g. Nafcillin, Oxacillin or Cefazolin) as definitive therapy Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process Yes Hospitalists, Infectious Disease
Quality ID NQF Measure Title Measure Description NQS Domain
+
408 N/A Opioid Therapy Follow-up Evaluation All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process Yes Family Medicine, Geriatrics, Internal Medicine, Neurology, Orthopedic Surgery, Physical Medicine
Quality ID NQF Measure Title Measure Description NQS Domain
+
409 N/A Clinical Outcome Post Endovascular Stroke Treatment Percentage of patients with a mRs score of 0 to 2 at 90 days following endovascular stroke intervention Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Outcome Yes Interventional Radiology, Neurosurgical
Quality ID NQF Measure Title Measure Description NQS Domain
+
410 N/A Psoriasis: Clinical Response to Systemic Medications Percentage of psoriasis vulgaris patients receiving systemic therapy who meet minimal physician-or patient- reported disease activity levels. It is implied that establishment and maintenance of an established minimum level of disease control as measured by physician-and/or patient-reported outcomes will increase patient satisfaction with and adherence to treatment Person and Caregiver-Centered Experience and Outcomes
Measure Type High Priority Specialty Measure Sets
Outcome Yes Dermatology
Quality ID NQF Measure Title Measure Description NQS Domain
+
411 0711 Depression Remission at Six Months The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission six months (+/- 60 days) after an index event date Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Outcome Yes Mental/Behavioral Health
Quality ID NQF Measure Title Measure Description NQS Domain
+
412 N/A Documentation of Signed Opioid Treatment Agreement All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process Yes Family Medicine, Geriatrics, Internal Medicine, Neurology, Orthopedic Surgery, Physical Medicine
Quality ID NQF Measure Title Measure Description NQS Domain
+
413 N/A Door to Puncture Time for Endovascular Stroke Treatment Percentage of patients undergoing endovascular stroke treatment who have a door to puncture time of less than two hours Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Intermediate Outcome Yes Interventional Radiology, Neurosurgical
Quality ID NQF Measure Title Measure Description NQS Domain
+
414 N/A Evaluation or Interview for Risk of Opioid Misuse All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical record Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process Yes Family Medicine, Geriatrics, Internal Medicine, Neurology, Orthopedic Surgery, Physical Medicine
Quality ID NQF Measure Title Measure Description NQS Domain
+
415 N/A Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older  Percentage of emergency department visits for patients aged 18 years and older who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT Efficiency and Cost Reduction
Measure Type High Priority Specialty Measure Sets
Efficiency Yes Emergency Medicine
Quality ID NQF Measure Title Measure Description NQS Domain
+
416 N/A Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years   Percentage of emergency department visits for patients aged 2 through 17 years who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the Pediatric Emergency Care Applied Research Network (PECARN) prediction rules for traumatic brain injury Efficiency and Cost Reduction
Measure Type High Priority Specialty Measure Sets
Efficiency Yes Emergency Medicine
Quality ID NQF Measure Title Measure Description NQS Domain
+
417 1523 Rate of Open Repair of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) Where Patients Are Discharged Alive Percentage of patients undergoing open repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) who are discharged alive Patient Safety
Measure Type High Priority Specialty Measure Sets
Outcome Yes Vascular Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
+
418 0053 Osteoporosis Management in Women Who Had a Fracture The percentage of women age 50-85 who suffered a fracture in the six months prior to the performance period through June 30 of the performance period and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis in the six months after the fracture Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Family Medicine Internal Medicine, Obstetrics/Gynecology, Orthopedic Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
+
419 N/A Overuse of Imaging for the Evaluation of Primary Headache Percentage of patients for whom imaging of the head (CT or MRI) is obtained for the evaluation of primary headache when clinical indications are not present Efficiency and Cost Reduction
Measure Type High Priority Specialty Measure Sets
Process Yes Neurology
Quality ID NQF Measure Title Measure Description NQS Domain
+
420 N/A Varicose Vein Treatment with Saphenous Ablation: Outcome Survey Percentage of patients treated for varicose veins (CEAP C2-S) who are treated with saphenous ablation (with or without adjunctive tributary treatment) that report an improvement on a disease specific patient reported outcome survey instrument after treatment Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Patient Reported Outcome Yes Interventional Radiology, Vascular Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
+
421 N/A Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal Percentage of patients in whom a retrievable IVC filter is placed who, within 3 months post-placement, have a documented assessment for the appropriateness of continued filtration, device removal or the inability to contact the patient with at least two attempts Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Interventional Radiology
Quality ID NQF Measure Title Measure Description NQS Domain
+
422 2063 Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury Percentage of patients who undergo cystoscopy to evaluate for lower urinary tract injury at the time of hysterectomy for pelvic organ prolapse Patient Safety
Measure Type High Priority Specialty Measure Sets
Process Yes Obstetrics/Gynecology
Quality ID NQF Measure Title Measure Description NQS Domain
+
424 2681 Perioperative Temperature Management Percentage of patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was achieved within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time Patient Safety
Measure Type High Priority Specialty Measure Sets
Outcome Yes Anesthesiology
Quality ID NQF Measure Title Measure Description NQS Domain
+
425 N/A Photodocumentation of Cecal Intubation The rate of screening and surveillance colonoscopies for which photodocumentation of at least two landmarks of cecal intubation is performed to establish a complete examination Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Gastroenterology
Quality ID NQF Measure Title Measure Description NQS Domain
+
428 N/A Pelvic Organ Prolapse: Preoperative Assessment of Occult Stress Urinary Incontinence Percentage of patients undergoing appropriate preoperative evaluation of stress urinary incontinence prior to pelvic organ prolapse surgery per ACOG/AUGS/AUA guidelines Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Obstetrics/Gynecology, Urology
Quality ID NQF Measure Title Measure Description NQS Domain
+
429 N/A Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy Percentage of patients who are screened for uterine malignancy prior to vaginal closure or obliterative surgery for pelvic organ prolapse Patient Safety
Measure Type High Priority Specialty Measure Sets
Process Yes Obstetrics/Gynecology, Urology
Quality ID NQF Measure Title Measure Description NQS Domain
+
430 N/A Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy Percentage of patients, aged 18 years and older, who undergo a procedure under an inhalational general anesthetic, AND who have three or more risk factors for post-operative nausea and vomiting (PONV), who receive combination therapy consisting of at least two prophylactic pharmacologic antiemetic agents of different classes preoperatively and/or intraoperatively Patient Safety
Measure Type High Priority Specialty Measure Sets
Process Yes Anesthesiology
Quality ID NQF Measure Title Measure Description NQS Domain
+
431 2152 Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user Community/Population Health
Measure Type High Priority Specialty Measure Sets
Process No Cardiology, Family Medicine, Gastroenterology, Internal Medicine, Mental/Behavioral Health, Neurology, Obstetrics/Gynecology, Oncology, Otolaryngology, Physical Medicine, Preventative Medicine, Urgent Care, Urology
Quality ID NQF Measure Title Measure Description NQS Domain
+
432 N/A Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair Percentage of patients undergoing any surgery to repair pelvic organ prolapse who sustains an injury to the bladder recognized either during or within 30 days after surgery Patient Safety
Measure Type High Priority Specialty Measure Sets
Outcome Yes Obstetrics/Gynecology, Urology
Quality ID NQF Measure Title Measure Description NQS Domain
+
433 N/A Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by a bowel injury at the time of index surgery that is recognized intraoperatively or within 30 days after surgery Patient Safety
Measure Type High Priority Specialty Measure Sets
Outcome Yes Obstetrics/Gynecology, Urology
Quality ID NQF Measure Title Measure Description NQS Domain
+
434 N/A Proportion of Patients Sustaining a Ureter Injury at the Time of Pelvic Organ Prolapse Repair Percentage of patients undergoing pelvic organ prolapse repairs who sustain an injury to the ureter recognized either during or within 30 days after surgery Patient Safety
Measure Type High Priority Specialty Measure Sets
Outcome Yes Obstetrics/Gynecology, Urology
Quality ID NQF Measure Title Measure Description NQS Domain
+
435 N/A Quality of Life Assessment For Patients With Primary Headache Disorders Percentage of patients with a diagnosis of primary headache disorder whose health related quality of life (HRQoL) was assessed with a tool(s) during at least two visits during the 12 month measurement period AND whose health related quality of life score stayed the same or improved Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Patient Reported Outcome Yes Neurology
Quality ID NQF Measure Title Measure Description NQS Domain
+
436 N/A Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques Percentage of final reports for patients aged 18 years and older undergoing CT with documentation that one or more of the following dose reduction techniques were used
• Automated exposure control
• Adjustment of the mA and/or kV according to patient size
• Use of iterative reconstruction technique

Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Diagnostic Radiology
Quality ID NQF Measure Title Measure Description NQS Domain
+
437 N/A Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure Inpatients assigned to endovascular treatment for obstructive arterial disease, the percent of patients who undergo unplanned major amputation or surgical bypass within 48 hours of the index procedure Patient Safety
Measure Type High Priority Specialty Measure Sets
Outcome Yes Interventional Radiology
Quality ID NQF Measure Title Measure Description NQS Domain
+
438 N/A Statin Therapy for the Prevention and Treatment of Cardiovascular Disease Percentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the measurement period:
*Adults aged >= 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR

*Adults aged >= 21 years who have ever had a fasting or direct low-density lipoprotein cholesterol (LDL-C) level >= 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia; OR

*Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL
Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Cardiology, Family Medicine, Internal Medicine, Preventative Medicine
Quality ID NQF Measure Title Measure Description NQS Domain
+
439 N/A Age Appropriate Screening Colonoscopy  The percentage of patients greater than 85 years of age who received a screening colonoscopy from January 1 to December 31 Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Efficiency Yes Gastroenterology
Quality ID NQF Measure Title Measure Description NQS Domain
+
440 N/A Basal Cell Carcinoma (BCC)/Squamous Cell Carcinoma (SCC): Biopsy Reporting Time – Pathologist to Clinician Percentage of biopsies with a diagnosis of cutaneous Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC) (including in situ disease) in which the pathologist communicates results to the clinician within 7 days from the time when the tissue specimen was received by the pathologist Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Process Yes Dermatology
Quality ID NQF Measure Title Measure Description NQS Domain
+
441 N/A Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control) The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization's total IVD denominator. All-or-None Outcome Measure (Optimal Control) - Using the IVD denominator optimal results include:

•  Most recent blood pressure (BP) measurement is less than or equal to 140/90 mm Hg -- AND

• Most recent tobacco status is Tobacco Free -- AND

• Daily Aspirin or Other Antiplatelet Unless Contraindicated -- AND

• Statin Use Unless Contraindicated
Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Intermediate Outcome Yes Cardiology, Family Medicine, Internal Medicine, Vascular Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
+
442 0071 Persistence of Beta-Blocker Treatment After a Heart Attack The percentage of patients 18 years of age and older during the measurement year who were hospitalized and discharged from July 1 of the year prior to the measurement year to June 30 of the measurement year with a diagnosis of acute myocardial infarction (AMI) and who were prescribed persistent beta-blocker treatment for six months after discharge Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Cardiology, Family Medicine, Internal Medicine
Quality ID NQF Measure Title Measure Description NQS Domain
+
443 N/A Non-Recommended Cervical Cancer Screening in Adolescent Females The percentage of adolescent females 16–20 years of age who were screened unnecessarily for cervical cancer Patient Safety
Measure Type High Priority Specialty Measure Sets
Process Yes Family Medicine, Internal Medicine, Obstetrics/Gynecology
Quality ID NQF Measure Title Measure Description NQS Domain
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444 N/A Medication Management for People with Asthma The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment period Efficiency and Cost Reduction
Measure Type High Priority Specialty Measure Sets
Process Yes Family Medicine, Internal Medicine, Pediatrics
Quality ID NQF Measure Title Measure Description NQS Domain
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445 0119 Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG) Percent of patients aged 18 years and older undergoing isolated CABG who die, including both all deaths occurring during the hospitalization in which the CABG was performed, even if after 30 days, and those deaths occurring after discharge from the hospital, but within 30 days of the procedure Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Outcome Yes Thoracic Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
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446 0733 Operative Mortality Stratified by the Five STS-EACTS Mortality Categories Percent of patients undergoing index pediatric and/or congenital heart surgery who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days (including patients transferred to other acute care facilities), and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, stratified by the five STAT Mortality Levels, a multi-institutional validated complexity stratification tool Patient Safety
Measure Type High Priority Specialty Measure Sets
Outcome Yes N/A
Quality ID NQF Measure Title Measure Description NQS Domain
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448 0567 Appropriate Workup Prior to Endometrial Ablation  Percentage of women, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy and results documented before undergoing an endometrial ablation Communication and Care Coordination
Measure Type High Priority Specialty Measure Sets
Process Yes Obstetrics/Gynecology
Quality ID NQF Measure Title Measure Description NQS Domain
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449 1857 HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment with HER2-Targeted Therapies Percentage of female patients (aged 18 years and older) with breast cancer who are human epidermal growth factor receptor 2 (HER2)/neu negative who are not administered HER2-targeted therapies Efficiency and Cost Reduction
Measure Type High Priority Specialty Measure Sets
Process Yes Oncology
Quality ID NQF Measure Title Measure Description NQS Domain
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450 1858 Trastuzumab Received By Patients With AJCC Stage I (T1c) – III And HER2 Positive Breast Cancer Receiving Adjuvant Chemotherapy Percentage of female patients (aged 18 years and older) with AJCC stage I (T1c) – III, human epidermal growth factor receptor 2 (HER2) positive breast cancer receiving adjuvant chemotherapy who are also receiving Trastuzumab Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process Yes Oncology
Quality ID NQF Measure Title Measure Description NQS Domain
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451 1859 RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy for whom RAS (KRAS and NRAS) gene mutation testing was performed Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process No Oncology
Quality ID NQF Measure Title Measure Description NQS Domain
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452 1860 Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies Percentage of adult patients (aged 18 or over) with metastatic colorectal cancer and RAS (KRAS or NRAS) gene mutation spared treatment with anti-EGFR monoclonal antibodies Patient Safety
Measure Type High Priority Specialty Measure Sets
Process Yes Oncology
Quality ID NQF Measure Title Measure Description NQS Domain
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453 0210 Percentage of Patients Who Died from Cancer Receiving Chemotherapy in the Last 14 Days of Life (lower score – better) Percentage of patients who died from cancer receiving chemotherapy in the last 14 days of life Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process Yes Oncology
Quality ID NQF Measure Title Measure Description NQS Domain
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454 N/A Percentage of Patients who Died from Cancer with More than One Emergency Department Visit in the Last 30 Days of Life (lower score – better) Percentage of patients who died from cancer with more than one emergency department visit in the last 30 days of life Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Outcome Yes Oncology
Quality ID NQF Measure Title Measure Description NQS Domain
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455 0213 Percentage of Patients Who Died from Cancer Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life (lower score – better) Percentage of patients who died from cancer admitted to the ICU in the last 30 days of life Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Outcome Yes Geriatrics, Oncology
Quality ID NQF Measure Title Measure Description NQS Domain
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456 0215 Percentage of Patients Who Died From Cancer Not Admitted To Hospice (lower score – better) Percentage of patients who died from cancer not admitted to hospice Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process Yes Oncology
Quality ID NQF Measure Title Measure Description NQS Domain
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457 0216 Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score – better) Percentage of patients who died from cancer, and admitted to hospice and spent less than 3 days there Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Outcome Yes Oncology
Quality ID NQF Measure Title Measure Description NQS Domain
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459 N/A Average Change in Back Pain Following Lumbar Discectomy/Laminotomy The average change (preoperative to three months postoperative) in back pain for patients 18 years of age or older who had a lumbar discectomy/laminotomy procedure Person and Caregiver-Centered Experience and Outcomes
Measure Type High Priority Specialty Measure Sets
Patient Reported Outcome Yes Neurosurgical, Orthopedic Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
+
460 N/A Average Change in Back Pain Following Lumbar Fusion The average change (preoperative to one year postoperative) in back pain for patients 18 years of age or older who had a lumbar fusion procedure Person and Caregiver-Centered Experience and Outcomes
Measure Type High Priority Specialty Measure Sets
Patient Reported Outcome Yes Neurosurgical, Orthopedic Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
+
461 N/A Average Change in Leg Pain Following Lumbar Discectomy and/or Laminotomy The average change (preoperative to three months postoperative) in leg pain for patients 18 years of age or older who had a lumbar discectomy/laminotomy procedure Person and Caregiver-Centered Experience and Outcomes
Measure Type High Priority Specialty Measure Sets
Patient Reported Outcome Yes Neurosurgical, Orthopedic Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
+
463 N/A Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics) Percentage of patients aged 3 through 17 years, who undergo a procedure under general anesthesia in which an inhalational anesthetic is used for maintenance AND who have two or more risk factors for post-operative vomiting (POV), who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively and/or intraoperatively Patient Safety
Measure Type High Priority Specialty Measure Sets
Process Yes Anesthesiology
Quality ID NQF Measure Title Measure Description NQS Domain
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464 0657 Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process Yes Family Medicine, Infectious Disease, Otolaryngology, Pediatrics, Urgent Care
Quality ID NQF Measure Title Measure Description NQS Domain
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465 N/A Uterine Artery Embolization Technique: Documentation of Angigraphic Endpoints and Interrogation of Ovarian Arteries The percentage of patients with documentation of angiographic endpoints of embolization AND the documentation of embolization strategies in the presence of unilateral or bilateral absent uterine arteries Patient Safety
Measure Type High Priority Specialty Measure Sets
Process Yes Interventional Radiology
Quality ID NQF Measure Title Measure Description NQS Domain
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467 1448 Developmental Screening in the First Three Years of Life The percentage of children screened for risk of developmental, behavioral and social delays using a standardized screening tool in the 12 months preceding or on their first, second, or third birthday. This is a composite measure of screening in the first three years of life that includes three, age-specific indicators assessing whether children are screened in the 12 months preceding or on their first, second or third birthday Community/Population Health
Measure Type High Priority Specialty Measure Sets
Process No Pediatrics
Quality ID NQF Measure Title Measure Description NQS Domain
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468 3175 Continuity of Pharmacotherapy for Opioid Use Disorder (OUD) Percentage of adults aged 18 years and older with pharmacotherapy for opioid use disorder (OUD) who have at least 180 days of continuous treatment Effective Clinical Care
Measure Type High Priority Specialty Measure Sets
Process Yes Family Medicine, Internal Medicine, Mental/Behavioral Health, Physical Medicine
Quality ID NQF Measure Title Measure Description NQS Domain
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469 2643 Average Change in Functional Status Following Lumbar Fusion Surgery The average change (preoperative to postoperative) in functional status using the Oswestry Disability Index (ODI version 2.1a) for patients 18 years of age and older who had a lumbar fusion procedure Person and Caregiver-Centered Experience and Outcomes
Measure Type High Priority Specialty Measure Sets
Patient Reported Outcome Yes Neurosurgical, Orthopedic Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
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470 2653 Average Change In Functional Status Following Total Knee Replacement Surgery The average change (preoperative to postoperative) in functional status using the Oxford Knee Score (OKS) for patients age 18 and older who had a primary total knee replacement Person and Caregiver-Centered Experience and Outcomes
Measure Type High Priority Specialty Measure Sets
Patient Reported Outcome Yes Orthopedic Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
+
471 N/A Average Change in Functional Status Following Lumbar Discectomy/Laminotomy Surgery The average change (preoperative to postoperative) in functional status using the Oswestry Disability Index (ODI version 2.1a) for patients age 18 and older who had lumbar discectomy/laminotomy procedure Person and Caregiver-Centered Experience and Outcomes
Measure Type High Priority Specialty Measure Sets
Patient Reported Outcome Yes Neurosurgical, Orthopedic Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
+
473 N/A Average Change in Leg Pain Following Lumbar Fusion Surgery The average change (preoperative to one year postoperative) in leg pain for patients 18 years of age or older who had a lumbar fusion procedure Person and Caregiver-Centered Experience and Outcomes
Measure Type High Priority Specialty Measure Sets
Patient Reported Outcome Yes Neurosurgical, Orthopedic Surgery
Quality ID NQF Measure Title Measure Description NQS Domain
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474 N/A Zoster (Shingles) Vaccination The percentage of patients aged 50 years and older who have had a Varicella Zoster (shingles) vaccination. Community/Population Health
Measure Type High Priority Specialty Measure Sets
Process No Family Medicine, Geriatrics, Infectious Disease, Internal Medicine, Nephrology, Oncology, Preventative Medicine, Skilled Nursing Facility, Gastroenterology