CMS Quality ID Measure Name Measure Description Measure Type High Priority Measure Primary Measure Steward
331 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 Process No American Academy of Otolaryngology - Head and Neck Surgery
332 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 Process No American Academy of Otolaryngology - Head and Neck Surgery
333 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 No American Academy of Otolaryngology - Head and Neck Surgery
334 Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse) Percentage of patients aged 18 years and older with a diagnosis of chronic sinusitis who had more than one CT scan of the paranasal sinuses ordered or received within 90 days after date of diagnosis Efficiency No American Academy of Otolaryngology - Head and Neck Surgery
439 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 Efficiency No American Gastroenterological Association
14 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 12 months Process No American Academy of Ophthalmology
387 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 Process No Physician Consortium for Performance Improvement
65 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 Process No National Committee for Quality Assurance
326 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 anticoagulant drug for the prevention of thromboembolism during the measurement period Process No American College of Cardiology
112 Breast Cancer Screening Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer Process No National Committee for Quality Assurance
47 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 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 Process Yes National Committee for Quality Assurance
113 Colorectal Cancer Screening Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer Process No National Committee for Quality Assurance
236 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 (<140/90mmHg) during the measurement period Intermediate Outcome Yes National Committee for Quality Assurance
6 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 Process No National Committee for Quality Assurance
7 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 Process No Physician Consortium for Performance Improvement
283 Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management Percentage of patients with dementia for whom there was a documented symptoms screening for behavioral and psychiatric symptoms, including depression, AND for whom, if symptoms screening was positive, there was also documentation of recommendations for symptoms management in the last 12 months Process No American Academy of Neurology
288 Dementia: Caregiver Education and Support 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 Process Yes American Academy of Neurology
282 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 Process No American Academy of Neurology
286 Dementia: Safety Concerns Screening and Mitigation Recommendations or Referral 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 or orders for home safety evaluation Process Yes American Academy of Neurology
370 Depression Remission at Twelve Months The percentage of patients 18 years of age and or older with major depression or dysthymia who reached remission 12 months (+/- 30 days) after an index visit Outcome Yes Minnesota Community Measurement
126 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 were evaluated for proper footwear and sizing Process No American Podiatric Medical Association
117 Diabetes: Eye Exam Percentage of patients 18-75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal exam (no evidence of retinopathy) in the 12 months prior to the measurement period Process No National Committee for Quality Assurance
1 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 Intermediate Outcome Yes National Committee for Quality Assurance
119 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 Process No National Committee for Quality Assurance
19 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 Process Yes Physician Consortium for Performance Improvement
130 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 Process Yes Centers for Medicare & Medicaid Services
412 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 Process No American Academy of Neurology
181 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 Process Yes Centers for Medicare & Medicaid Services
414 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 Process No American Academy of Neurology
155 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 Process Yes National Committee for Quality Assurance
154 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 Process Yes National Committee for Quality Assurance
5 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 Process No American Academy of Neurology
8 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 Process No Physician Consortium for Performance Improvement
401 Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12 month reporting period Process No American Gastroenterological Association
275 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 Process No American Gastroenterological Association
204 Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antiplatelet during the measurement period Process No National Committee for Quality Assurance
46 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 Process Yes National Committee for Quality Assurance
400 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 Process No Physician Consortium for Performance Improvement
408 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 Process No American Academy of Neurology
398 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 Outcome Yes Minnesota Community Measurement
109 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 Process Yes American Academy of Orthopedic Surgeons
418 Osteoporosis Management in Women Who Had a Fracture The percentage of women age 50-85 who suffered a fracture and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis in the six months after the fracture Process No National Committee for Quality Assurance
131 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 Process Yes Centers for Medicare & Medicaid Services
21 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 Process No American Society of Plastic Surgeons
23 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 Process Yes American Society of Plastic Surgeons
111 Pneumococcal Vaccination Status for Older Adults Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine Process No National Committee for Quality Assurance
76 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 Process Yes American Society of Anesthesiologists
128 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 Process No Centers for Medicare & Medicaid Services
110 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 Process No Physician Consortium for Performance Improvement
134 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 Process No Centers for Medicare & Medicaid Services
317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented Percentage of patients aged 18 years and older seen during the submitting 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 Process No Centers for Medicare & Medicaid Services
226 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 Process No Physician Consortium for Performance Improvement
431 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 Process No Physician Consortium for Performance Improvement
12 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 Process No Physician Consortium for Performance Improvement
337 Psoriasis: Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier Percentage of patients whose providers are ensuring active tuberculosis prevention either through yearly negative standard tuberculosis screening tests or are reviewing the patient's history to determine if they have had appropriate management for a recent or prior positive test Process No American Academy of Dermatology
343 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 Outcome Yes American Society for Gastrointestinal Endoscopy
39 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 Process No National Committee for Quality Assurance
438 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 Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL Process No Centers for Medicare & Medicaid Services
402 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 Process No National Committee for Quality Assurance
353 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 Process Yes American Association of Hip and Knee Surgeons
352 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 Process Yes American Association of Hip and Knee Surgeons
350 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 Process Yes American Association of Hip and Knee Surgeons
351 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) Process Yes American Association of Hip and Knee Surgeons
48 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 Process No National Committee for Quality Assurance
50 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 Process Yes National Committee for Quality Assurance
238 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 Process Yes National Committee for Quality Assurance

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