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2018 Quality Measures

  • Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy - Avoidance of Inappropriate Use

     Process
    Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy

    Submission Methods

    • Claims
    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Acute Otitis Externa (AOE): Topical Therapy

     Process
    Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations

    Submission Methods

    • Claims
    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Adherence to Antipsychotic Medications For Individuals with Schizophrenia

    High Priority Measure:  Intermediate Outcome
    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)

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Adult Kidney Disease: Blood Pressure Management

    High Priority Measure:  Intermediate Outcome

    Percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (stage 3, 4, or 5, not receiving Renal Replacement Therapy [RRT]) with a blood pressure < 140/90 mmHg OR >= 140/90 mmHg with a documented plan of care

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis

    High Priority Measure:  Outcome
    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

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days

     Outcome
    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

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Adult Kidney Disease: Referral to Hospice

    High Priority Measure:  Process
    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

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions

    High Priority Measure:  Process
    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

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Adult Major Depressive Disorder (MDD): Suicide Risk Assessment

     Process
    Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified

    Submission Methods

    • EHR

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery

    High Priority Measure:  Outcome
    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

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery

    High Priority Measure:  Outcome
    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

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)

     Process
    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

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)

     Process
    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

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse)

     Efficiency
    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

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse)

     Efficiency
    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

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Age Appropriate Screening Colonoscopy

     Efficiency
    The percentage of patients greater than 85 years of age who received a screening colonoscopy from January 1 to December 31

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement

     Process
    Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) or their caregiver(s) who were counseled within 12 months on the benefits and/or risks of the Age-Related Eye Disease Study (AREDS) formulation for preventing progression of AMD

    Submission Methods

    • Claims
    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Age-Related Macular Degeneration (AMD): Dilated Macular Examination

     Process
    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

    Submission Methods

    • Claims
    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • All-cause Hospital Readmission

     Outcome
    The 30-day All-Cause Hospital Readmission measure is a risk-standardized readmission rate for beneficiaries age 65 or older who were hospitalized at a short-stay acute care hospital and experienced an unplanned readmission for any cause to an acute care hospital within 30 days of discharge

    Submission Methods

    • Administrative Claims

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences

    High Priority Measure:  Process
    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

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Anastomotic Leak Intervention

    High Priority Measure:  Outcome
    Percentage of patients aged 18 years and older who required an anastomotic leak intervention following gastric bypass or colectomy surgery

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Anesthesiology Smoking Abstinence

    High Priority Measure:  Intermediate Outcome
    The percentage of current smokers who abstain from cigarettes prior to anesthesia on the day of elective surgery or procedure

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users

     Process
    Percentage of patients, regardless of age, who are active injection drug users who received screening for HCV infection within the 12 month reporting period

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Anti-Depressant Medication Management

     Process

    Percentage of patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported: 


    1. 1.Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks) 
    2. 2.Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months)
       

    Submission Methods

    • EHR

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal

     Process
    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

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Appropriate Follow-up Imaging for Incidental Abdominal Lesions

     Process

    Percentage of final reports for abdominal imaging studies for asymptomatic 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

    Submission Methods

    • Claims
    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients

     Process
    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

    Submission Methods

    • Claims
    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients

     Process
    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

    Submission Methods

    • Claims
    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Appropriate Testing for Children with Pharyngitis

     Process
    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

    Submission Methods

    • EHR
    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Appropriate Treatment for Children with Upper Respiratory Infection (URI)

     Process
    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

    Submission Methods

    • EHR
    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia

     Process
    Percentage of patients with sepsis due to MSSA bacteremia who received beta-lactam antibiotic (e.g. nafcillin, oxacillin or cefazolin) as definitive therapy

    Submission Methods

    • Claims
    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Appropriate Work Up Prior to Endometrial Ablation

    High Priority Measure:  Process
    Percentage of women, aged 18 years and older, who undergo endometrial sampling or hysteroscopy with biopsy and results documented before undergoing an endometrial ablation

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy

     Process
    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

    Submission Methods

    • Claims
    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Average Change in Back Pain following Lumbar Discectomy / Laminotomy

    High Priority Measure:  Outcome
    The average change (preoperative to three months postoperative) in back pain for patients 18 years of age or older who had lumbar discectomy/laminotomy procedure

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Average Change in Back Pain following Lumbar Fusion

    High Priority Measure:  Outcome
    The average change (preoperative to one year postoperative) in back pain for patients 18 years of age or older who had lumbar spine fusion procedure

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Average Change in Leg Pain following Lumbar Discectomy and/or Laminotomy

    High Priority Measure:  Outcome
    The average change (preoperative to three months postoperative) in leg pain for patients 18 years of age or older who had lumbar discectomy/laminotomy procedure

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis

     Process
    The percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not prescribed or dispensed an antibiotic prescription

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Barrett's Esophagus

     Process
    Percentage of esophageal biopsy reports that document the presence of Barrett's mucosa that also include a statement about dysplasia

    Submission Methods

    • Claims
    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Basal Cell Carcinoma (BCC)/Squamous Cell Carcinoma (SCC): Biopsy Reporting Time - Pathologist to Clinician

    High Priority Measure:  Process
    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

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Biopsy Follow-Up

    High Priority Measure:  Process
    Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient by the performing physician

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance use

     Process
    Percentage of patients with depression or bipolar disorder with evidence of an initial assessment that includes an appraisal for alcohol or chemical substance use

    Submission Methods

    • EHR

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy

     Process
    Patients determined as having prostate cancer who are currently starting or undergoing androgen deprivation therapy (ADT), for an anticipated period of 12 months or greater and who receive an initial bone density evaluation. The bone density evaluation must be prior to the start of ADT or within 3 months of the start of ADT

    Submission Methods

    • EHR

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade

     Process
    Percentage of breast cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes), and the histologic grade

    Submission Methods

    • Claims
    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Breast Cancer Screening

     Process
    Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer

    Submission Methods

    • Claims
    • CMS Web Interface
    • EHR
    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • CAHPS for MIPs Clinician/Group Survey

    High Priority Measure:  Patient Engagement Experience
    • Getting timely care, appointments, and information; • How well providers Communicate; • Patient's Rating of Provider; • Access to Specialists; • Health Promotion & Education; • Shared Decision Making; • Health Status/Functional Status; • Courteous and Helpful Office Staff; • Care Coordination; and • Stewardship of Patient Resources

    Submission Methods

    • CSV

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Cardiac Rehabilitation Patient Referral from an Outpatient Setting

    High Priority Measure:  Process
    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

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients

     Efficiency
    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

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI)

     Efficiency
    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

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients

     Efficiency
    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

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Care Plan

    High Priority Measure:  Process
    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

    Submission Methods

    • Claims
    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy)

    High Priority Measure:  Outcome
    Percentage of patients aged 18 years and older who had cataract surgery performed and had an unplanned rupture of the posterior capsule requiring vitrectomy

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Cataract Surgery: Difference Between Planned and Final Refraction

    High Priority Measure:  Outcome
    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

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery

    High Priority Measure:  Outcome
    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

    Submission Methods

    • EHR
    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures

    High Priority Measure:  Outcome
    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

    Submission Methods

    • EHR
    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Cataracts: Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery

    High Priority Measure:  Outcome
    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

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery

    High Priority Measure:  Outcome
    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

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Cervical Cancer Screening

     Process

     Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria:


    • Women age 21-64 who had cervical cytology performed every 3 years
    • Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years

    Submission Methods

    • EHR

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment

    High Priority Measure:  Process
    Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk

    Submission Methods

    • EHR

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Childhood Immunization Status

     Process
    Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday

    Submission Methods

    • EHR

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Children Who Have Dental Decay or Cavities

    High Priority Measure:  Outcome
    Percentage of children, age 0-20 years, who have had tooth decay or cavities during the measurement period

    Submission Methods

    • EHR

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Chlamydia Screening and Follow Up

     Process
    The percentage of female adolescents 16 years of age who had a chlamydia screening test with proper follow-up during the measurement period

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Chlamydia Screening for Women

     Process
    Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period

    Submission Methods

    • EHR

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy

     Process
    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 an long-acting inhaled bronchodilator

    Submission Methods

    • Claims
    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation

     Process
    Percentage of patients aged 18 years and older with a diagnosis of COPD who had spirometry results documented

    Submission Methods

    • Claims
    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Clinical Outcome Post Endovascular Stroke Treatment

    High Priority Measure:  Outcome
    Percentage of patients with a mRs score of 0 to 2 at 90 days following endovascular stroke intervention

    Submission Methods

    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Closing the Referral Loop: Receipt of Specialist Report

    High Priority Measure:  Process
    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

    Submission Methods

    • EHR
    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Colonoscopy Interval for Patients with a History of Adenomatous Polyps - Avoidance of Inappropriate Use

     Process
    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

    Submission Methods

    • Claims
    • Registry

    Documentation

    Specifications and benchmarking files per measure will be available Summer 2018.

  • Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade

     Process
    Percentage of colon and rectum cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes) and the histologic grade