cms-gov/www.cms.gov/files/document/2024-quality-benchmarks.csv

Measure Title,Measure ID,CMS eCQM ID,Collection Type,Measure Type,High Priority,Average Performance Rate,Measure has a Benchmark,Benchmark Type,Decile 1,Decile 2,Decile 3, Decile 4,Decile 5,Decile 6,Decile 7, Decile 8,Decile 9,Decile 10,Topped Out,Seven Point Cap,Reason for No Benchmarks 
"Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)","001","N/A","MIPS CQM","Intermediate Outcome","Yes","27.30","Yes","Historical","99.00 - 90.01","90.00 - 80.01","80.00 - 70.01","70.00 - 60.01","60.00 - 50.01","50.00 - 40.01","40.00 - 30.01","30.00 - 20.01","20.00 - 10.01","<= 10.00","No","No","N/A"
"Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)","001","N/A","Medicare Part B Claims","Intermediate Outcome","Yes","11.70","Yes","Historical","99.00 - 90.01","90.00 - 80.01","80.00 - 70.01","70.00 - 60.01","60.00 - 50.01","50.00 - 40.01","40.00 - 30.01","30.00 - 20.01","20.00 - 10.01","<= 10.00","No","No","N/A"
"Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)","001","CMS122v12","eCQM","Intermediate Outcome","Yes","43.53","Yes","Historical","99.50 - 93.63","93.62 - 72.22","72.21 - 53.19","53.18 - 41.63","41.62 - 34.16","34.15 - 29.06","29.05 - 24.26","24.25 - 19.84","19.83 - 14.54","<= 14.53","No","No","N/A"
"Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)","005","N/A","MIPS CQM","Process","No","96.65","Yes","Historical","42.86 - 90.27","90.28 - 96.54","96.55 - 98.98","98.99 - 99.99","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)","005","CMS135v12","eCQM","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure was suppressed in PY 2022 (baseline period); data isn't available for historical benchmarking."
"Coronary Artery Disease (CAD): Antiplatelet Therapy","006","N/A","MIPS CQM","Process","No","92.71","Yes","Historical","48.81 - 79.82","79.83 - 87.37","87.38 - 91.33","91.34 - 94.84","94.85 - 97.43","97.44 - 99.99","--","--","--","100.00","Yes","No","N/A"
"Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%)","007","N/A","MIPS CQM","Process","No","92.47","Yes","Historical","61.29 - 80.55","80.56 - 86.62","86.63 - 89.55","89.56 - 92.97","92.98 - 95.70","95.71 - 98.19","98.20 - 99.99","--","--","100.00","Yes","No","N/A"
"Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%)","007","CMS145v12","eCQM","Process","No","88.05","Yes","Historical","42.86 - 78.32","78.33 - 83.81","83.82 - 86.66","86.67 - 88.63","88.64 - 90.19","90.20 - 91.66","91.67 - 93.00","93.01 - 94.73","94.74 - 96.46",">= 96.47","No","No","N/A"
"Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)","008","N/A","MIPS CQM","Process","No","96.94","Yes","Historical","43.33 - 94.28","94.29 - 97.93","97.94 - 99.41","99.42 - 99.99","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)","008","CMS144v12","eCQM","Process","No","90.11","Yes","Historical","31.18 - 82.60","82.61 - 86.66","86.67 - 89.12","89.13 - 90.90","90.91 - 92.46","92.47 - 93.68","93.69 - 94.99","95.00 - 96.49","96.50 - 98.22",">= 98.23","No","No","N/A"
"Anti-Depressant Medication Management","009","CMS128v12","eCQM","Process","No","78.60","Yes","Historical","10.40 - 66.97","66.98 - 74.31","74.32 - 77.02","77.03 - 79.25","79.26 - 81.24","81.25 - 82.89","82.90 - 84.37","84.38 - 86.76","86.77 - 90.62",">= 90.63","No","No","N/A"
"Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation","012","CMS143v12","eCQM","Process","No","88.78","Yes","Historical","4.43 - 70.52","70.53 - 85.70","85.71 - 90.80","90.81 - 93.99","94.00 - 96.25","96.26 - 97.66","97.67 - 98.69","98.70 - 99.43","99.44 - 99.99","100.00","Yes","No","N/A"
"Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care","019","N/A","MIPS CQM","Process","Yes","94.72","Yes","Historical","4.44 - 88.29","88.30 - 97.82","97.83 - 99.99","--","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care","019","CMS142v12","eCQM","Process","Yes","80.91","Yes","Historical","9.52 - 50.42","50.43 - 69.49","69.50 - 77.94","77.95 - 83.59","83.60 - 88.35","88.36 - 91.35","91.36 - 93.97","93.98 - 96.54","96.55 - 98.75",">= 98.76","No","No","N/A"
"Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older","024","N/A","MIPS CQM","Process","Yes","80.77","Yes","Historical","0.60 - 44.34","44.35 - 68.10","68.11 - 77.77","77.78 - 84.65","84.66 - 91.59","91.60 - 96.94","96.95 - 99.99","--","--","100.00","No","No","N/A"
"Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older","024","N/A","Medicare Part B Claims","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Screening for Osteoporosis for Women Aged 65-85 Years of Age","039","N/A","MIPS CQM","Process","No","57.90","Yes","Historical","0.25 - 6.70","6.71 - 21.96","21.97 - 42.30","42.31 - 54.65","54.66 - 63.25","63.26 - 71.19","71.20 - 81.19","81.20 - 89.65","89.66 - 97.97",">= 97.98","No","No","N/A"
"Screening for Osteoporosis for Women Aged 65-85 Years of Age","039","N/A","Medicare Part B Claims","Process","No","73.57","Yes","Historical","1.52 - 24.99","25.00 - 52.24","52.25 - 65.57","65.58 - 73.77","73.78 - 82.34","82.35 - 88.55","88.56 - 96.18","96.19 - 99.22","99.23 - 99.99","100.00","No","No","N/A"
"Advance Care Plan","047","N/A","MIPS CQM","Process","Yes","77.76","Yes","Historical","0.21 - 14.72","14.73 - 53.34","53.35 - 76.44","76.45 - 88.37","88.38 - 95.45","95.46 - 98.91","98.92 - 99.89","99.90 - 99.99","--","100.00","Yes","No","N/A"
"Advance Care Plan","047","N/A","Medicare Part B Claims","Process","Yes","100.00","Yes","Historical","--","--","--","--","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older","048","N/A","MIPS CQM","Process","No","88.33","Yes","Historical","3.44 - 52.93","52.94 - 82.63","82.64 - 93.15","93.16 - 98.04","98.05 - 99.58","99.59 - 99.99","--","--","--","100.00","Yes","Yes","N/A"
"Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older","050","N/A","MIPS CQM","Process","Yes","83.59","Yes","Historical","6.45 - 49.99","50.00 - 73.60","73.61 - 79.79","79.80 - 85.05","85.06 - 90.07","90.08 - 97.09","97.10 - 99.99","--","--","100.00","No","No","N/A"
"Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation for Long-Acting Inhaled Bronchodilator Therapy","052","N/A","MIPS CQM","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Substantive changes to specification in PY 2024; PY 2024 measure can't be compared to baseline period (PY 2022) measure."
"Appropriate Treatment for Upper Respiratory Infection (URI)","065","N/A","MIPS CQM","Process","Yes","94.37","Yes","Historical","52.69 - 88.36","88.37 - 92.61","92.62 - 94.91","94.92 - 96.11","96.12 - 97.23","97.24 - 98.26","98.27 - 98.89","98.90 - 99.44","99.45 - 99.99","100.00","Yes","No","N/A"
"Appropriate Treatment for Upper Respiratory Infection (URI)","065","CMS154v12","eCQM","Process","Yes","89.51","Yes","Historical","26.42 - 72.31","72.32 - 84.34","84.35 - 88.93","88.94 - 91.73","91.74 - 94.28","94.29 - 96.31","96.32 - 97.95","97.96 - 99.31","99.32 - 99.99","100.00","No","No","N/A"
"Appropriate Testing for Pharyngitis","066","N/A","MIPS CQM","Process","Yes","95.78","Yes","Historical","34.65 - 91.22","91.23 - 94.77","94.78 - 96.93","96.94 - 98.17","98.18 - 99.32","99.33 - 99.89","99.90 - 99.99","--","--","100.00","Yes","Yes","N/A"
"Appropriate Testing for Pharyngitis","066","CMS146v12","eCQM","Process","Yes","60.60","Yes","Historical","1.05 - 9.99","10.00 - 29.16","29.17 - 46.13","46.14 - 60.60","60.61 - 69.37","69.38 - 77.41","77.42 - 83.42","83.43 - 87.84","87.85 - 91.13",">= 91.14","No","No","N/A"
"Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients","102","N/A","MIPS CQM","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients","102","CMS129v13","eCQM","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate Cancer","104","N/A","MIPS CQM","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Breast Cancer Screening","112 (MVP Reporting Only)","N/A","MIPS CQM","Process","No","68.94","Yes","Historical","0.43 - 29.73","29.74 - 49.38","49.39 - 58.08","58.09 - 67.08","67.09 - 75.15","75.16 - 79.60","79.61 - 86.35","86.36 - 94.05","94.06 - 99.99","100.00","No","No","N/A"
"Breast Cancer Screening","112 (MVP Reporting Only)","N/A","Medicare Part B Claims","Process","No","80.07","Yes","Historical","2.25 - 34.03","34.04 - 67.91","67.92 - 75.85","75.86 - 84.09","84.10 - 92.18","92.19 - 95.87","95.88 - 98.65","98.66 - 99.99","--","100.00","No","No","N/A"
"Breast Cancer Screening","112 (MVP Reporting Only)","CMS125v12","eCQM","Process","No","53.86","Yes","Historical","0.20 - 8.28","8.29 - 28.45","28.46 - 42.75","42.76 - 52.41","52.42 - 59.78","59.79 - 65.63","65.64 - 71.42","71.43 - 77.11","77.12 - 84.55",">= 84.56","No","No","N/A"
"Colorectal Cancer Screening","113 (MVP Reporting Only)","N/A","MIPS CQM","Process","No","70.98","Yes","Historical","1.16 - 31.77","31.78 - 51.57","51.58 - 62.55","62.56 - 70.30","70.31 - 77.01","77.02 - 84.18","84.19 - 88.31","88.32 - 94.59","94.60 - 99.54",">= 99.55","No","No","N/A"
"Colorectal Cancer Screening","113 (MVP Reporting Only)","N/A","Medicare Part B Claims","Process","No","100.00","Yes","Historical","--","--","--","--","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Colorectal Cancer Screening","113 (MVP Reporting Only)","CMS130v12","eCQM","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure was suppressed in PY 2022 (baseline period); data isn't available for historical benchmarking."
"Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis","116","N/A","MIPS CQM","Process","Yes","89.97","Yes","Historical","36.11 - 76.31","76.32 - 86.04","86.05 - 89.24","89.25 - 92.69","92.70 - 94.25","94.26 - 95.88","95.89 - 97.63","97.64 - 98.60","98.61 - 99.99","100.00","No","No","N/A"
"Diabetes: Eye Exam","117","N/A","MIPS CQM","Process","No","93.63","Yes","Historical","10.26 - 79.99","80.00 - 96.45","96.46 - 99.20","99.21 - 99.99","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Diabetes: Eye Exam","117","CMS131v12","eCQM","Process","No","59.95","Yes","Historical","0.50 - 6.32","6.33 - 16.14","16.15 - 27.24","27.25 - 41.08","41.09 - 65.66","65.67 - 93.56","93.57 - 98.45","98.46 - 99.65","99.66 - 99.99","100.00","No","No","N/A"
"Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%)","118","N/A","MIPS CQM","Process","No","86.88","Yes","Historical","37.29 - 73.73","73.74 - 78.14","78.15 - 81.96","81.97 - 85.22","85.23 - 88.09","88.10 - 91.57","91.58 - 97.77","97.78 - 99.99","--","100.00","No","No","N/A"
"Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy - Neurological Evaluation","126","N/A","MIPS CQM","Process","No","83.38","Yes","Historical","0.81 - 27.91","27.92 - 66.36","66.37 - 88.76","88.77 - 98.30","98.31 - 99.99","--","--","--","--","100.00","Yes","Yes","N/A"
"Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention - Evaluation of Footwear","127","N/A","MIPS CQM","Process","No","89.34","Yes","Historical","0.95 - 54.06","54.07 - 87.69","87.70 - 97.91","97.92 - 99.99","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan","128 (MVP Reporting Only)","N/A","MIPS CQM","Process","No","85.84","Yes","Historical","1.20 - 39.82","39.83 - 75.09","75.10 - 91.88","91.89 - 98.31","98.32 - 99.75","99.76 - 99.99","--","--","--","100.00","Yes","Yes","N/A"
"Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan","128 (MVP Reporting Only)","N/A","Medicare Part B Claims","Process","No","92.25","Yes","Historical","14.94 - 67.50","67.51 - 94.85","94.86 - 99.08","99.09 - 99.87","99.88 - 99.99","--","--","--","--","100.00","Yes","Yes","N/A"
"Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan","128 (MVP Reporting Only)","CMS69v12","eCQM","Process","No","49.56","Yes","Historical","4.31 - 18.11","18.12 - 22.08","22.09 - 25.61","25.62 - 29.94","29.95 - 36.83","36.84 - 51.42","51.43 - 73.21","73.22 - 87.41","87.42 - 96.48",">= 96.49","No","No","N/A"
"Documentation of Current Medications in the Medical Record","130","N/A","MIPS CQM","Process","Yes","90.69","Yes","Historical","3.80 - 68.12","68.13 - 92.99","93.00 - 98.22","98.23 - 99.64","99.65 - 99.94","99.95 - 99.99","--","--","--","100.00","Yes","Yes","N/A"
"Documentation of Current Medications in the Medical Record","130","CMS68v13","eCQM","Process","Yes","86.81","Yes","Historical","5.12 - 61.37","61.38 - 80.24","80.25 - 87.90","87.91 - 92.23","92.24 - 95.20","95.21 - 97.07","97.08 - 98.32","98.33 - 99.26","99.27 - 99.87",">= 99.88","Yes","Yes","N/A"
"Preventive Care and Screening: Screening for Depression and Follow-Up Plan","134","N/A","MIPS CQM","Process","No","89.55","Yes","Historical","0.05 - 61.76","61.77 - 89.45","89.46 - 97.24","97.25 - 99.21","99.22 - 99.96","99.97 - 99.99","--","--","--","100.00","Yes","Yes","N/A"
"Preventive Care and Screening: Screening for Depression and Follow-Up Plan","134","N/A","Medicare Part B Claims","Process","No","95.38","Yes","Historical","2.38 - 90.27","90.28 - 99.43","99.44 - 99.99","--","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Preventive Care and Screening: Screening for Depression and Follow-Up Plan","134","CMS2v13","eCQM","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure was suppressed in PY 2022 (baseline period); data isn't available for historical benchmarking."
"Melanoma: Continuity of Care - Recall System","137","N/A","MIPS CQM","Structure","Yes","96.54","Yes","Historical","9.58 - 95.54","95.55 - 99.99","--","--","--","--","--","--","--","100.00","No","No","N/A"
"Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 20% OR Documentation of a Plan of Care.","141","N/A","MIPS CQM","Outcome","Yes","94.47","Yes","Historical","10.13 - 86.05","86.06 - 94.42","94.43 - 97.38","97.39 - 98.94","98.95 - 99.53","99.54 - 99.86","99.87 - 99.99","--","--","100.00","No","No","N/A"
"Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 20% OR Documentation of a Plan of Care.","141","N/A","Medicare Part B Claims","Outcome","Yes","100.00","Yes","Historical","--","--","--","--","--","--","--","--","--","100.00","Yes","No","N/A"
"Oncology: Medical and Radiation - Pain Intensity Quantified","143","N/A","MIPS CQM","Process","Yes","94.25","Yes","Historical","1.60 - 81.72","81.73 - 97.05","97.06 - 99.53","99.54 - 99.99","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Oncology: Medical and Radiation - Pain Intensity Quantified","143","CMS157v12","eCQM","Process","Yes","83.70","Yes","Historical","2.12 - 24.04","24.05 - 77.94","77.95 - 90.64","90.65 - 94.62","94.63 - 96.71","96.72 - 98.05","98.06 - 98.73","98.74 - 99.37","99.38 - 99.95",">= 99.96","Yes","Yes","N/A"
"Oncology: Medical and Radiation - Plan of Care for Pain","144","N/A","MIPS CQM","Process","Yes","87.04","Yes","Historical","7.89 - 56.67","56.68 - 83.77","83.78 - 90.51","90.52 - 94.58","94.59 - 97.08","97.09 - 98.90","98.91 - 99.79","99.80 - 99.99","--","100.00","Yes","No","N/A"
"Radiology: Exposure Dose Indices Reported for Procedures Using Fluoroscopy","145","N/A","MIPS CQM","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Substantive changes to specification in PY 2023; PY 2024 measure can't be compared to baseline period (PY 2022) measure."
"Radiology: Exposure Dose Indices Reported for Procedures Using Fluoroscopy","145","N/A","Medicare Part B Claims","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Substantive changes to specification in PY 2023; PY 2024 measure can't be compared to baseline period (PY 2022) measure."
"Falls: Plan of Care","155","N/A","MIPS CQM","Process","Yes","96.68","Yes","Historical","18.29 - 93.05","93.06 - 99.81","99.82 - 99.99","--","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Falls: Plan of Care","155","N/A","Medicare Part B Claims","Process","Yes","100.00","Yes","Historical","--","--","--","--","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Coronary Artery Bypass Graft (CABG): Prolonged Intubation","164","N/A","MIPS CQM","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure","167","N/A","MIPS CQM","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration","168","N/A","MIPS CQM","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Tuberculosis Screening Prior to First Course of Biologic and/or Immune Response Modifier Therapy","176","N/A","MIPS CQM","Process","No","89.76","Yes","Historical","18.63 - 67.38","67.39 - 81.81","81.82 - 91.22","91.23 - 98.35","98.36 - 99.99","--","--","--","--","100.00","Yes","Yes","N/A"
"Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity","177","N/A","MIPS CQM","Process","No","88.04","Yes","Historical","6.62 - 64.80","64.81 - 77.93","77.94 - 86.70","86.71 - 92.08","92.09 - 97.89","97.90 - 99.61","99.62 - 99.99","--","--","100.00","Yes","Yes","N/A"
"Rheumatoid Arthritis (RA): Functional Status Assessment","178","N/A","MIPS CQM","Process","No","90.61","Yes","Historical","5.00 - 75.12","75.13 - 91.14","91.15 - 94.85","94.86 - 98.40","98.41 - 99.76","99.77 - 99.99","--","--","--","100.00","Yes","Yes","N/A"
"Rheumatoid Arthritis (RA): Glucocorticoid Management","180","N/A","MIPS CQM","Process","No","90.65","Yes","Historical","54.05 - 68.69","68.70 - 78.07","78.08 - 87.87","87.88 - 95.75","95.76 - 99.32","99.33 - 99.74","99.75 - 99.99","--","--","100.00","Yes","Yes","N/A"
"Elder Maltreatment Screen and Follow-Up Plan","181","N/A","MIPS CQM","Process","Yes","98.22","Yes","Historical","55.00 - 98.48","98.49 - 99.84","99.85 - 99.99","--","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Elder Maltreatment Screen and Follow-Up Plan","181","N/A","Medicare Part B Claims","Process","Yes","96.06","Yes","Historical","0.44 - 96.74","96.75 - 99.99","--","--","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Functional Outcome Assessment","182","N/A","MIPS CQM","Process","Yes","95.92","Yes","Historical","0.10 - 98.90","98.91 - 99.84","99.85 - 99.99","--","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Colonoscopy Interval for Patients with a History of Adenomatous Polyps - Avoidance of Inappropriate Use","185","N/A","MIPS CQM","Process","Yes","95.09","Yes","Historical","12.91 - 86.49","86.50 - 96.80","96.81 - 99.51","99.52 - 99.99","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Stroke and Stroke Rehabilitation: Thrombolytic Therapy","187","N/A","MIPS CQM","Process","No","96.31","Yes","Historical","42.86 - 90.55","90.56 - 94.41","94.42 - 97.91","97.92 - 99.99","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery","191","N/A","MIPS CQM","Outcome","Yes","97.03","Yes","Historical","51.85 - 93.74","93.75 - 97.04","97.05 - 98.53","98.54 - 99.27","99.28 - 99.99","--","--","--","--","100.00","Yes","No","N/A"
"Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery","191","CMS133v12","eCQM","Outcome","Yes","92.92","Yes","Historical","28.70 - 82.28","82.29 - 91.06","91.07 - 94.66","94.67 - 96.42","96.43 - 97.49","97.50 - 98.30","98.31 - 98.92","98.93 - 99.51","99.52 - 99.99","100.00","No","No","N/A"
"Sexually Transmitted Infection (STI) Testing for People with HIV","205","N/A","MIPS CQM","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Sexually Transmitted Infection (STI) Testing for People with HIV","205","CMS1188v1","eCQM","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Functional Status Change for Patients with Knee Impairments","217","N/A","MIPS CQM","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","72.17","Yes","Historical","29.27 - 42.41","42.42 - 52.37","52.38 - 56.93","56.94 - 63.37","63.38 - 72.93","72.94 - 79.99","80.00 - 90.23","90.24 - 99.99","--","100.00","No","No","N/A"
"Functional Status Change for Patients with Hip Impairments","218","N/A","MIPS CQM","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","69.33","Yes","Historical","26.98 - 37.77","37.78 - 47.61","47.62 - 54.16","54.17 - 61.89","61.90 - 68.28","68.29 - 73.71","73.72 - 84.79","84.80 - 99.99","--","100.00","No","No","N/A"
"Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments","219","N/A","MIPS CQM","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","69.07","Yes","Historical","25.00 - 38.23","38.24 - 48.71","48.72 - 53.74","53.75 - 63.63","63.64 - 69.61","69.62 - 74.43","74.44 - 83.75","83.76 - 97.43","97.44 - 99.99","100.00","No","No","N/A"
"Functional Status Change for Patients with Low Back Impairments","220","N/A","MIPS CQM","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","74.02","Yes","Historical","29.71 - 45.97","45.98 - 53.01","53.02 - 58.17","58.18 - 67.96","67.97 - 75.29","75.30 - 81.35","81.36 - 93.54","93.55 - 99.99","--","100.00","No","No","N/A"
"Functional Status Change for Patients with Shoulder Impairments","221","N/A","MIPS CQM","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","71.47","Yes","Historical","27.59 - 42.21","42.22 - 48.97","48.98 - 58.17","58.18 - 62.75","62.76 - 71.10","71.11 - 76.24","76.25 - 92.58","92.59 - 99.99","--","100.00","No","No","N/A"
"Functional Status Change for Patients with Elbow, Wrist or Hand Impairments","222","N/A","MIPS CQM","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","73.37","Yes","Historical","23.81 - 49.99","50.00 - 57.13","57.14 - 61.53","61.54 - 67.85","67.86 - 74.92","74.93 - 78.70","78.71 - 82.75","82.76 - 94.43","94.44 - 99.99","100.00","No","No","N/A"
"Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention","226","N/A","MIPS CQM","Process","No","73.71","Yes","Historical","3.39 - 18.91","18.92 - 39.12","39.13 - 61.53","61.54 - 78.59","78.60 - 89.28","89.29 - 97.09","97.10 - 99.99","--","--","100.00","No","No","N/A"
"Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention","226","N/A","Medicare Part B Claims","Process","No","93.63","Yes","Historical","14.29 - 78.16","78.17 - 95.93","95.94 - 99.99","--","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention","226","CMS138v12","eCQM","Process","No","59.20","Yes","Historical","2.22 - 14.28","14.29 - 24.99","25.00 - 36.58","36.59 - 49.77","49.78 - 61.53","61.54 - 74.41","74.42 - 85.70","85.71 - 94.02","94.03 - 99.99","100.00","No","No","N/A"
"Controlling High Blood Pressure","236","N/A","MIPS CQM","Intermediate Outcome","Yes","71.26","Yes","Historical","1.00 - 9.99","10.00 - 19.99","20.00 - 29.99","30.00 - 39.99","40.00 - 49.99","50.00 - 59.99","60.00 - 69.99","70.00 - 79.99","80.00 - 89.99",">= 90.00","No","No","N/A"
"Controlling High Blood Pressure","236","N/A","Medicare Part B Claims","Intermediate Outcome","Yes","76.33","Yes","Historical","1.00 - 9.99","10.00 - 19.99","20.00 - 29.99","30.00 - 39.99","40.00 - 49.99","50.00 - 59.99","60.00 - 69.99","70.00 - 79.99","80.00 - 89.99",">= 90.00","No","No","N/A"
"Controlling High Blood Pressure","236","CMS165v12","eCQM","Intermediate Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure was suppressed in PY 2022 (baseline period); data isn't available for historical benchmarking."
"Use of High-Risk Medications in Older Adults","238","N/A","MIPS CQM","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure was suppressed in PY 2022 (baseline period); data isn't available for historical benchmarking."
"Use of High-Risk Medications in Older Adults","238","CMS156v12","eCQM","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","No historical benchmark due to issues identified with submission data in the baseline period."
"Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents","239","CMS155v12","eCQM","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure was suppressed in PY 2022 (baseline period); data isn't available for historical benchmarking."
"Childhood Immunization Status","240","CMS117v12","eCQM","Process","No","25.53","Yes","Historical","1.00 - 4.75","4.76 - 7.83","7.84 - 12.15","12.16 - 16.66","16.67 - 22.60","22.61 - 28.16","28.17 - 35.47","35.48 - 42.17","42.18 - 49.99",">= 50.00","No","No","N/A"
"Cardiac Rehabilitation Patient Referral from an Outpatient Setting","243","N/A","MIPS CQM","Process","Yes","51.02","Yes","Historical","1.99 - 24.43","24.44 - 26.46","26.47 - 29.29","29.30 - 33.95","33.96 - 39.34","39.35 - 52.49","52.50 - 64.65","64.66 - 86.35","86.36 - 96.96",">= 96.97","No","No","N/A"
"Barrett's Esophagus","249","N/A","MIPS CQM","Process","No","99.78","Yes","Historical","97.02 - 99.99","--","--","--","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Barrett's Esophagus","249","N/A","Medicare Part B Claims","Process","No","100.00","Yes","Historical","--","--","--","--","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Radical Prostatectomy Pathology Reporting","250","N/A","MIPS CQM","Process","No","99.95","Yes","Historical","97.86 - 99.99","--","--","--","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Radical Prostatectomy Pathology Reporting","250","N/A","Medicare Part B Claims","Process","No","100.00","Yes","Historical","--","--","--","--","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain","254","N/A","MIPS CQM","Process","No","94.01","Yes","Historical","15.79 - 88.31","88.32 - 93.31","93.32 - 95.70","95.71 - 97.72","97.73 - 98.23","98.24 - 98.90","98.91 - 99.99","--","--","100.00","Yes","Yes","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)","259","N/A","MIPS CQM","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2)","260","N/A","MIPS CQM","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness","261","N/A","MIPS CQM","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness","261","N/A","Medicare Part B Claims","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Sentinel Lymph Node Biopsy for Invasive Breast Cancer","264","N/A","MIPS CQM","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy","268","N/A","MIPS CQM","Process","No","86.56","Yes","Historical","7.27 - 42.06","42.07 - 69.22","69.23 - 95.82","95.83 - 99.99","--","--","--","--","--","100.00","Yes","No","N/A"
"Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy","275","N/A","MIPS CQM","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Sleep Apnea: Severity Assessment at Initial Diagnosis","277","N/A","MIPS CQM","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Substantive changes to specification in PY 2023; PY 2024 measure can't be compared to baseline period (PY 2022) measure."
"Sleep Apnea: Assessment of Adherence to Obstructive Sleep Apnea (OSA) Therapy.","279","N/A","MIPS CQM","Process","No","91.93","Yes","Historical","8.00 - 78.50","78.51 - 91.35","91.36 - 99.79","99.80 - 99.99","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Dementia: Cognitive Assessment","281","CMS149v12","eCQM","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure was suppressed in PY 2022 (baseline period); data isn't available for historical benchmarking."
"Dementia: Functional Status Assessment","282","N/A","MIPS CQM","Process","No","96.92","Yes","Historical","38.71 - 94.73","94.74 - 99.99","--","--","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia","286","N/A","MIPS CQM","Process","Yes","97.89","Yes","Historical","50.00 - 99.55","99.56 - 99.99","--","--","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Dementia: Education and Support of Caregivers for Patients with Dementia","288","N/A","MIPS CQM","Process","Yes","91.45","Yes","Historical","0.82 - 78.32","78.33 - 94.33","94.34 - 99.99","--","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Assessment of Mood Disorders and Psychosis for Patients with Parkinson's Disease","290","N/A","MIPS CQM","Process","No","92.29","Yes","Historical","13.79 - 70.36","70.37 - 90.70","90.71 - 97.49","97.50 - 99.99","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Assessment of Cognitive Impairment or Dysfunction for Patients with Parkinson's Disease","291","N/A","MIPS CQM","Process","No","88.23","Yes","Historical","7.55 - 40.23","40.24 - 82.59","82.60 - 96.66","96.67 - 99.99","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Rehabilitative Therapy Referral for Patients with Parkinson's Disease","293","N/A","MIPS CQM","Process","Yes","90.62","Yes","Historical","4.43 - 56.81","56.82 - 92.91","92.92 - 97.61","97.62 - 99.99","--","--","--","--","--","100.00","Yes","No","N/A"
"Cataracts: Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery","303","N/A","MIPS CQM","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery","304","N/A","MIPS CQM","Patient Engagement/Experience","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Initiation and Engagement of Substance Use Disorder Treatment","305","CMS137v12","eCQM","Process","Yes","5.22","Yes","Historical","0.31 - 1.31","1.32 - 2.03","2.04 - 2.49","2.50 - 3.08","3.09 - 3.57","3.58 - 4.36","4.37 - 5.31","5.32 - 6.69","6.70 - 9.99",">= 10.00","No","No","N/A"
"Cervical Cancer Screening","309","CMS124v12","eCQM","Process","No","38.29","Yes","Historical","0.34 - 7.88","7.89 - 16.34","16.35 - 23.77","23.78 - 30.94","30.95 - 37.23","37.24 - 43.85","43.86 - 50.30","50.31 - 57.82","57.83 - 68.89",">= 68.90","No","No","N/A"
"Chlamydia Screening for Women","310","CMS153v12","eCQM","Process","No","32.59","Yes","Historical","0.84 - 7.68","7.69 - 12.49","12.50 - 18.74","18.75 - 24.99","25.00 - 30.70","30.71 - 36.89","36.90 - 43.47","43.48 - 49.99","50.00 - 60.23",">= 60.24","No","No","N/A"
"Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented","317","N/A","MIPS CQM","Process","No","62.35","Yes","Historical","0.11 - 7.06","7.07 - 18.20","18.21 - 27.75","27.76 - 48.04","48.05 - 81.63","81.64 - 93.85","93.86 - 98.92","98.93 - 99.92","99.93 - 99.99","100.00","No","No","N/A"
"Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented","317","N/A","Medicare Part B Claims","Process","No","84.84","Yes","Historical","0.17 - 23.20","23.21 - 79.04","79.05 - 95.66","95.67 - 99.08","99.09 - 99.77","99.78 - 99.99","--","--","--","100.00","Yes","Yes","N/A"
"Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented","317","CMS22v12","eCQM","Process","No","24.90","Yes","Historical","0.06 - 4.41","4.42 - 12.46","12.47 - 17.05","17.06 - 19.94","19.95 - 22.79","22.80 - 25.69","25.70 - 28.78","28.79 - 33.10","33.11 - 40.79",">= 40.80","No","No","N/A"
"Falls: Screening for Future Fall Risk","318","CMS139v12","eCQM","Process","Yes","62.37","Yes","Historical","0.14 - 5.14","5.15 - 22.69","22.70 - 42.14","42.15 - 58.32","58.33 - 73.07","73.08 - 84.17","84.18 - 91.82","91.83 - 97.02","97.03 - 99.29",">= 99.30","No","No","N/A"
"Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients","320","N/A","MIPS CQM","Process","Yes","93.54","Yes","Historical","13.45 - 87.92","87.93 - 91.66","91.67 - 95.59","95.60 - 97.23","97.24 - 98.32","98.33 - 99.99","--","--","--","100.00","Yes","Yes","N/A"
"Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients","320","N/A","Medicare Part B Claims","Process","Yes","100.00","Yes","Historical","--","--","--","--","--","--","--","--","--","100.00","Yes","Yes","N/A"
"CAHPS for MIPS SSM: Getting Timely Care, Appointments, and Information","321","N/A","CAHPS Survey Vendor","Patient Engagement/Experience","Yes","null","Yes","Historical","63.18 - 77.46","77.47 - 80.26","80.27 - 82.27","82.28 - 83.58","83.59 - 84.48","84.49 - 85.51","85.52 - 86.36","86.37 - 87.13","87.14 - 88.71",">= 88.72","No","No","N/A"
"CAHPS for MIPS SSM: How Well Providers Communicate","321","N/A","CAHPS Survey Vendor","Patient Engagement/Experience","Yes","null","Yes","Historical","85.18 - 91.17","91.18 - 92.17","92.18 - 92.74","92.75 - 93.19","93.20 - 93.62","93.63 - 93.98","93.99 - 94.40","94.41 - 94.80","94.81 - 95.29",">= 95.30","No","No","N/A"
"CAHPS for MIPS SSM: Patient’s Rating of Provider","321","N/A","CAHPS Survey Vendor","Patient Engagement/Experience","Yes","null","Yes","Historical","82.69 - 89.66","89.67 - 90.53","90.54 - 91.14","91.15 - 91.75","91.76 - 92.26","92.27 - 92.61","92.62 - 93.04","93.05 - 93.47","93.48 - 94.01",">= 94.02","No","No","N/A"
"CAHPS for MIPS SSM: Access to Specialists","321","N/A","CAHPS Survey Vendor","Patient Engagement/Experience","Yes","null","Yes","Historical","62.71 - 71.27","71.28 - 73.31","73.32 - 74.61","74.62 - 75.89","75.90 - 77.18","77.19 - 78.08","78.09 - 79.37","79.38 - 80.51","80.52 - 82.04",">= 82.05","No","No","N/A"
"CAHPS for MIPS SSM: Health Promotion and Education","321","N/A","CAHPS Survey Vendor","Patient Engagement/Experience","Yes","null","Yes","Historical","41.59 - 56.67","56.68 - 58.77","58.78 - 60.27","60.28 - 61.44","61.45 - 62.72","62.73 - 63.86","63.87 - 65.11","65.12 - 66.16","66.17 - 67.66",">= 67.67","No","No","N/A"
"CAHPS for MIPS SSM: Shared Decision Making","321","N/A","CAHPS Survey Vendor","Patient Engagement/Experience","Yes","null","Yes","Historical","45.26 - 55.04","55.05 - 57.42","57.43 - 58.82","58.83 - 59.99","60.00 - 61.07","61.08 - 62.40","62.41 - 63.44","63.45 - 64.61","64.62 - 66.49",">= 66.50","No","No","N/A"
"CAHPS for MIPS SSM: Care Coordination","321","N/A","CAHPS Survey Vendor","Patient Engagement/Experience","Yes","null","Yes","Historical","72.67 - 82.17","82.18 - 83.38","83.39 - 84.32","84.33 - 85.22","85.23 - 85.71","85.72 - 86.31","86.32 - 86.88","86.89 - 87.46","87.47 - 88.09",">= 88.10","No","No","N/A"
"CAHPS for MIPS SSM: Courteous and Helpful Office Staff","321","N/A","CAHPS Survey Vendor","Patient Engagement/Experience","Yes","null","Yes","Historical","81.19 - 89.02","89.03 - 90.31","90.32 - 91.25","91.26 - 91.86","91.87 - 92.37","92.38 - 92.91","92.92 - 93.34","93.35 - 93.85","93.86 - 94.57",">= 94.58","No","No","N/A"
"CAHPS for MIPS SSM: Stewardship of Patient Resources","321","N/A","CAHPS Survey Vendor","Patient Engagement/Experience","Yes","null","Yes","Historical","9.77 - 19.42","19.43 - 21.49","21.50 - 22.95","22.96 - 24.11","24.12 - 25.63","25.64 - 26.79","26.80 - 27.98","27.99 - 29.06","29.07 - 31.03",">= 31.04","No","No","N/A"
"Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients","322","N/A","MIPS CQM","Efficiency","Yes","1.34","Yes","Historical","99.77 - 0.01","--","--","--","--","--","--","--","--","0.00","No","No","N/A"
"Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy","326","N/A","MIPS CQM","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure was suppressed in PY 2022 (baseline period); data isn't available for historical benchmarking."
"Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)","331","N/A","MIPS CQM","Process","Yes","23.32","Yes","Historical","94.23 - 72.74","72.73 - 53.58","53.57 - 32.44","32.43 - 17.25","17.24 - 8.28","8.27 - 2.57","2.56 - 0.01","--","--","0.00","No","No","N/A"
"Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)","332","N/A","MIPS CQM","Process","Yes","87.97","Yes","Historical","12.50 - 64.43","64.44 - 81.07","81.08 - 88.34","88.35 - 92.58","92.59 - 95.44","95.45 - 97.55","97.56 - 99.99","--","--","100.00","Yes","No","N/A"
"Maternity Care: Elective Delivery (Without Medical Indication) at < 39 Weeks (Overuse)","335","N/A","MIPS CQM","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Maternity Care: Postpartum Follow-up and Care Coordination","336","N/A","MIPS CQM","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"HIV Viral Suppression","338","N/A","MIPS CQM","Outcome","Yes","89.56","Yes","Historical","11.81 - 68.26","68.27 - 86.77","86.78 - 91.37","91.38 - 94.23","94.24 - 95.84","95.85 - 99.99","--","--","--","100.00","No","No","N/A"
"HIV Viral Suppression","338","CMS314v1","eCQM","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"HIV Medical Visit Frequency","340","N/A","MIPS CQM","Process","Yes","83.40","Yes","Historical","32.07 - 58.64","58.65 - 72.65","72.66 - 79.77","79.78 - 85.05","85.06 - 86.35","86.36 - 89.18","89.19 - 92.91","92.92 - 99.99","--","100.00","No","No","N/A"
"Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)","344","N/A","MIPS CQM","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Total Knee or Hip Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy","350","N/A","MIPS CQM","Process","Yes","97.25","Yes","Historical","26.18 - 98.41","98.42 - 99.90","99.91 - 99.99","--","--","--","--","--","--","100.00","Yes","No","N/A"
"Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation","351","N/A","MIPS CQM","Process","Yes","97.00","Yes","Historical","47.98 - 91.95","91.96 - 99.03","99.04 - 99.99","--","--","--","--","--","--","100.00","Yes","No","N/A"
"Anastomotic Leak Intervention","354","N/A","MIPS CQM","Outcome","Yes","2.41","Yes","Historical","23.33 - 6.38","6.37 - 4.00","3.99 - 2.63","2.62 - 1.29","1.28 - 0.18","0.17 - 0.01","--","--","--","0.00","No","No","N/A"
"Unplanned Reoperation within the 30 Day Postoperative Period","355","N/A","MIPS CQM","Outcome","Yes","1.59","Yes","Historical","35.82 - 1.81","1.80 - 0.82","0.81 - 0.01","--","--","--","--","--","--","0.00","No","No","N/A"
"Unplanned Hospital Readmission within 30 Days of Principal Procedure","356","N/A","MIPS CQM","Outcome","Yes","1.97","Yes","Historical","45.37 - 5.23","5.22 - 3.03","3.02 - 1.19","1.18 - 0.01","--","--","--","--","--","0.00","No","No","N/A"
"Surgical Site Infection (SSI)","357","N/A","MIPS CQM","Outcome","Yes","0.88","Yes","Historical","12.31 - 1.50","1.49 - 0.24","0.23 - 0.01","--","--","--","--","--","--","0.00","No","No","N/A"
"Patient-Centered Surgical Risk Assessment and Communication","358","N/A","MIPS CQM","Process","Yes","86.59","Yes","Historical","0.62 - 20.95","20.96 - 90.59","90.60 - 98.90","98.91 - 99.99","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies","360","N/A","MIPS CQM","Process","Yes","91.28","Yes","Historical","0.07 - 73.25","73.26 - 82.59","82.60 - 99.57","99.58 - 99.99","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines","364","N/A","MIPS CQM","Process","Yes","84.76","Yes","Historical","1.75 - 36.35","36.36 - 63.31","63.32 - 98.06","98.07 - 99.99","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Follow-Up Care for Children Prescribed ADHD Medication (ADD)","366","CMS136v13","eCQM","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure was suppressed in PY 2022 (baseline period); data isn't available for historical benchmarking."
"Depression Remission at Twelve Months","370","N/A","MIPS CQM","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Depression Remission at Twelve Months","370","CMS159v12","eCQM","Outcome","Yes","12.33","Yes","Historical","0.48 - 2.07","2.08 - 3.49","3.50 - 4.95","4.96 - 6.92","6.93 - 8.94","8.95 - 10.88","10.89 - 13.99","14.00 - 18.15","18.16 - 24.99",">= 25.00","No","No","N/A"
"Closing the Referral Loop: Receipt of Specialist Report","374","N/A","MIPS CQM","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","No historical benchmark due to issues identified with submission data in the baseline period."
"Closing the Referral Loop: Receipt of Specialist Report","374","CMS50v12","eCQM","Process","Yes","45.63","Yes","Historical","0.73 - 8.32","8.33 - 18.60","18.61 - 27.37","27.38 - 35.16","35.17 - 43.01","43.02 - 51.29","51.30 - 60.18","60.19 - 72.08","72.09 - 89.28",">= 89.29","No","No","N/A"
"Functional Status Assessment for Total Hip Replacement","376","CMS56v12","eCQM","Process","Yes","17.04","Yes","Historical","0.51 - 1.29","1.30 - 2.44","2.45 - 7.06","7.07 - 9.91","9.92 - 11.67","11.68 - 14.11","14.12 - 18.37","18.38 - 25.36","25.37 - 43.08",">= 43.09","No","No","N/A"
"Functional Status Assessments for Heart Failure","377","CMS90v13","eCQM","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Children Who Have Dental Decay or Cavities","378","CMS75v12","eCQM","Outcome","Yes","28.68","Yes","Historical","79.07 - 66.07","66.06 - 48.64","48.63 - 45.10","45.09 - 34.34","34.33 - 29.02","29.01 - 9.20","9.19 - 3.65","3.64 - 0.91","0.90 - 0.01","0.00","No","No","N/A"
"Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists","379","CMS74v13","eCQM","Process","No","4.37","Yes","Historical","0.01 - 0.04","0.05 - 0.23","0.24 - 0.48","0.49 - 0.99","1.00 - 1.72","1.73 - 3.11","3.12 - 4.57","4.58 - 6.93","6.94 - 11.02",">= 11.03","No","No","N/A"
"Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment","382","CMS177v12","eCQM","Process","Yes","39.11","Yes","Historical","0.46 - 2.26","2.27 - 5.80","5.81 - 13.52","13.53 - 20.61","20.62 - 34.87","34.88 - 46.93","46.94 - 59.67","59.68 - 67.94","67.95 - 88.08",">= 88.09","No","No","N/A"
"Adherence to Antipsychotic Medications For Individuals with Schizophrenia","383","N/A","MIPS CQM","Intermediate Outcome","Yes","94.09","Yes","Historical","6.25 - 93.74","93.75 - 94.33","94.34 - 99.33","99.34 - 99.99","--","--","--","--","--","100.00","No","No","N/A"
"Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery","384","N/A","MIPS CQM","Outcome","Yes","93.14","Yes","Historical","67.57 - 79.16","79.17 - 83.99","84.00 - 90.47","90.48 - 95.82","95.83 - 97.61","97.62 - 99.34","99.35 - 99.99","--","--","100.00","Yes","Yes","N/A"
"Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery","385","N/A","MIPS CQM","Outcome","Yes","55.95","Yes","Historical","10.87 - 22.30","22.31 - 34.54","34.55 - 53.26","53.27 - 56.62","56.63 - 58.94","58.95 - 62.67","62.68 - 65.19","65.20 - 70.20","70.21 - 74.99",">= 75.00","No","No","N/A"
"Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences","386","N/A","MIPS CQM","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users","387","N/A","MIPS CQM","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Cataract Surgery: Difference Between Planned and Final Refraction","389","N/A","MIPS CQM","Outcome","Yes","71.10","Yes","Historical","0.32 - 18.31","18.32 - 41.03","41.04 - 51.24","51.25 - 66.79","66.80 - 89.49","89.50 - 96.33","96.34 - 99.00","99.01 - 99.99","--","100.00","No","No","N/A"
"Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation","392","N/A","MIPS CQM","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision","393","N/A","MIPS CQM","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Immunizations for Adolescents","394","N/A","MIPS CQM","Process","No","30.75","Yes","Historical","1.06 - 10.95","10.96 - 15.78","15.79 - 19.99","20.00 - 23.07","23.08 - 26.66","26.67 - 30.55","30.56 - 33.54","33.55 - 39.99","40.00 - 53.84",">= 53.85","No","No","N/A"
"Lung Cancer Reporting (Biopsy/Cytology Specimens)","395","N/A","MIPS CQM","Process","Yes","99.59","Yes","Historical","87.50 - 99.99","--","--","--","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Lung Cancer Reporting (Biopsy/Cytology Specimens)","395","N/A","Medicare Part B Claims","Process","Yes","99.71","Yes","Historical","88.37 - 99.99","--","--","--","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Lung Cancer Reporting (Resection Specimens)","396","N/A","MIPS CQM","Process","Yes","99.74","Yes","Historical","96.92 - 99.99","--","--","--","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Lung Cancer Reporting (Resection Specimens)","396","N/A","Medicare Part B Claims","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Melanoma Reporting","397","N/A","MIPS CQM","Process","Yes","97.80","Yes","Historical","36.71 - 97.81","97.82 - 99.99","--","--","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Melanoma Reporting","397","N/A","Medicare Part B Claims","Process","Yes","99.70","Yes","Historical","92.94 - 99.99","--","--","--","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Optimal Asthma Control","398","N/A","MIPS CQM","Outcome","Yes","61.02","Yes","Historical","0.15 - 3.33","3.34 - 4.37","4.38 - 29.90","29.91 - 56.12","56.13 - 76.00","76.01 - 95.01","95.02 - 98.81","98.82 - 99.99","--","100.00","No","No","N/A"
"One-Time Screening for Hepatitis C Virus (HCV) and Treatment Initiation","400","N/A","MIPS CQM","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Substantive changes to specification in PY 2024; PY 2024 measure can't be compared to baseline period (PY 2022) measure."
"Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis","401","N/A","MIPS CQM","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Anesthesiology Smoking Abstinence","404","N/A","MIPS CQM","Intermediate Outcome","Yes","72.72","Yes","Historical","7.70 - 41.37","41.38 - 59.24","59.25 - 66.66","66.67 - 73.17","73.18 - 77.26","77.27 - 80.15","80.16 - 85.47","85.48 - 91.26","91.27 - 96.44",">= 96.45","No","No","N/A"
"Appropriate Follow-up Imaging for Incidental Abdominal Lesions","405","N/A","MIPS CQM","Process","Yes","78.55","Yes","Historical","0.96 - 8.71","8.72 - 31.96","31.97 - 98.37","98.38 - 99.99","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Appropriate Follow-up Imaging for Incidental Abdominal Lesions","405","N/A","Medicare Part B Claims","Process","Yes","54.10","Yes","Historical","0.47 - 4.07","4.08 - 6.66","6.67 - 16.91","16.92 - 26.91","26.92 - 57.13","57.14 - 76.70","76.71 - 97.00","97.01 - 99.99","--","100.00","No","No","N/A"
"Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients","406","N/A","MIPS CQM","Process","Yes","3.73","Yes","Historical","60.00 - 12.51","12.50 - 2.28","2.27 - 0.01","--","--","--","--","--","--","0.00","Yes","Yes","N/A"
"Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients","406","N/A","Medicare Part B Claims","Process","Yes","3.87","Yes","Historical","40.00 - 14.30","14.29 - 3.71","3.70 - 0.01","--","--","--","--","--","--","0.00","Yes","No","N/A"
"Clinical Outcome Post Endovascular Stroke Treatment","409","N/A","MIPS CQM","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Psoriasis: Clinical Response to Systemic Medications","410","N/A","MIPS CQM","Outcome","Yes","88.35","Yes","Historical","11.11 - 55.05","55.06 - 79.02","79.03 - 91.52","91.53 - 97.55","97.56 - 99.99","--","--","--","--","100.00","No","No","N/A"
"Door to Puncture Time for Endovascular Stroke Treatment","413","N/A","MIPS CQM","Intermediate Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older","415","N/A","MIPS CQM","Efficiency","Yes","97.75","Yes","Historical","80.56 - 93.74","93.75 - 96.10","96.11 - 96.90","96.91 - 98.11","98.12 - 99.36","99.37 - 99.99","--","--","--","100.00","Yes","Yes","N/A"
"Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years","416","N/A","MIPS CQM","Efficiency","Yes","5.92","Yes","Historical","37.50 - 18.04","18.03 - 9.53","9.52 - 7.70","7.69 - 4.18","4.17 - 2.81","2.80 - 0.01","--","--","--","0.00","No","No","N/A"
"Osteoporosis Management in Women Who Had a Fracture","418","N/A","MIPS CQM","Process","No","25.03","Yes","Historical","1.04 - 5.44","5.45 - 9.08","9.09 - 12.02","12.03 - 14.94","14.95 - 15.99","16.00 - 18.17","18.18 - 22.63","22.64 - 32.13","32.14 - 58.32",">= 58.33","No","No","N/A"
"Osteoporosis Management in Women Who Had a Fracture","418","N/A","Medicare Part B Claims","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Overuse of Imaging for the Evaluation of Primary Headache","419","N/A","MIPS CQM","Process","Yes","1.27","Yes","Historical","26.47 - 2.94","2.93 - 0.77","0.76 - 0.01","--","--","--","--","--","--","0.00","Yes","Yes","N/A"
"Varicose Vein Treatment with Saphenous Ablation: Outcome Survey","420","N/A","MIPS CQM","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal","421","N/A","MIPS CQM","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury","422","N/A","MIPS CQM","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury","422","N/A","Medicare Part B Claims","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Perioperative Temperature Management","424","N/A","MIPS CQM","Outcome","Yes","99.14","Yes","Historical","84.46 - 98.40","98.41 - 99.45","99.46 - 99.88","99.89 - 99.96","99.97 - 99.98","99.99 - 99.99","--","--","--","100.00","Yes","Yes","N/A"
"Prevention of Post-Operative Nausea and Vomiting (PONV) - Combination Therapy","430","N/A","MIPS CQM","Process","Yes","98.80","Yes","Historical","83.13 - 96.12","96.13 - 99.14","99.15 - 99.73","99.74 - 99.88","99.89 - 99.95","99.96 - 99.99","--","--","--","100.00","Yes","Yes","N/A"
"Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling","431","N/A","MIPS CQM","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","No historical benchmark due to issues identified with submission data in the baseline period."
"Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair","432","N/A","MIPS CQM","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair","433","N/A","MIPS CQM","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques","436","N/A","MIPS CQM","Process","No","97.56","Yes","Historical","38.16 - 96.39","96.40 - 99.90","99.91 - 99.99","--","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques","436","N/A","Medicare Part B Claims","Process","No","92.90","Yes","Historical","0.46 - 82.96","82.97 - 96.51","96.52 - 98.89","98.90 - 99.58","99.59 - 99.99","--","--","--","--","100.00","Yes","Yes","N/A"
"Statin Therapy for the Prevention and Treatment of Cardiovascular Disease","438","N/A","MIPS CQM","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Substantive changes to specification in PY 2024; PY 2024 measure can't be compared to baseline period (PY 2022) measure."
"Statin Therapy for the Prevention and Treatment of Cardiovascular Disease","438","CMS347v7","eCQM","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Substantive changes to specification in PY 2024; PY 2024 measure can't be compared to baseline period (PY 2022) measure."
"Age Appropriate Screening Colonoscopy","439","N/A","MIPS CQM","Efficiency","Yes","0.15","Yes","Historical","3.03 - 0.10","0.09 - 0.01","--","--","--","--","--","--","--","0.00","No","No","N/A"
"Skin Cancer: Biopsy Reporting Time - Pathologist to Clinician","440","N/A","MIPS CQM","Process","Yes","98.45","Yes","Historical","70.53 - 97.15","97.16 - 98.56","98.57 - 99.43","99.44 - 99.94","99.95 - 99.99","--","--","--","--","100.00","Yes","Yes","N/A"
"Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)","441","N/A","MIPS CQM","Intermediate Outcome","Yes","44.45","Yes","Historical","2.79 - 18.33","18.34 - 29.58","29.59 - 34.61","34.62 - 39.95","39.96 - 43.11","43.12 - 47.40","47.41 - 52.84","52.85 - 58.57","58.58 - 69.44",">= 69.45","No","No","N/A"
"Non-Recommended Cervical Cancer Screening in Adolescent Females","443","N/A","MIPS CQM","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)","445","N/A","MIPS CQM","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Appropriate Workup Prior to Endometrial Ablation","448","N/A","MIPS CQM","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Appropriate Treatment for Patients with Stage I (T1c) - III HER2 Positive Breast Cancer","450","N/A","MIPS CQM","Process","Yes","84.83","Yes","Historical","43.33 - 68.41","68.42 - 74.99","75.00 - 80.86","80.87 - 84.37","84.38 - 86.81","86.82 - 89.99","90.00 - 92.58","92.59 - 94.11","94.12 - 99.99","100.00","No","No","N/A"
"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","451","N/A","MIPS CQM","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies","452","N/A","MIPS CQM","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Percentage of Patients Who Died from Cancer Receiving Systemic Cancer-Directed Therapy in the Last 14 Days of Life (lower score – better)","453","N/A","MIPS CQM","Process","Yes","10.71","Yes","Historical","31.82 - 20.84","20.83 - 16.01","16.00 - 13.54","13.53 - 11.28","11.27 - 9.37","9.36 - 7.96","7.95 - 6.26","6.25 - 4.56","4.55 - 2.97","<= 2.96","No","No","N/A"
"Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score - better)","457","N/A","MIPS CQM","Outcome","Yes","11.02","Yes","Historical","77.78 - 22.59","22.58 - 19.49","19.48 - 13.66","13.65 - 11.75","11.74 - 8.91","8.90 - 5.68","5.67 - 3.57","3.56 - 1.97","1.96 - 0.01","0.00","No","No","N/A"
"Back Pain After Lumbar Surgery","459","N/A","MIPS CQM","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Substantive changes to specification in PY 2023; PY 2024 measure can't be compared to baseline period (PY 2022) measure."
"Leg Pain After Lumbar Surgery","461","N/A","MIPS CQM","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Substantive changes to specification in PY 2023; PY 2024 measure can't be compared to baseline period (PY 2022) measure."
"Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy","462","CMS645v7","eCQM","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics)","463","N/A","MIPS CQM","Process","Yes","98.81","Yes","Historical","58.11 - 97.72","97.73 - 99.60","99.61 - 99.86","99.87 - 99.99","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use","464","N/A","MIPS CQM","Process","Yes","90.33","Yes","Historical","30.77 - 77.60","77.61 - 85.22","85.23 - 90.69","90.70 - 92.85","92.86 - 94.77","94.78 - 96.29","96.30 - 97.45","97.46 - 99.99","--","100.00","No","No","N/A"
"Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian Arteries","465","N/A","MIPS CQM","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)","468","N/A","MIPS CQM","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Functional Status After Primary Total Knee Replacement","470","N/A","MIPS CQM","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Functional Status After Lumbar Surgery","471","N/A","MIPS CQM","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Substantive changes to specification in PY 2023; PY 2024 measure can't be compared to baseline period (PY 2022) measure."
"Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture","472","CMS249v6","eCQM","Process","Yes","1.10","Yes","Historical","11.48 - 4.09","4.08 - 1.97","1.96 - 0.01","--","--","--","--","--","--","0.00","Yes","Yes","N/A"
"HIV Screening","475","CMS349v6","eCQM","Process","No","21.46","Yes","Historical","0.13 - 4.58","4.59 - 8.63","8.64 - 12.31","12.32 - 15.32","15.33 - 18.25","18.26 - 21.86","21.87 - 26.17","26.18 - 32.08","32.09 - 41.80",">= 41.81","No","No","N/A"
"Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia","476","CMS771v5","eCQM","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Multimodal Pain Management","477","N/A","MIPS CQM","Process","Yes","95.29","Yes","Historical","43.18 - 85.18","85.19 - 93.86","93.87 - 96.68","96.69 - 98.24","98.25 - 99.24","99.25 - 99.77","99.78 - 99.96","99.97 - 99.99","--","100.00","Yes","Yes","N/A"
"Functional Status Change for Patients with Neck Impairments","478","N/A","MIPS CQM","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","65.24","Yes","Historical","22.58 - 34.86","34.87 - 48.80","48.81 - 56.00","56.01 - 58.26","58.27 - 62.75","62.76 - 69.21","69.22 - 73.86","73.87 - 87.84","87.85 - 99.99","100.00","No","No","N/A"
"Intravesical Bacillus-Calmette Guerin for Non-muscle Invasive Bladder Cancer","481","CMS646v4","eCQM","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Hemodialysis Vascular Access: Practitioner Level Long-term Catheter Rate","482","N/A","MIPS CQM","Intermediate Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM)","483","N/A","MIPS CQM","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Psoriasis- Improvement in Patient-Reported Itch Severity","485","N/A","MIPS CQM","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2023; subject to 5-point scoring floor if data completeness is met."
"Dermatitis – Improvement in Patient-Reported Itch Severity","486","N/A","MIPS CQM","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2023; subject to 5-point scoring floor if data completeness is met."
"Screening for Social Drivers of Health","487","N/A","MIPS CQM","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2023; subject to 5-point scoring floor if data completeness is met."
"Kidney Health Evaluation","488","N/A","MIPS CQM","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2023; subject to 5-point scoring floor if data completeness is met."
"Kidney Health Evaluation","488","CMS951v2","eCQM","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2023; subject to 5-point scoring floor if data completeness is met."
"Adult Kidney Disease: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy","489","N/A","MIPS CQM","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2023; subject to 5-point scoring floor if data completeness is met."
"Appropriate Intervention of Immune-Related Diarrhea and/or Colitis in Patients Treated with Immune Checkpoint Inhibitors","490","N/A","MIPS CQM","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2023; subject to 5-point scoring floor if data completeness is met."
"Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status in Colorectal Carcinoma, Endometrial, Gastroesophageal, or Small Bowel Carcinoma","491","N/A","MIPS CQM","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2023; subject to 5-point scoring floor if data completeness is met."
"Adult Immunization Status","493","N/A","MIPS CQM","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2023; subject to 5-point scoring floor if data completeness is met."
"Ambulatory Palliative Care Patients’ Experience of Feeling Heard and Understood","495","N/A","MIPS CQM","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Cardiovascular Disease (CVD) Risk Assessment Measure - Proportion of Pregnant/Postpartum Patients that Receive CVD Risk Assessment with a Standardized Instrument","496","N/A","MIPS CQM","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Preventive Care and Wellness (composite)","497","N/A","MIPS CQM","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Connection to Community Service Provider","498","N/A","MIPS CQM","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Appropriate screening and plan of care for elevated intraocular pressure following intravitreal or periocular steroid therapy","499","N/A","MIPS CQM","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Acute posterior vitreous detachment appropriate examination and follow-up","500","N/A","MIPS CQM","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Acute posterior vitreous detachment and acute vitreous hemorrhage appropriate examination and follow-up","501","N/A","MIPS CQM","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Improvement or Maintenance of Functioning for Individuals with a Mental and/or Substance Use Disorder","502","N/A","MIPS CQM","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Gains in Patient Activation Measure (PAM) Scores at 12 Months","503","N/A","MIPS CQM","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Initiation, Review, And/Or Update To Suicide Safety Plan For Individuals With Suicidal Thoughts, Behavior, Or Suicide Risk","504","N/A","MIPS CQM","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Reduction in Suicidal Ideation or Behavior Symptoms","505","N/A","MIPS CQM","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Melanoma: – Appropriate Surgical Margins","AAD12","N/A","QCDR Measure","Intermediate Outcome","Yes","97.55","Yes","Historical","75.51 - 96.66","96.67 - 99.99","--","--","--","--","--","--","--","100.00","Yes","No","N/A"
"Melanoma: Tracking and Evaluation of Recurrence","AAD14","N/A","QCDR Measure","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Psoriasis – Appropriate Assessment & Treatment of Severe Psoriasis","AAD15","N/A","QCDR Measure","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2023; subject to 5-point scoring floor if data completeness is met."
"Avoidance of Post-operative Systemic Antibiotics for Office-based Closures and Reconstruction After Skin Cancer Procedures","AAD16","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Continuation of Anticoagulation Therapy in the Office-based Setting for Closure and Reconstruction After Skin Cancer Resection Procedures","AAD17","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Avoidance of Opioid Prescriptions for Closure and Reconstruction After Skin Cancer Resection","AAD18","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Psoriasis – Shared Decision Making in the Treatment of Psoriasis","AAD19","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Skin Cancer: Biopsy Reporting Time - Clinician to Patient","AAD6","N/A","QCDR Measure","Process","Yes","94.45","Yes","Historical","3.95 - 92.21","92.22 - 97.19","97.20 - 98.31","98.32 - 99.02","99.03 - 99.78","99.79 - 99.99","--","--","--","100.00","Yes","Yes","N/A"
"Psoriasis: Screening for Psoriatic Arthritis","AAD7","N/A","QCDR Measure","Process","Yes","90.21","Yes","Historical","0.45 - 67.26","67.27 - 86.99","87.00 - 90.90","90.91 - 94.43","94.44 - 96.59","96.60 - 98.79","98.80 - 99.72","99.73 - 99.99","--","100.00","Yes","Yes","N/A"
"Chronic Skin Conditions: Patient Reported Quality-of-Life","AAD8","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Quality of Life Outcome for Patients with Neurologic Conditions","AAN22","N/A","QCDR Measure","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Pediatric Medication reconciliation","AAN25","N/A","QCDR Measure","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Acute Treatment Prescribed for Cluster Headache","AAN31","N/A","QCDR Measure","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Preventive Treatment Prescribed for Cluster Headache","AAN32","N/A","QCDR Measure","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Patient reported falls and plan of care","AAN34","N/A","QCDR Measure","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Reduction of Pain for Patients with Polyneuropathy","AAN35","N/A","QCDR Measure","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Seizure Type, Frequency, Time Since Last Seizure Recorded, and Seizure Reduction","AAN36","N/A","QCDR Measure","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Treatment Prescribed For Acute Migraine Attacks","AAN5","N/A","QCDR Measure","Process","No","77.53","Yes","Historical","0.59 - 62.49","62.50 - 73.73","73.74 - 78.12","78.13 - 79.84","79.85 - 81.51","81.52 - 83.25","83.26 - 85.89","85.90 - 89.95","89.96 - 95.60",">= 95.61","No","No","N/A"
"Exercise and Appropriate Physical Activity Counseling for Patients with MS","AAN8","N/A","QCDR Measure","Process","No","80.48","Yes","Historical","30.30 - 53.02","53.03 - 70.63","70.64 - 76.31","76.32 - 78.62","78.63 - 85.70","85.71 - 90.10","90.11 - 92.53","92.54 - 95.78","95.79 - 97.17",">= 97.18","No","No","N/A"
"Querying and Follow-up About Symptoms of Autonomic Dysfunction for Patients with Parkinson’s Disease","AAN9","N/A","QCDR Measure","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Tympanostomy Tubes: Topical Ear Drop Monotherapy for Acute Otorrhea","AAO12","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Bell's Palsy: Inappropriate Use of Magnetic Resonance Imaging or Computed Tomography Scan","AAO13","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Age-Related Hearing Loss: Comprehensive Audiometric Evaluation","AAO16","N/A","QCDR Measure","Process","Yes","91.57","Yes","Historical","45.96 - 73.28","73.29 - 86.15","86.16 - 91.26","91.27 - 94.43","94.44 - 96.76","96.77 - 97.14","97.15 - 99.31","99.32 - 99.99","--","100.00","Yes","Yes","N/A"
"Tympanostomy Tubes: Comprehensive Audiometric Evaluation","AAO20","N/A","QCDR Measure","Process","No","74.14","Yes","Historical","10.92 - 20.37","20.38 - 48.99","49.00 - 63.03","63.04 - 85.72","85.73 - 91.16","91.17 - 93.44","93.45 - 94.43","94.44 - 96.02","96.03 - 99.35",">= 99.36","No","No","N/A"
"Otitis Media with Effusion (OME): Comprehensive Audiometric Evaluation for Chronic OME > or = 3 months","AAO21","N/A","QCDR Measure","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Allergic Rhinitis: Intranasal Corticosteroids or Oral Antihistamines","AAO23","N/A","QCDR Measure","Process","No","64.08","Yes","Historical","8.90 - 24.45","24.46 - 39.02","39.03 - 54.01","54.02 - 63.36","63.37 - 70.35","70.36 - 77.64","77.65 - 80.26","80.27 - 87.05","87.06 - 94.69",">= 94.70","No","No","N/A"
"Standard Benign Positional Paroxysmal Vertigo (BPPV) Management","AAO32","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Tympanostomy Tubes: Resolution of Otitis Media with Effusion (OME) in Adults and Children","AAO36","N/A","QCDR Measure","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Dysphonia: Laryngeal Examination","AAO37","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Thyroidectomy and Parathyroidectomy Nerve Injury","AAO38","N/A","QCDR Measure","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Neck Mass Evaluation","AAO39","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Measuring the Value-Functions of Primary Care: Physician Level Continuity of Care Measure","ABFM12","N/A","QCDR Measure","Efficiency","Yes","82.11","Yes","Historical","14.57 - 45.43","45.44 - 58.08","58.09 - 73.55","73.56 - 87.79","87.80 - 99.72","99.73 - 99.99","--","--","--","100.00","No","No","N/A"
"Measuring the Value-Functions of Primary Care: Comprehensiveness of Care","ABFM13","N/A","QCDR Measure","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Known or Suspected Difficult Airway Mitigation Strategies","ABG42","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Low Flow Inhalational General Anesthesia","ABG44","N/A","QCDR Measure","Efficiency","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2023; subject to 5-point scoring floor if data completeness is met."
"Appropriate Emergency Department Utilization of CT for Pulmonary Embolism","ACEP22","N/A","QCDR Measure","Process","Yes","64.44","Yes","Historical","27.18 - 37.62","37.63 - 43.00","43.01 - 48.11","48.12 - 55.34","55.35 - 59.98","59.99 - 66.85","66.86 - 80.45","80.46 - 90.53","90.54 - 97.36",">= 97.37","No","No","N/A"
"Tobacco Use: Screening and Cessation Intervention for Patients with Asthma and COPD","ACEP25","N/A","QCDR Measure","Process","No","83.57","Yes","Historical","6.80 - 62.75","62.76 - 75.59","75.60 - 80.07","80.08 - 83.37","83.38 - 88.01","88.02 - 91.52","91.53 - 94.83","94.84 - 97.45","97.46 - 98.93",">= 98.94","No","No","N/A"
"Sepsis Management: Septic Shock: Lactate Clearance Rate of >=10%","ACEP30","N/A","QCDR Measure","Outcome","Yes","86.88","Yes","Historical","73.33 - 79.99","80.00 - 81.28","81.29 - 83.63","83.64 - 84.37","84.38 - 86.95","86.96 - 87.99","88.00 - 90.47","90.48 - 91.88","91.89 - 94.82",">= 94.83","No","No","N/A"
"Appropriate Foley catheter use in the emergency department","ACEP31","N/A","QCDR Measure","Process","Yes","75.79","Yes","Historical","29.73 - 59.04","59.05 - 64.53","64.54 - 66.82","66.83 - 68.67","68.68 - 76.46","76.47 - 82.77","82.78 - 84.99","85.00 - 90.75","90.76 - 98.98",">= 98.99","No","No","N/A"
"Sepsis Management: Septic Shock: Lactate Level Measurement, Antibiotics Ordered, and Fluid Resuscitation","ACEP48","N/A","QCDR Measure","Process","No","90.97","Yes","Historical","29.41 - 83.32","83.33 - 87.76","87.77 - 89.57","89.58 - 91.52","91.53 - 93.80","93.81 - 95.08","95.09 - 95.94","95.95 - 97.09","97.10 - 98.72",">= 98.73","No","No","N/A"
"ED Median Time from ED arrival to ED departure for all Adult Patients","ACEP50","N/A","QCDR Measure","Outcome","Yes","187.34","Yes","Historical","319.00 - 242.01","242.00 - 222.51","222.50 - 203.01","203.00 - 189.01","189.00 - 181.01","181.00 - 170.01","170.00 - 165.01","165.00 - 157.01","157.00 - 133.01","<= 133.00","No","No","N/A"
"ED Median Time from ED arrival to ED departure for all Pediatric ED Patients","ACEP51","N/A","QCDR Measure","Outcome","Yes","133.49","Yes","Historical","236.00 - 183.01","183.00 - 157.01","157.00 - 146.01","146.00 - 140.01","140.00 - 129.01","129.00 - 123.01","123.00 - 117.01","117.00 - 111.01","111.00 - 89.01","<= 89.00","No","No","N/A"
"Appropriate Emergency Department Utilization of Lumbar Spine Imaging for Atraumatic Low Back Pain","ACEP52","N/A","QCDR Measure","Process","Yes","81.56","Yes","Historical","51.86 - 67.17","67.18 - 72.27","72.28 - 74.88","74.89 - 77.97","77.98 - 80.32","80.33 - 81.24","81.25 - 84.37","84.38 - 99.99","--","100.00","No","No","N/A"
"Appropriate Use of Imaging for Recurrent Renal Colic","ACEP53","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Follow-Up Care Coordination Documented in Discharge Summary","ACEP56","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Chest Pain – Avoidance of admission for adult patients with low-risk chest pain.","ACEP59","N/A","QCDR Measure","Outcome","Yes","82.45","Yes","Historical","51.38 - 66.06","66.07 - 71.15","71.16 - 78.62","78.63 - 81.91","81.92 - 84.11","84.12 - 86.92","86.93 - 89.09","89.10 - 93.28","93.29 - 94.93",">= 94.94","No","No","N/A"
"Syncope – Avoidance of admission for adult patients with low-risk syncope","ACEP60","N/A","QCDR Measure","Outcome","Yes","88.26","Yes","Historical","68.10 - 76.82","76.83 - 82.77","82.78 - 84.23","84.24 - 87.76","87.77 - 89.75","89.76 - 91.88","91.89 - 93.32","93.33 - 94.71","94.72 - 96.50",">= 96.51","No","No","N/A"
"Avoidance of Chest X-ray in pediatric patients with Asthma, Bronchiolitis or Croup","ACEP61","N/A","QCDR Measure","Process","Yes","36.82","Yes","Historical","68.86 - 60.01","60.00 - 55.35","55.34 - 43.38","43.37 - 40.75","40.74 - 38.89","38.88 - 33.65","33.64 - 30.49","30.48 - 26.35","26.34 - 9.59","<= 9.58","No","No","N/A"
"Avoidance of Opioid therapy for dental pain.","ACEP62","N/A","QCDR Measure","Process","Yes","84.64","Yes","Historical","52.80 - 70.05","70.06 - 75.77","75.78 - 79.70","79.71 - 82.83","82.84 - 85.55","85.56 - 89.51","89.52 - 93.20","93.21 - 95.63","95.64 - 97.47",">= 97.48","No","No","N/A"
"Avoidance of Acute High-Risk Prescriptions in geriatric patients at discharge","ACEP63","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2023; subject to 5-point scoring floor if data completeness is met."
"Avoidance of admission for adult patients in Emergency Department with low-risk Deep Vein Thrombosis (DVT).","ACEP64","N/A","QCDR Measure","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Appropriate Utilization of Imaging in rAAA (ruptured Abdominal Aortic Aneurysm) patients in Emergency Department","ACEP65","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Co-testing for HIV in high-risk patients in Emergency Department who are being tested for other sexually transmitted infections (STI) (Gonorrhea, Chlamydia, Syphilis or Trichomonas).","ACEP66","N/A","QCDR Measure","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Hepatitis B Safety Screening","ACR10","N/A","QCDR Measure","Process","Yes","44.26","Yes","Historical","0.74 - 14.62","14.63 - 27.49","27.50 - 31.87","31.88 - 35.81","35.82 - 43.05","43.06 - 49.99","50.00 - 55.52","55.53 - 65.25","65.26 - 74.99",">= 75.00","No","No","N/A"
"Disease Activity Measurement for Patients with PsA","ACR12","N/A","QCDR Measure","Process","No","67.00","Yes","Historical","0.16 - 10.52","10.53 - 52.29","52.30 - 60.60","60.61 - 66.80","66.81 - 75.53","75.54 - 78.94","78.95 - 88.35","88.36 - 89.66","89.67 - 97.33",">= 97.34","No","No","N/A"
"Gout: Serum Urate Target","ACR14","N/A","QCDR Measure","Intermediate Outcome","Yes","53.71","Yes","Historical","3.85 - 37.16","37.17 - 46.33","46.34 - 48.32","48.33 - 51.99","52.00 - 54.38","54.39 - 58.61","58.62 - 61.44","61.45 - 64.09","64.10 - 68.84",">= 68.85","No","No","N/A"
"Safe Hydroxychloroquine Dosing","ACR15","N/A","QCDR Measure","Process","Yes","70.87","Yes","Historical","10.01 - 53.84","53.85 - 60.62","60.63 - 64.55","64.56 - 69.81","69.82 - 73.01","73.02 - 75.55","75.56 - 79.02","79.03 - 82.04","82.05 - 89.05",">= 89.06","No","No","N/A"
"Rheumatoid Arthritis Patients with Low Disease Activity or Remission","ACR16","N/A","QCDR Measure","Intermediate Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Report Turnaround Time: Radiography","ACRAD15","N/A","QCDR Measure","Outcome","Yes","4.12","Yes","Historical","34.94 - 9.54","9.53 - 3.88","3.87 - 2.72","2.71 - 2.14","2.13 - 1.80","1.79 - 1.48","1.47 - 1.10","1.09 - 0.76","0.75 - 0.55","<= 0.54","No","No","N/A"
"Report Turnaround Time: Ultrasound (Excluding Breast US)","ACRAD16","N/A","QCDR Measure","Outcome","Yes","3.48","Yes","Historical","22.58 - 7.79","7.78 - 4.49","4.48 - 3.59","3.58 - 2.68","2.67 - 2.27","2.26 - 1.70","1.69 - 1.26","1.25 - 0.93","0.92 - 0.61","<= 0.60","No","No","N/A"
"Report Turnaround Time: MRI","ACRAD17","N/A","QCDR Measure","Outcome","Yes","8.44","Yes","Historical","34.40 - 18.24","18.23 - 12.77","12.76 - 9.56","9.55 - 7.47","7.46 - 5.85","5.84 - 5.02","5.01 - 3.42","3.41 - 2.39","2.38 - 1.66","<= 1.65","No","No","N/A"
"Report Turnaround Time: CT","ACRAD18","N/A","QCDR Measure","Outcome","Yes","4.77","Yes","Historical","30.45 - 10.50","10.49 - 5.32","5.31 - 3.95","3.94 - 2.78","2.77 - 2.27","2.26 - 1.94","1.93 - 1.54","1.53 - 1.12","1.11 - 0.71","<= 0.70","No","No","N/A"
"Report Turnaround Time: PET","ACRAD19","N/A","QCDR Measure","Outcome","Yes","7.59","Yes","Historical","22.47 - 15.95","15.94 - 13.59","13.58 - 10.03","10.02 - 7.41","7.40 - 5.43","5.42 - 3.73","3.72 - 3.14","3.13 - 2.41","2.40 - 1.91","<= 1.90","No","No","N/A"
"Report Turnaround Time: Mammography","ACRAD25","N/A","QCDR Measure","Outcome","Yes","12.31","Yes","Historical","62.23 - 29.83","29.82 - 16.50","16.49 - 12.63","12.62 - 8.88","8.87 - 6.48","6.47 - 4.31","4.30 - 2.63","2.62 - 1.29","1.28 - 0.50","<= 0.49","No","No","N/A"
"Multi-strata weighted average for 3 CT Exam Types: Overall Percent of CT exams for which Dose Length Product is at or below the size-specific diagnostic reference level (for CT Abdomen-pelvis with contrast/single phase scan, CT Chest without contrast/single phase scan and CT Head/Brain without contrast/single phase scan)","ACRAD34","N/A","QCDR Measure","Outcome","Yes","83.96","Yes","Historical","39.78 - 69.16","69.17 - 78.27","78.28 - 83.58","--","83.59 - 83.85","83.86 - 87.25","87.26 - 91.83","91.84 - 94.86","94.87 - 96.44",">= 96.45","No","No","N/A"
"Incidental Coronary Artery Calcification Reported on Chest CT","ACRAD36","N/A","QCDR Measure","Process","Yes","87.17","Yes","Historical","31.00 - 55.34","55.35 - 73.84","73.85 - 85.24","85.25 - 93.99","94.00 - 98.99","99.00 - 99.99","--","--","--","100.00","Yes","No","N/A"
"Interpretation of CT Pulmonary Angiography (CTPA) for Pulmonary Embolism","ACRAD37","N/A","QCDR Measure","Process","Yes","97.39","Yes","Historical","81.19 - 90.49","90.50 - 94.99","95.00 - 97.99","98.00 - 99.99","--","--","--","--","--","100.00","Yes","No","N/A"
"Use of Quantitative Criteria for Oncologic FDG PET Imaging","ACRAD41","N/A","QCDR Measure","Process","Yes","81.37","Yes","Historical","16.00 - 35.99","36.00 - 57.99","58.00 - 71.99","72.00 - 85.99","86.00 - 97.99","98.00 - 99.06","99.07 - 99.99","--","--","100.00","Yes","No","N/A"
"Cement Use for Displaced Femoral Neck Fracture in Older Adults","AJRR10","N/A","QCDR Measure","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2023; subject to 5-point scoring floor if data completeness is met."
"Improvement in Pain Assessment Following Spine Fusion Procedures","AJRR11","N/A","QCDR Measure","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2023; subject to 5-point scoring floor if data completeness is met."
"Physical Health Outcomes in Total Hip and Knee Arthroplasty","AJRR12","N/A","QCDR Measure","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Postoperative Ambulation","AJRR7","N/A","QCDR Measure","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Risk-Standardized Routine Discharge Rate Following Elective Primary Hip and Knee Arthroplasty","AJRR9","N/A","QCDR Measure","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2023; subject to 5-point scoring floor if data completeness is met."
"Coronary Artery Bypass Graft (CABG): Prolonged Intubation – Inverse Measure","AQI18","N/A","QCDR Measure","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Patient-Reported Experience with Anesthesia","AQI48","N/A","QCDR Measure","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","94.09","Yes","Historical","88.18 - 90.60","90.61 - 91.96","91.97 - 92.69","92.70 - 93.50","93.51 - 94.27","94.28 - 94.98","94.99 - 95.60","95.61 - 96.25","96.26 - 97.22",">= 97.23","No","No","N/A"
"Adherence to Blood Conservation Guidelines for Cardiac Operations using Cardiopulmonary Bypass (CPB) – Composite","AQI49","N/A","QCDR Measure","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Avoidance of Cerebral Hyperthermia for Procedures Involving Cardiopulmonary Bypass","AQI65","N/A","QCDR Measure","Outcome","Yes","93.96","Yes","Historical","33.33 - 78.66","78.67 - 95.88","95.89 - 98.89","98.90 - 99.59","99.60 - 99.92","99.93 - 99.99","--","--","--","100.00","No","No","N/A"
"Consultation for Frail Patients","AQI67","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Ambulatory Glucose Management","AQI71","N/A","QCDR Measure","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Perioperative Anemia Management","AQI72","N/A","QCDR Measure","Process","Yes","99.38","Yes","Historical","80.25 - 98.42","98.43 - 99.79","99.80 - 99.99","--","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Stones: Repeat Shock Wave Lithotripsy (SWL) Within 6 Months of Initial Treatment","AQUA14","N/A","QCDR Measure","Outcome","Yes","11.40","Yes","Historical","47.12 - 26.91","26.90 - 15.89","15.88 - 13.42","13.41 - 10.30","10.29 - 9.10","9.09 - 6.53","6.52 - 4.82","4.81 - 3.24","3.23 - 1.40","<= 1.39","No","No","N/A"
"Stones: Urinalysis or Urine Culture Performed Before Surgical Stone Procedures","AQUA15","N/A","QCDR Measure","Process","Yes","72.06","Yes","Historical","2.63 - 42.41","42.42 - 55.42","55.43 - 62.32","62.33 - 70.14","70.15 - 77.24","77.25 - 84.31","84.32 - 87.42","87.43 - 92.63","92.64 - 96.71",">= 96.72","No","No","N/A"
"Non-Muscle Invasive Bladder Cancer: Repeat Transurethral Resection of Bladder Tumor (TURBT) for T1 disease","AQUA16","N/A","QCDR Measure","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Benign Prostate Hyperplasia (BPH): Inappropriate Lab & Imaging Services for Patients with BPH","AQUA26","N/A","QCDR Measure","Process","Yes","6.66","Yes","Historical","88.89 - 11.96","11.95 - 2.03","2.02 - 1.13","1.12 - 0.38","0.37 - 0.01","--","--","--","--","0.00","Yes","Yes","N/A"
"Non-Muscle Invasive Bladder Cancer: Initial Management/Surveillance for Non-Muscle Invasive Bladder Cancer","AQUA35","N/A","QCDR Measure","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Prostate Cancer: Confirmation Biopsy in Newly Diagnosed Patients on Active Surveillance","AQUA36","N/A","QCDR Measure","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Hospital admissions or infectious complications within 30 days of prostate biopsy","AQUA8","N/A","QCDR Measure","Outcome","Yes","3.44","Yes","Historical","34.43 - 10.86","10.85 - 4.42","4.41 - 2.81","2.80 - 1.97","1.96 - 1.56","1.55 - 1.28","1.27 - 0.97","0.96 - 0.48","0.47 - 0.01","0.00","No","No","N/A"
"Biopsy Reporting Time to Clinician","CAP22","N/A","QCDR Measure","Process","Yes","89.64","Yes","Historical","46.74 - 70.40","70.41 - 83.68","83.69 - 91.02","91.03 - 94.22","94.23 - 95.95","95.96 - 96.94","96.95 - 97.98","97.99 - 98.97","98.98 - 99.99","100.00","Yes","No","N/A"
"Gastritis: Timely Helicobacter pylori Reporting","CAP28","N/A","QCDR Measure","Process","Yes","93.08","Yes","Historical","50.99 - 74.15","74.16 - 90.97","90.98 - 94.70","94.71 - 96.32","96.33 - 97.25","97.26 - 98.88","98.89 - 99.66","99.67 - 99.99","--","100.00","Yes","Yes","N/A"
"Urinary Bladder Cancer: Complete Analysis and Timely Reporting","CAP30","N/A","QCDR Measure","Process","Yes","84.48","Yes","Historical","39.57 - 53.12","53.13 - 72.72","72.73 - 77.38","77.39 - 79.99","80.00 - 89.99","90.00 - 97.58","97.59 - 98.51","98.52 - 99.99","--","100.00","No","No","N/A"
"Molecular Assessment: Biomarkers in Non-Small Cell Lung Cancer","CAP34","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Prostate Cancer Reporting: Complete Analysis","CAP38","N/A","QCDR Measure","Process","Yes","94.57","Yes","Historical","40.56 - 84.95","84.96 - 89.35","89.36 - 95.14","95.15 - 98.43","98.44 - 99.82","99.83 - 99.99","--","--","--","100.00","Yes","No","N/A"
"Squamous Cell Skin Cancer: Complete Reporting","CAP40","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Basal Cell Skin Cancer: Complete Reporting","CAP41","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Barrett’s Esophagus: Complete Analysis with Appropriate Consultation","CAP42","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Avoid Head CT for Patients with Uncomplicated Syncope","ECPR39","N/A","QCDR Measure","Process","Yes","97.75","Yes","Historical","57.17 - 97.04","97.05 - 99.06","99.07 - 99.55","99.56 - 99.72","99.73 - 99.99","--","--","--","--","100.00","Yes","Yes","N/A"
"Avoidance of Opiates for Low Back Pain or Migraines","ECPR46","N/A","QCDR Measure","Process","Yes","98.78","Yes","Historical","84.60 - 95.89","95.90 - 98.98","98.99 - 99.67","99.68 - 99.87","99.88 - 99.99","--","--","--","--","100.00","Yes","Yes","N/A"
"Door to Diagnostic Evaluation by a Provider Within 30 Minutes – Urgent Care Patients","ECPR50","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Discharge Prescription of Naloxone after Opioid Poisoning or Overdose","ECPR51","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Appropriate Treatment of Psychosis and Agitation in the Emergency Department","ECPR52","N/A","QCDR Measure","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Avoidance of Long-Acting (LA) or Extended-Release (ER) Opiate Prescriptions and Opiate Prescriptions for Greater Than 3 Days Duration for Acute Pain","ECPR55","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Opioid Withdrawal: Initiation of Medication-Assisted Treatment (MAT) and Referral to Outpatient Opioid Treatment","ECPR56","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Patient-Reported Understanding of Discharge Diagnosis and Plan of Care","ECPR58","N/A","QCDR Measure","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2023; subject to 5-point scoring floor if data completeness is met."
"Patient Reported Trust in Provider","ECPR59","N/A","QCDR Measure","Patient Engagement/Experience","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Ultrasound Guidance for Peripheral Nerve Block with Patient Experience","EPREOP30","N/A","QCDR Measure","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Intraoperative Hypotension (IOH) among Non-Emergent Noncardiac Surgical Cases","EPREOP31","N/A","QCDR Measure","Intermediate Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Functional Status Change for Patients with Upper or Lower Quadrant Edema","FOTO4","N/A","QCDR Measure","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Functional Status Change in Balance Confidence","FOTO5","N/A","QCDR Measure","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","55.81","Yes","Historical","15.38 - 36.62","36.63 - 42.66","42.67 - 44.99","45.00 - 52.77","52.78 - 58.32","58.33 - 62.87","62.88 - 64.51","64.52 - 66.51","66.52 - 74.99",">= 75.00","No","No","N/A"
"Functional Status Change in Dizziness","FOTO6","N/A","QCDR Measure","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","71.51","Yes","Historical","36.97 - 47.26","47.27 - 52.02","52.03 - 61.57","61.58 - 72.72","72.73 - 76.31","76.32 - 78.21","78.22 - 80.57","80.58 - 83.32","83.33 - 90.90",">= 90.91","No","No","N/A"
"Functional Status Change for Patients Post Stroke","FOTO7","N/A","QCDR Measure","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Appropriate follow-up interval based on pathology findings in screening colonoscopy","GIQIC23","N/A","QCDR Measure","Process","Yes","86.67","Yes","Historical","30.69 - 59.43","59.44 - 78.12","78.13 - 88.28","88.29 - 92.22","92.23 - 93.45","93.46 - 93.67","93.68 - 94.99","95.00 - 98.27","98.28 - 99.32",">= 99.33","No","No","N/A"
"Screening Colonoscopy Adenoma Detection Rate","GIQIC26","N/A","QCDR Measure","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Clostridium Difficile – Risk Assessment and Plan of Care","HCPR20","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Avoidance of Echocardiogram and Carotid Ultrasound for Syncope","HCPR23","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Appropriate Utilization of Vancomycin for Cellulitis","HCPR24","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Physician’s Orders for Life-Sustaining Treatment (POLST) Form","HCPR25","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Heart Failure (HF): SGLT-2 Inhibitor Therapy for Left Ventricular Systolic Dysfunction (LVSD)","HCPR26","N/A","QCDR Measure","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Point-of-Care Ultrasound: Evaluation for Pneumothorax after Central Venous Catheter (CVC) Placement","HCPR27","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Functional Status Change for Patients with Vestibular Dysfunction","HM7","N/A","QCDR Measure","Outcome","Yes","58.11","Yes","Historical","7.41 - 21.48","21.49 - 34.18","34.19 - 43.12","43.13 - 49.99","50.00 - 60.81","60.82 - 69.99","70.00 - 78.12","78.13 - 83.32","83.33 - 89.18",">= 89.19","No","No","N/A"
"Endothelial Keratoplasty - Post-operative improvement in best corrected visual acuity to 20/40 or better","IRIS1","N/A","QCDR Measure","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Diabetic Macular Edema - Loss of Visual Acuity","IRIS13","N/A","QCDR Measure","Outcome","Yes","98.36","Yes","Historical","87.18 - 94.22","94.23 - 97.34","97.35 - 98.91","98.92 - 99.47","99.48 - 99.73","99.74 - 99.99","--","--","--","100.00","Yes","No","N/A"
"Acute Anterior Uveitis: Post-treatment Grade 0 anterior chamber cells","IRIS17","N/A","QCDR Measure","Outcome","Yes","73.16","Yes","Historical","47.06 - 59.99","60.00 - 61.75","61.76 - 65.61","65.62 - 70.26","70.27 - 74.10","74.11 - 76.59","76.60 - 79.99","80.00 - 84.20","84.21 - 86.66",">= 86.67","No","No","N/A"
"Glaucoma – Intraocular Pressure Reduction","IRIS2","N/A","QCDR Measure","Intermediate Outcome","Yes","80.02","Yes","Historical","22.22 - 57.76","57.77 - 68.08","68.09 - 73.59","73.60 - 80.00","80.01 - 85.31","85.32 - 89.36","89.37 - 91.86","91.87 - 93.96","93.97 - 96.11",">= 96.12","No","No","N/A"
"Refractive Surgery: Patients with a postoperative uncorrected visual acuity (UCVA) of 20/20 or better within 30 days","IRIS23","N/A","QCDR Measure","Outcome","Yes","78.71","Yes","Historical","10.14 - 49.22","49.23 - 65.41","65.42 - 71.87","71.88 - 78.78","78.79 - 86.96","86.97 - 90.90","90.91 - 92.45","92.46 - 99.99","--","100.00","No","No","N/A"
"Refractive Surgery: Patients with a postoperative correction within + or - 0.5 Diopter (D) of the intended correction","IRIS24","N/A","QCDR Measure","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Improvement of Macular Edema in Patients with Uveitis","IRIS35","N/A","QCDR Measure","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Endothelial Keratoplasty – Dislocation Requiring Surgical Intervention","IRIS38","N/A","QCDR Measure","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Intraocular Pressure Reduction Following Trabeculectomy or an Aqueous Shunt Procedure","IRIS39","N/A","QCDR Measure","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Amblyopia: Interocular visual acuity","IRIS50","N/A","QCDR Measure","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Complications After Cataract Surgery","IRIS54","N/A","QCDR Measure","Outcome","Yes","1.08","Yes","Historical","9.09 - 2.03","2.02 - 1.39","1.38 - 0.87","0.86 - 0.55","0.54 - 0.35","0.34 - 0.15","0.14 - 0.01","--","--","0.00","No","No","N/A"
"Improved Visual Acuity after Vitrectomy for Complications of Diabetic Retinopathy within 120 Days","IRIS58","N/A","QCDR Measure","Outcome","Yes","77.35","Yes","Historical","45.45 - 61.29","61.30 - 63.32","63.33 - 71.00","71.01 - 78.25","78.26 - 78.98","78.99 - 81.81","81.82 - 82.85","82.86 - 87.99","88.00 - 91.54",">= 91.55","No","No","N/A"
"Visual Acuity Improvement Following Cataract Surgery and Minimally Invasive Glaucoma Surgery","IRIS61","N/A","QCDR Measure","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Regaining Vision After Cataract Surgery","IRIS62","N/A","QCDR Measure","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Use of Anxiety Severity Measure","MBHR1","N/A","QCDR Measure","Process","No","83.61","Yes","Historical","44.95 - 67.33","67.34 - 68.04","68.05 - 80.24","80.25 - 82.48","82.49 - 87.56","87.57 - 90.69","90.70 - 95.75","95.76 - 99.99","--","100.00","No","No","N/A"
"Symptom Improvement in adults with ADHD","MBHR10","N/A","QCDR Measure","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Cognitive Assessment with Counseling on Safety and Potential Risk","MBHR11","N/A","QCDR Measure","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Social Role Functioning Assessment utilizing PROMIS Adult Ability to Participate in Social Roles and Activities","MBHR13","N/A","QCDR Measure","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Sleep Quality Response at 3-months","MBHR14","N/A","QCDR Measure","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Consideration of Cultural-Linguistic and Demographic Factors in Cognitive Assessment","MBHR15","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Comprehensive Cognitive Assessment Assists with Differential Diagnosis","MBHR16","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Provision of Feedback Following a Cognitive or Mental Status Assessment with Documentation of Understanding of Test Results and Subsequent Healthcare Plan with Timely Transmission of Results","MBHR18","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2023; subject to 5-point scoring floor if data completeness is met."
"Anxiety Response at 6-months","MBHR2","N/A","QCDR Measure","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Posttraumatic Stress Disorder (PTSD) Outcome Assessment for Adults and Children","MBHR7","N/A","QCDR Measure","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Alcohol Use Disorder Outcome Response","MBHR8","N/A","QCDR Measure","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Outcome monitoring of ADHD functional impairment in children and youth","MBHR9","N/A","QCDR Measure","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Use of ASPECTS (Alberta Stroke Program Early CT Score) for non-contrast CT Head performed for suspected acute stroke.","MEDNAX55","N/A","QCDR Measure","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Hammer Toe Outcome","MEX5","N/A","QCDR Measure","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","23.55","Yes","Historical","0.38 - 1.84","1.85 - 2.79","2.80 - 3.69","3.70 - 5.12","5.13 - 12.27","12.28 - 21.87","21.88 - 25.20","25.21 - 28.14","28.15 - 95.11",">= 95.12","No","No","N/A"
"Patients Suffering From a Neck Injury who Improve Physical Function","MSK1","N/A","QCDR Measure","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Patients Suffering From a Knee Injury who Improve Pain","MSK10","N/A","QCDR Measure","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Patients Suffering From an Upper Extremity Injury who Improve Physical Function","MSK2","N/A","QCDR Measure","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Patients Suffering From a Back Injury who Improve Physical Function","MSK3","N/A","QCDR Measure","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Patients Suffering From a Lower Extremity Injury who Improve Physical Function","MSK4","N/A","QCDR Measure","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Patients Suffering From a Knee Injury who Improve Physical Function","MSK5","N/A","QCDR Measure","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Patients Suffering From a Neck Injury who Improve Pain","MSK6","N/A","QCDR Measure","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Patients Suffering From an Upper Extremity Injury who Improve Pain","MSK7","N/A","QCDR Measure","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Patients Suffering From a Back Injury who Improve Pain","MSK8","N/A","QCDR Measure","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Patients Suffering From a Lower Extremity Injury who Improve Pain","MSK9","N/A","QCDR Measure","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Screening Coronary Calcium Scoring for Cardiovascular Risk Assessment Including Coronary Artery Calcification Regional Distribution Scoring","MSN13","N/A","QCDR Measure","Process","No","93.68","Yes","Historical","18.00 - 72.72","72.73 - 99.62","99.63 - 99.99","--","--","--","--","--","--","100.00","Yes","No","N/A"
"Use of Thyroid Imaging Reporting & Data System (TI-RADS) in Final Report to Stratify Thyroid Nodule Risk","MSN15","N/A","QCDR Measure","Process","Yes","96.28","Yes","Historical","55.39 - 88.99","89.00 - 98.99","99.00 - 99.99","--","--","--","--","--","--","100.00","Yes","Yes","N/A"
"Prostate Cancer: Active Surveillance/Watchful Waiting for Newly Diagnosed Low Risk Prostate Cancer Patients","MUSIC4","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Repeat screening or surveillance colonoscopy recommended within one year due to inadequate/poor bowel preparation","NHCR4","N/A","QCDR Measure","Process","Yes","79.26","Yes","Historical","9.52 - 44.49","44.50 - 61.89","61.90 - 73.90","73.91 - 82.60","82.61 - 88.32","88.33 - 95.29","95.30 - 96.14","96.15 - 99.99","--","100.00","No","No","N/A"
"Appropriate non-invasive arterial testing for patients with intermittent claudication who are undergoing a LE peripheral vascular intervention","OEIS6","N/A","QCDR Measure","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Structured Walking Program Prior to Intervention for Claudication","OEIS7","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Use of ultrasound guidance for vascular access","OEIS8","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Oncology: Advance Care Planning in Metastatic Cancer Patients","PIMSH1","N/A","QCDR Measure","Patient Engagement/Experience","Yes","39.41","Yes","Historical","0.80 - 3.79","3.80 - 17.09","17.10 - 30.39","30.40 - 35.69","35.70 - 39.44","39.45 - 43.29","43.30 - 46.79","46.80 - 57.59","57.60 - 74.69",">= 74.70","No","No","N/A"
"Oncology: Hepatitis B Serology Testing and Prophylactic Treatment Prior to Receiving Anti-CD20 Targeting Drugs","PIMSH10","N/A","QCDR Measure","Process","Yes","55.58","Yes","Historical","4.90 - 15.99","16.00 - 38.19","38.20 - 43.89","43.90 - 48.09","48.10 - 57.94","57.95 - 61.79","61.80 - 71.09","71.10 - 81.79","81.80 - 87.99",">= 88.00","No","No","N/A"
"Oncology: Mutation Testing for Stage IV Lung Cancer Completed Prior to the Start of Targeted Therapy","PIMSH13","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2023; subject to 5-point scoring floor if data completeness is met."
"Antiemetic Therapy for Low- and Minimal-Emetic-Risk Antineoplastic Agents in the Infusion Center - Avoidance of Overuse (Lower Score - Better)","PIMSH15","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2023; subject to 5-point scoring floor if data completeness is met."
"Appropriate Antiemetic Therapy for High- and Moderate-Emetic-Risk Antineoplastic Agents in the Infusion Center","PIMSH16","N/A","QCDR Measure","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2023; subject to 5-point scoring floor if data completeness is met."
"Oncology: Utilization of GCSF in Metastatic Colorectal Cancer","PIMSH2","N/A","QCDR Measure","Efficiency","Yes","24.56","Yes","Historical","60.00 - 55.01","55.00 - 38.51","38.50 - 32.31","32.30 - 29.81","29.80 - 26.61","26.60 - 13.91","13.90 - 11.81","11.80 - 9.11","9.10 - 0.01","0.00","No","No","N/A"
"Oncology: Patient-Reported Pain Improvement","PIMSH4","N/A","QCDR Measure","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","51.50","Yes","Historical","27.50 - 38.49","38.50 - 43.09","43.10 - 45.89","45.90 - 48.69","48.70 - 51.99","52.00 - 54.19","54.20 - 56.49","56.50 - 60.89","60.90 - 64.29",">= 64.30","No","No","N/A"
"Oncology: Supportive Care Drug Utilization in Last 14 Days of Life","PIMSH9","N/A","QCDR Measure","Efficiency","Yes","7.26","Yes","Historical","30.80 - 15.11","15.10 - 10.01","10.00 - 8.11","8.10 - 6.71","6.70 - 5.71","5.70 - 4.51","4.50 - 3.71","3.70 - 2.81","2.80 - 0.01","0.00","No","No","N/A"
"Use of Peripheral Nerve Block within the Emergency Department in Patients Admitted with Low Energy Hip Fracture","PQRANES1","N/A","QCDR Measure","Process","Yes","13.42","Yes","Historical","0.96 - 3.15","3.16 - 5.07","5.08 - 7.31","7.32 - 9.26","9.27 - 10.64","10.65 - 13.78","13.79 - 16.14","16.15 - 21.27","21.28 - 25.92",">= 25.93","No","No","N/A"
"IVC Filter Management Confirmation","QMM16","N/A","QCDR Measure","Process","Yes","86.72","Yes","Historical","2.00 - 49.99","50.00 - 94.99","95.00 - 96.99","97.00 - 99.99","--","--","--","--","--","100.00","Yes","No","N/A"
"Appropriate Follow-up Recommendations for Ovarian-Adnexal Lesions using the Ovarian-Adnexal Reporting and Data System (O-RADS)","QMM17","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Use of Breast Cancer Risk Score on Mammography","QMM18","N/A","QCDR Measure","Process","Yes","77.31","Yes","Historical","2.23 - 7.76","7.77 - 36.08","36.09 - 81.99","82.00 - 94.49","94.50 - 98.99","99.00 - 99.99","--","--","--","100.00","Yes","No","N/A"
"DEXA/DXA and Fracture Risk Assessment for Patients with Osteopenia","QMM19","N/A","QCDR Measure","Process","No","94.56","Yes","Historical","38.00 - 81.93","81.94 - 96.99","97.00 - 98.99","99.00 - 99.99","--","--","--","--","--","100.00","Yes","No","N/A"
"Incorporating results of concurrent studies into Final Reports for Bone Marrow Aspirate of patients with Leukemia, Myelodysplastic syndrome, or Chronic Anemia","QMM21","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Molecular Testing Recommended on Fine Needle Aspirations (FNA) of Thyroid Nodule(s) with Bethesda Category 3 or 4 Cytology Diagnosis","QMM22","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Low dose cancer screening recommendation for computed tomography (CT) and computed tomography angiography (CTA) of chest with diagnosis of Emphysema.","QMM23","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2023; subject to 5-point scoring floor if data completeness is met."
"Acute Rib Fracture Numbering on ED Trauma Patients","QMM24","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2023; subject to 5-point scoring floor if data completeness is met."
"Use of Structured Reporting for Urine Cytology Specimens","QMM25","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2023; subject to 5-point scoring floor if data completeness is met."
"Screening Abdominal Aortic Aneurysm Reporting with Recommendations","QMM26","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Appropriate Classification and Follow-up Imaging for Incidental Pancreatic Cysts","QMM27","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Reporting Breast Arterial Calcification (BAC) on Screening Mammography","QMM28","N/A","QCDR Measure","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Use of Appropriate Classification System for Lymphoma Specimen","QMM29","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Tunneled Hemodialysis Catheter Clinical Success Rate","RCOIR12","N/A","QCDR Measure","Outcome","Yes","76.68","Yes","Historical","48.68 - 58.54","58.55 - 68.47","68.48 - 73.07","73.08 - 74.24","74.25 - 79.54","79.55 - 83.06","83.07 - 84.54","84.55 - 87.41","87.42 - 88.80",">= 88.81","No","No","N/A"
"Percutaneous Arteriovenous Fistula for Dialysis - Clinical Success Rate","RCOIR13","N/A","QCDR Measure","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Arteriovenous Fistula Patency Rate","RCOIR14","N/A","QCDR Measure","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Arteriovenous Graft Patency Rate","RCOIR15","N/A","QCDR Measure","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Heel Pain Treatment Outcomes for Adults","REGCLR1","N/A","QCDR Measure","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","44.02","Yes","Historical","1.27 - 6.66","6.67 - 18.65","18.66 - 21.42","21.43 - 33.16","33.17 - 39.21","39.22 - 55.57","55.58 - 60.86","60.87 - 72.82","72.83 - 83.99",">= 84.00","No","No","N/A"
"Bunion Outcome - Adult and Adolescent","REGCLR3","N/A","QCDR Measure","Patient-Reported Outcome-Based Performance Measure (PRO-PM)","Yes","28.95","Yes","Historical","0.31 - 1.04","1.05 - 2.23","2.24 - 3.38","3.39 - 11.81","11.82 - 14.80","14.81 - 30.14","30.15 - 39.46","39.47 - 50.07","50.08 - 94.58",">= 94.59","No","No","N/A"
"Offloading with Remote Monitoring","REGCLR5","N/A","QCDR Measure","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Monitor and Improve Treatment Outcomes in Chronic Wound Healing","REGCLR8","N/A","QCDR Measure","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2023; subject to 5-point scoring floor if data completeness is met."
"Arteriovenous Graft Thrombectomy Clinical Success Rate","RPAQIR14","N/A","QCDR Measure","Outcome","Yes","85.67","Yes","Historical","56.41 - 70.22","70.23 - 78.37","78.38 - 82.68","82.69 - 87.03","87.04 - 88.53","88.54 - 89.56","89.57 - 91.20","91.21 - 92.21","92.22 - 94.33",">= 94.34","No","No","N/A"
"Arteriovenous Fistulae Thrombectomy Clinical Success Rate","RPAQIR15","N/A","QCDR Measure","Outcome","Yes","85.76","Yes","Historical","67.03 - 73.52","73.53 - 77.77","77.78 - 81.36","81.37 - 85.81","85.82 - 86.40","86.41 - 88.45","88.46 - 90.31","90.32 - 93.47","93.48 - 96.29",">= 96.30","No","No","N/A"
"High Intensity Statin Prescribed for Acute and Subacute Ischemic Stroke and Transient Ischemic Attack (TIA)","THEPQR1","N/A","QCDR Measure","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2023; subject to 5-point scoring floor if data completeness is met."
"Discontinuation of  Proton Pump Inhibitors for patients who do not meet criteria for long-term utilization.","THEPQR2","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2023; subject to 5-point scoring floor if data completeness is met."
"SGLT-2 inhibitors for patients with HFrEF with or without Type 2 Diabetes","THEPQR3","N/A","QCDR Measure","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Consultation to Palliative Care for Patients with End Stage Conditions","THEPQR4","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Ankylosing Spondylitis: Controlled Disease Or Improved Disease Function","UREQA10","N/A","QCDR Measure","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2023; subject to 5-point scoring floor if data completeness is met."
"Ankylosing Spondylitis: Appropriate Pharmacologic Therapy","UREQA2","N/A","QCDR Measure","Process","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Vitamin D level: Effective Control of Low Bone Mass/Osteopenia and Osteoporosis: Therapeutic Level Of 25 OH Vitamin D Level Achieved","UREQA8","N/A","QCDR Measure","Outcome","Yes","45.75","Yes","Historical","0.21 - 6.40","6.41 - 23.28","23.29 - 33.58","33.59 - 38.89","38.90 - 43.33","43.34 - 52.09","52.10 - 64.03","64.04 - 68.19","68.20 - 84.50",">= 84.51","No","No","N/A"
"Screening for Osteoporosis for Men Aged 70 Years and Older","UREQA9","N/A","QCDR Measure","Process","No","20.80","Yes","Historical","0.22 - 2.59","2.60 - 7.96","7.97 - 11.92","11.93 - 13.80","13.81 - 20.30","20.31 - 23.69","23.70 - 26.99","27.00 - 33.56","33.57 - 34.70",">= 34.71","No","No","N/A"
"Nutritional Assessment and Intervention Plan in patients with Wounds and Ulcers","USWR22","N/A","QCDR Measure","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Non-Invasive Arterial Assessment of patients with lower extremity wounds or ulcers for determination of healing potential","USWR30","N/A","QCDR Measure","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Insufficient volume of data submitted in PY 2022 to establish historical benchmark."
"Adequate Compression at each visit for Patients with Venous Leg Ulcers (VLUs) appropriate to arterial supply","USWR32","N/A","QCDR Measure","Intermediate Outcome","Yes","76.40","Yes","Historical","9.81 - 31.22","31.23 - 68.84","68.85 - 78.78","78.79 - 79.46","79.47 - 82.76","82.77 - 87.09","87.10 - 91.25","91.26 - 94.61","94.62 - 96.27",">= 96.28","No","No","N/A"
"Diabetic Foot Ulcer (DFU) Healing or Closure","USWR33","N/A","QCDR Measure","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Venous Leg Ulcer (VLU) Healing or Closure","USWR34","N/A","QCDR Measure","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Adequate Off-loading of Diabetic Foot Ulcers performed at each visit, appropriate to location of ulcer","USWR35","N/A","QCDR Measure","Process","No","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."
"Pressure Ulcer* (PU) Healing or Closure (not on the lower extremity )","USWR36","N/A","QCDR Measure","Outcome","Yes","--","No","--","--","--","--","--","--","--","--","--","--","--","N/A","N/A","Measure added in PY 2024; subject to 7-point scoring floor if data completeness is met."