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

1	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
2	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
3	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
4	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
5	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
6	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.
7	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
8	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
9	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
10	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
11	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
12	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
13	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
14	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
15	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
16	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
17	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.
18	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
19	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
20	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
21	Advance Care Plan	047	N/A	Medicare Part B Claims	Process	Yes	100.00	Yes	Historical	--	--	--	--	--	--	--	--	--	100.00	Yes	Yes	N/A
22	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
23	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
24	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.
25	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
26	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
27	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
28	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
29	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.
30	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.
31	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.
32	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
33	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
34	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
35	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
36	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
37	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.
38	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
39	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
40	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
41	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
42	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
43	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
44	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
45	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
46	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
47	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
48	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
49	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
50	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
51	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.
52	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
53	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
54	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
55	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
56	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
57	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
58	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.
59	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.
60	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
61	Falls: Plan of Care	155	N/A	Medicare Part B Claims	Process	Yes	100.00	Yes	Historical	--	--	--	--	--	--	--	--	--	100.00	Yes	Yes	N/A
62	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.
63	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.
64	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.
65	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
66	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
67	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
68	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
69	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
70	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
71	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
72	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
73	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
74	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
75	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
76	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.
77	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.
78	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
79	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
80	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
81	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
82	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
83	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
84	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
85	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
86	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
87	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
88	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
89	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.
90	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.
91	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.
92	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.
93	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
94	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
95	Barrett's Esophagus	249	N/A	MIPS CQM	Process	No	99.78	Yes	Historical	97.02 - 99.99	--	--	--	--	--	--	--	--	100.00	Yes	Yes	N/A
96	Barrett's Esophagus	249	N/A	Medicare Part B Claims	Process	No	100.00	Yes	Historical	--	--	--	--	--	--	--	--	--	100.00	Yes	Yes	N/A
97	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
98	Radical Prostatectomy Pathology Reporting	250	N/A	Medicare Part B Claims	Process	No	100.00	Yes	Historical	--	--	--	--	--	--	--	--	--	100.00	Yes	Yes	N/A
99	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
100	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.
101	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.
102	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.
103	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.
104	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.
105	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
106	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.
107	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.
108	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
109	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.
110	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
111	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
112	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
113	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
114	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
115	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
116	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.
117	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.
118	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
119	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
120	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
121	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
122	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
123	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
124	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
125	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
126	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
127	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
128	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
129	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
130	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
131	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
132	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
133	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
134	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
135	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
136	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
137	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.
138	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
139	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
140	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.
141	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.
142	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
143	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.
144	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
145	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.
146	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
147	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
148	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
149	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
150	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
151	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
152	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
153	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
154	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
155	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.
156	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.
157	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
158	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.
159	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
160	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
161	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.
162	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
163	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
164	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
165	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
166	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
167	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
168	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.
169	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.
170	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
171	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.
172	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.
173	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
174	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
175	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
176	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
177	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.
178	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
179	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
180	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
181	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.
182	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.
183	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
184	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
185	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
186	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
187	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
188	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.
189	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
190	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.
191	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
192	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
193	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
194	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.
195	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
196	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.
197	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.
198	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.
199	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.
200	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
201	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
202	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.
203	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.
204	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.
205	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
206	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
207	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.
208	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.
209	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
210	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
211	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
212	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.
213	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.
214	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.
215	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
216	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.
217	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.
218	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
219	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
220	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.
221	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.
222	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.
223	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
224	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
225	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.
226	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.
227	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.
228	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.
229	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
230	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
231	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.
232	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
233	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
234	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.
235	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.
236	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.
237	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.
238	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.
239	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.
240	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.
241	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.
242	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.
243	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.
244	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.
245	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.
246	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.
247	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.
248	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.
249	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.
250	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.
251	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.
252	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.
253	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.
254	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.
255	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.
256	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.
257	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
258	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.
259	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.
260	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.
261	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.
262	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.
263	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.
264	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
265	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
266	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.
267	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.
268	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.
269	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.
270	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.
271	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.
272	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.
273	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.
274	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
275	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
276	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.
277	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.
278	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.
279	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
280	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
281	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.
282	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
283	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.
284	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.
285	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.
286	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.
287	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.
288	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
289	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.
290	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.
291	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.
292	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
293	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
294	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
295	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
296	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
297	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
298	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
299	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
300	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.
301	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.
302	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
303	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
304	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
305	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
306	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.
307	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.
308	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.
309	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.
310	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
311	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
312	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
313	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
314	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.
315	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
316	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
317	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
318	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
319	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
320	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
321	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
322	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
323	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
324	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
325	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.
326	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.
327	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.
328	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.
329	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.
330	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.
331	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
332	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.
333	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
334	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.
335	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.
336	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
337	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
338	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
339	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.
340	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
341	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.
342	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.
343	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
344	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
345	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
346	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
347	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.
348	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
349	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.
350	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.
351	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.
352	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
353	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
354	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.
355	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.
356	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.
357	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.
358	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.
359	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.
360	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.
361	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.
362	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.
363	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.
364	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
365	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
366	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.
367	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
368	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.
369	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.
370	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.
371	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.
372	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.
373	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.
374	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.
375	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
376	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.
377	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
378	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
379	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
380	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
381	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.
382	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.
383	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.
384	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.
385	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.
386	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
387	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
388	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.
389	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.
390	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
391	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.
392	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.
393	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.
394	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.
395	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.
396	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.
397	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.
398	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.
399	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.
400	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.
401	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.
402	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.
403	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
404	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.
405	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.
406	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.
407	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.
408	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.
409	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.
410	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.
411	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.
412	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.
413	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.
414	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
415	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
416	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.
417	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
418	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.
419	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.
420	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.
421	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
422	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
423	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.
424	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.
425	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.
426	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
427	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
428	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
429	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
430	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
431	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.
432	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
433	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
434	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.
435	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.
436	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.
437	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.
438	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.
439	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.
440	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.
441	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.
442	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.
443	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
444	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.
445	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.
446	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.
447	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
448	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
449	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.
450	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.
451	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
452	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
453	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.
454	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.
455	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.
456	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.
457	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.
458	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.
459	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
460	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
461	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.
462	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.
463	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
464	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.
465	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.
466	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.
467	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.