"
Supplementary Exhibit 11. Individual Eligible Professional Performance on the 2014 PQRS Measures: First Name Last Name (NPI #)
Met the criteria to avoid the 2016 PQRS payment adjustment:  Yes 


"												
												
												
												
												
Performance Measure		Domain	Eligible Professional Performance			Benchmark Rate						
			Reporting Mechanism	Number of Eligible Cases	Performance Rate							
Measure Reference	Measure Name	Domain Name	[EHR/Claims/Registry/QCDR]	"#,###"	#.##%	#.##%						
1* (CMS122v2)	Diabetes Mellitus (DM): Hemoglobin A1c Poor Control 	Effective Clinical Care										
"2
(CMS163v2)"	Diabetes Mellitus (DM): Low Density Lipoprotein (LDL-C) Control 	Effective Clinical Care										
"5
(CMS135v2)"	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)	Effective Clinical Care										
6	Coronary Artery Disease (CAD): Antiplatelet Therapy	Effective Clinical Care										
"7
(CMS145v2)"	Coronary Artery Disease (CAD): Beta-Blocker TherapyPrior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVSD) (LVEF < 40%)	Effective Clinical Care										
"8
(CMS144v2)"	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)	Effective Clinical Care										
"9
(CMS128v2)"	Anti-Depressant Medication Management	Effective Clinical Care										
"12
(CMS143v2)"	Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation	Effective Clinical Care										
14	Age-Related Macular Degeneration (AMD): Dilated Macular Examination	Effective Clinical Care										
"18
(CMS167v2)"	Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy	Effective Clinical Care										
"19
(CMS142v2)"	Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care	Effective Clinical Care										
28	Aspirin at Arrival for Acute Myocardial Infarction (AMI)	Effective Clinical Care										
31	Stroke and Stroke Rehabilitation: Venous Thromboembolism (VTE) Prophylaxis for Ischemic Stroke or Intracranial Hemorrhage 	Effective Clinical Care										
32	Stroke and Stroke Rehabilitation: Discharged on Antithrombotic Therapy	Effective Clinical Care										
33	Stroke and Stroke Rehabilitation: Anticoagulant Therapy Prescribed for Atrial Fibrillation (AF) at Discharge	Effective Clinical Care										
35	Stroke and Stroke Rehabilitation: Screening for Dysphagia	Effective Clinical Care										
36	Stroke and Stroke Rehabilitation: Rehabilitation Services Ordered	Effective Clinical Care										
												
												
Performance Measure		Domain	Eligible Professional Performance			Benchmark Rate						
			Reporting Mechanism	Number of Eligible Cases	Performance Rate							
Measure Reference	Measure Name	Domain Name	[EHR/Claims/Registry/QCDR]	"#,###"	#.##%	#.##%						
39	Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older	Effective Clinical Care										
40	"Osteoporosis: Management Following Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older"	Effective Clinical Care										
41	Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years and Older	Effective Clinical Care										
43	Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery	Effective Clinical Care										
44	Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery	Effective Clinical Care										
48	Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older	Effective Clinical Care										
49	Urinary Incontinence: Characterization of Urinary Incontinence in Women Aged 65 Years and Older	Effective Clinical Care										
51	Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation	Effective Clinical Care										
52	Chronic Obstructive Pulmonary Disease (COPD): Bronchodilator Therapy	Effective Clinical Care										
53	Asthma: Pharmacologic Therapy for Persistent AsthmaAmbulatory Care Setting	Effective Clinical Care										
54	Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for Non-Traumatic Chest Pain	Effective Clinical Care										
55	Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for Syncope	Effective Clinical Care										
56	Emergency Medicine: Community-Acquired Pneumonia (CAP): Vital Signs	Effective Clinical Care										
59	Emergency Medicine: Community-Acquired Pneumonia (CAP): Empiric Antibiotic	Effective Clinical Care										
64	Asthma: Assessment of Asthma ControlAmbulatory Care Setting	Effective Clinical Care										
67	Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow	Effective Clinical Care										
68	Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy	Effective Clinical Care										
69	Hematology: Multiple Myeloma: Treatment with Bisphosphonates	Effective Clinical Care										
70	Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry	Effective Clinical Care										
"71
(CMS140v1)"	Breast Cancer: Hormonal Therapy for Stage ICIIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer	Effective Clinical Care										
												
Performance Measure		Domain	Eligible Professional Performance			Benchmark Rate						
			Reporting Mechanism	Number of Eligible Cases	Performance Rate							
Measure Reference	Measure Name	Domain Name	[EHR/Claims/Registry/QCDR]	"#,###"	#.##%	#.##%						
"72
(CMS141v3)"	Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients	Effective Clinical Care										
83	Hepatitis C: Confirmation of Hepatitis C Viremia	Effective Clinical Care										
84	Hepatitis C: Ribonucleic Acid (RNA) Testing Before Initiating Treatment	Effective Clinical Care										
85	Hepatitis C: Hepatitis C Virus (HCV) Genotype Testing Prior to Treatment	Effective Clinical Care										
87	Hepatitis C: Hepatitis C Virus (HCV) Ribonucleic Acid (RNA) Testing Between 4-12 Weeks After Initiation of Treatment	Effective Clinical Care										
91	Acute Otitis Externa (AOE): Topical Therapy	Effective Clinical Care										
99	Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade	Effective Clinical Care										
100	Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade	Effective Clinical Care										
104	Prostate Cancer: Adjuvant Hormonal Therapy for High Risk Prostate Cancer Patients	Effective Clinical Care										
106	Adult Major Depressive Disorder (MDD): Comprehensive Depression Evaluation: Diagnosis and Severity	Effective Clinical Care										
"107
(CMS161v2)"	Adult Major Depressive Disorder (MDD): Suicide Risk Assessment	Effective Clinical Care										
108	Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug (DMARD) Therapy	Effective Clinical Care										
"111
(CMS127v2)"	Preventive Care and Screening: Pneumococcal Vaccination for Older Adults	Effective Clinical Care										
"113
(CMS130v2)"	Preventive Care and Screening: Colorectal Cancer Screening	Effective Clinical Care										
"117
(CMS131v2)"	Diabetes Mellitus (DM): Dilated Eye Exam	Effective Clinical Care										
"118
"	Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) TherapyDiabetes or Left Ventricular Systolic Dysfunction (LVSD) (LVEF < 40%) 	Effective Clinical Care										
"119
(CMS134v2)"	Diabetes Mellitus (DM): Medical Attention for Nephropathy	Effective Clinical Care										
121	Adult Kidney Disease: Laboratory Testing (Lipid Profile)	Effective Clinical Care										
122	Adult Kidney Disease: Blood Pressure Management	Effective Clinical Care										
123*	Adult Kidney Disease: Patients On Erythropoiesis-Stimulating Agent (ESA)Hemoglobin Level > 12.0 g/dL	Effective Clinical Care										
												
												
												
												
												
Performance Measure		Domain	Eligible Professional Performance			Benchmark Rate						
			Reporting Mechanism	Number of Eligible Cases	Performance Rate							
Measure Reference	Measure Name	Domain Name	[EHR/Claims/Registry/QCDR]	"#,###"	#.##%	#.##%						
126	"Diabetes Mellitus (DM): Diabetic Foot and Ankle Care, Peripheral NeuropathyNeurological Evaluation"	Effective Clinical Care										
127	"Diabetes Mellitus (DM): Diabetic Foot and Ankle Care, Ulcer PreventionEvaluation of Footwear"	Effective Clinical Care										
137	Melanoma: Continuity of CareRecall System	Effective Clinical Care										
140	Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement	Effective Clinical Care										
142	Osteoarthritis (OA): Assessment for Use of Anti-Inflammatory or Analgesic Over-the-Counter (OTC) Medications	Effective Clinical Care										
149	Back Pain: Physical Exam	Effective Clinical Care										
150	Back Pain: Advice for Normal Activities	Effective Clinical Care										
151	Back Pain: Advice Against Bed Rest	Effective Clinical Care										
159	HIV/AIDS: CD4+ Cell Count or CD4+ Percentage	Effective Clinical Care										
"160
(CMS52v2)"	HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis	Effective Clinical Care										
"163
(CMS123v2)"	Diabetes Mellitus (DM): Foot Exam	Effective Clinical Care										
164*	Coronary Artery Bypass Graft (CABG): Prolonged Intubation	Effective Clinical Care										
165*	Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate	Effective Clinical Care										
166*	Coronary Artery Bypass Graft (CABG): Stroke	Effective Clinical Care										
167*	Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure	Effective Clinical Care										
168*	Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration	Effective Clinical Care										
169	Coronary Artery Bypass Graft (CABG): Antiplatelet Medications at Discharge	Effective Clinical Care										
170	Coronary Artery Bypass Graft (CABG): Beta-Blockers Administered at Discharge	Effective Clinical Care										
171	Coronary Artery Bypass Graft (CABG): Anti-Lipid Treatment at Discharge	Effective Clinical Care										
172	Hemodialysis Vascular Access Decision-Making by Surgeon to Maximize Placement of Autogenous Arterial Venous (AV) Fistula	Effective Clinical Care										
176	Rheumatoid Arthritis (RA): Tuberculosis Screening	Effective Clinical Care										
177	Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity	Effective Clinical Care										
178	Rheumatoid Arthritis (RA): Functional Status Assessment	Effective Clinical Care										
179	Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis	Effective Clinical Care										
187	Stroke and Stroke Rehabilitation: Thrombolytic Therapy	Effective Clinical Care										
"191
(CMS133v2)"	Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery	Effective Clinical Care										
												
												
Performance Measure		Domain	Eligible Professional Performance			Benchmark Rate						
			Reporting Mechanism	Number of Eligible Cases	Performance Rate							
Measure Reference	Measure Name	Domain Name	[EHR/Claims/Registry/QCDR]	"#,###"	#.##%	#.##%						
194	Oncology: Cancer Stage Documented	Effective Clinical Care										
195	Radiology: Stenosis Measurement in Carotid Imaging Reports	Effective Clinical Care										
"197
"	Coronary Artery Disease (CAD): Lipid Control	Effective Clinical Care										
198	Heart Failure (HF): Left Ventricular Ejection Fraction (LVEF) Assessment	Effective Clinical Care										
"204
(CMS164v2)"	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic	Effective Clinical Care										
205	"HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis"	Effective Clinical Care										
228	Heart Failure (HF): Left Ventricular Function (LVF) Testing	Effective Clinical Care										
231	Asthma: Tobacco Use: ScreeningAmbulatory Care Setting	Effective Clinical Care										
232	Asthma: Tobacco Use: InterventionAmbulatory Care Setting	Effective Clinical Care										
233	Thoracic Surgery: Recording of Performance Status Prior to Lung or Esophageal Cancer Resection	Effective Clinical Care										
"236
(CMS165v2)"	Hypertension (HTN): Controlling High Blood Pressure	Effective Clinical Care										
"241
(CMS182v3)"	Ischemic Vascular Disease (IVD): Complete Lipid Profile and LDL-C Control (<100 mg/dL) 	Effective Clinical Care										
242	Coronary Artery Disease (CAD): Symptom Management	Effective Clinical Care										
243	Cardiac Rehabilitation Patient Referral from an Outpatient Setting	Effective Clinical Care										
245	Chronic Wound Care: Use of Wound Surface Culture Technique in Patients with Chronic Skin Ulcers (Overuse Measure)	Effective Clinical Care										
246	Chronic Wound Care: Use of Wet to Dry Dressings in Patients with Chronic Skin Ulcers (Overuse Measure)	Effective Clinical Care										
247	Substance Use Disorders: Counseling Regarding Psychosocial and Pharmacologic Treatment Options for Alcohol Dependence	Effective Clinical Care										
248	Substance Use Disorders: Screening for Depression Among Patients with Substance Abuse or Dependence	Effective Clinical Care										
249	Barretts Esophagus	Effective Clinical Care										
250	Radical Prostatectomy Pathology Reporting	Effective Clinical Care										
251	Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) for Breast Cancer Patients	Effective Clinical Care										
254	Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain	Effective Clinical Care										
255	Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure	Effective Clinical Care										
												
												
												
Performance Measure		Domain	Eligible Professional Performance			Benchmark Rate						
			Reporting Mechanism	Number of Eligible Cases	Performance Rate							
Measure Reference	Measure Name	Domain Name	[EHR/Claims/Registry/QCDR]	"#,###"	#.##%	#.##%						
257	Statin Therapy at Discharge after Lower Extremity Bypass (LEB)	Effective Clinical Care										
263	Preoperative Diagnosis of Breast Cancer	Effective Clinical Care										
264	Sentinel Lymph Node Biopsy for Invasive Breast Cancer	Effective Clinical Care										
266	Epilepsy: Seizure Type(s) and Current Seizure Frequency(ies)	Effective Clinical Care										
267	Epilepsy: Documentation of Etiology of Epilepsy or Epilepsy Syndrome	Effective Clinical Care										
268	Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy	Effective Clinical Care										
269	"Inflammatory Bowel Disease (IBD): Type, Anatomic Location and Activity All Documented"	Effective Clinical Care										
270	Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Sparing Therapy	Effective Clinical Care										
271	Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic InjuryBone Loss Assessment	Effective Clinical Care										
272	Inflammatory Bowel Disease (IBD): Preventive Care: Influenza Immunization	Effective Clinical Care										
273	Inflammatory Bowel Disease (IBD): Preventive Care: Pneumococcal Immunization	Effective Clinical Care										
274	Inflammatory Bowel Disease (IBD): Testing for Latent Tuberculosis (TB) Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy	Effective Clinical Care										
275	Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy	Effective Clinical Care										
276	Sleep Apnea: Assessment of Sleep Symptoms	Effective Clinical Care										
277	Sleep Apnea: Severity Assessment at Initial Diagnosis	Effective Clinical Care										
278	Sleep Apnea: Positive Airway Pressure Therapy Prescribed	Effective Clinical Care										
279	Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy	Effective Clinical Care										
"281
(CMS149v2)"	Dementia: Cognitive Assessment	Effective Clinical Care										
282	Dementia: Functional Status Assessment	Effective Clinical Care										
283	Dementia: Neuropsychiatric Symptom Assessment	Effective Clinical Care										
284	Dementia: Management of Neuropsychiatric Symptoms	Effective Clinical Care										
285	Dementia: Screening for Depressive Symptoms	Effective Clinical Care										
287	Dementia: Counseling Regarding Risks of Driving	Effective Clinical Care										
288	Dementia: Caregiver Education and Support	Effective Clinical Care										
												
												
Performance Measure		Domain	Eligible Professional Performance			Benchmark Rate						
			Reporting Mechanism	Number of Eligible Cases	Performance Rate							
Measure Reference	Measure Name	Domain Name	[EHR/Claims/Registry/QCDR]	"#,###"	#.##%	#.##%						
289	Parkinsons Disease: Annual Parkinsons Disease Diagnosis Review	Effective Clinical Care										
290	Parkinsons Disease: Psychiatric Disorders or Disturbances Assessment	Effective Clinical Care										
291	Parkinsons Disease: Cognitive Impairment or Dysfunction Assessment	Effective Clinical Care										
292	Parkinsons Disease: Querying about Sleep Disturbances	Effective Clinical Care										
293	Parkinsons Disease: Rehabilitative Therapy Options	Effective Clinical Care										
294	Parkinsons Disease: Parkinsons Disease Medical and Surgical Treatment Options Reviewed	Effective Clinical Care										
295	Hypertension (HTN): Appropriate Use of Aspirin or Other Antithrombotic Therapy	Effective Clinical Care										
296	Hypertension (HTN): Complete Lipid Profile	Effective Clinical Care										
297	Hypertension (HTN): Urine Protein Test	Effective Clinical Care										
298	Hypertension (HTN): Annual Serum Creatinine Test	Effective Clinical Care										
299	Hypertension (HTN): Diabetes Mellitus Screening Test	Effective Clinical Care										
300	Hypertension (HTN): Blood Pressure Control	Effective Clinical Care										
301	Hypertension (HTN): Low Density Lipoprotein (LDL-C) Control	Effective Clinical Care										
302	Hypertension (HTN): Dietary and Physical Activity Modifications Appropriately Prescribed	Effective Clinical Care										
303	Cataracts: Improvement in Patients Visual Function within 90 Days Following Cataract Surgery	Effective Clinical Care										
"305
(CMS137v2)"	"Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: (a) Initiation, (b) Engagement"	Effective Clinical Care										
"309
(CMS124v2)"	Cervical Cancer Screening	Effective Clinical Care										
"311
(CMS126v2)"	Use of Appropriate Medications for Asthma	Effective Clinical Care										
"316
(CMS61v3 and CMS64v3)"	Preventive Care and Screening: CholesterolFasting Low Density Lipoprotein (LDL) Test Performed AND Risk-Stratified Fasting LDL	Effective Clinical Care										
325	Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions	Effective Clinical Care										
327	Pediatric Kidney Disease: Adequacy of Volume Management	Effective Clinical Care										
328*	Pediatric Kidney Disease: End Stage Renal Disease (ESRD) Patients Receiving Dialysis: Hemoglobin Level < 10 g/dL	Effective Clinical Care										
329*	Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis	Effective Clinical Care										
330*	Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days	Effective Clinical Care										
331*	"Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis
(Appropriate Use)"	Effective Clinical Care										
												
Performance Measure		Domain	Eligible Professional Performance			Benchmark Rate						
			Reporting Mechanism	Number of Eligible Cases	Performance Rate							
Measure Reference	Measure Name	Domain Name	[EHR/Claims/Registry/QCDR]	"#,###"	#.##%	#.##%						
332	Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin Prescribed for Patients with Acute Bacterial Sinusitis	Effective Clinical Care										
337	Tuberculosis Prevention for Psoriasis and Psoriatic Arthritis Patients on a Biological Immune Response Modifier	Effective Clinical Care										
338	HIV Viral Load Suppression	Effective Clinical Care										
339	Prescription of HIV Antiretroviral Therapy	Effective Clinical Care										
343	Screening Colonoscopy Adenoma Detection Rate	Effective Clinical Care										
344	"Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)"	Effective Clinical Care										
345*	Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS)	Effective Clinical Care										
346*	Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Endarterectomy (CEA)	Effective Clinical Care										
347*	Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) Who Die While in Hospital	Effective Clinical Care										
348*	HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate	Effective Clinical Care										
349	Optimal Vascular Care Composite	Effective Clinical Care										
354*	Anastomotic Leak Intervention	Effective Clinical Care										
355*	Unplanned Reoperation within the 30 Day Postoperative Period	Effective Clinical Care										
356*	Unplanned Hospital Readmission within 30 Days of Principal Procedure	Effective Clinical Care										
357*	Surgical Site Infection (SSI)	Effective Clinical Care										
"365
(CMS148v2)"	Hemoglobin A1c Test for Pediatric Patients	Effective Clinical Care										
"366
(CMS136v3)"	ADHD: Follow-Up Care for Children Prescribed Attention- Deficit/Hyperactivity Disorder (ADHD) Medication	Effective Clinical Care										
"367
(CMS169v2)"	"Bipolar Disorder and Major Depression: Appraisal for Alcohol or
Chemical Substance Use"	Effective Clinical Care										
"368
(CMS62v2)"	HIV/AIDS: Medical Visit	Effective Clinical Care										
"369
(CMS158v2)"	Pregnant Women that Had HBsAg Testing	Effective Clinical Care										
"370
(CMS159v2)"	Depression Remission at Twelve Months	Effective Clinical Care										
"371
(CMS160v2)"	Depression Utilization of the PHQ-9 Tool	Effective Clinical Care										
"373
(CMS65v3)"	Hypertension: Improvement in Blood Pressure	Effective Clinical Care										
"378*
(CMS75v2)"	Children Who Have Dental Decay or Cavities	Effective Clinical Care										
"379
(CMS74v3)"	"Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists"	Effective Clinical Care										
"381
(CMS77v2)"	HIV/AIDS: RNA Control for Patients with HIV	Effective Clinical Care										
												
Performance Measure		Domain	Eligible Professional Performance			Benchmark Rate						
			Reporting Mechanism	Number of Eligible Cases	Performance Rate							
Measure Reference	Measure Name	Domain Name	[EHR/Claims/Registry/QCDR]	"#,###"	#.##%	#.##%						
AAAAI 1	Asthma: Pharmacologic Therapy for Persistent Asthma	Effective Clinical Care										
AAAAI 2	Asthma: Assessment of Asthma Control	Effective Clinical Care										
AAAAI 8	Achievement of Projected Effective Dose of Standardized Allergens for Patient Treated With Allergy Immunotherapy for at Least One Year	Effective Clinical Care										
AAAAI 11	Asthma Assessment and Classification	Effective Clinical Care										
AAAAI 12	Lung Function/Spirometry Evaluation	Effective Clinical Care										
ACR 1	Disease Activity Measurement for Patients with Rheumatoid Arthritis (RA)	Effective Clinical Care										
ACR 2	Functional Status Assessment for Patients with Rheumatoid Arthritis (RA)	Effective Clinical Care										
ACR 3	Disease-Modifying Anti-Rheumatic Drug (DMARD) Therapy for Active Rheumatoid Arthritis (RA)	Effective Clinical Care										
ACR 5	Glucocorticosteroids and Other Secondary Causes	Effective Clinical Care										
ACCFocus 9	Ratio:Initial Evaluations to Post Procedure/Follow-Up Evaluations with Cardiac Stress Imaging	Effective Clinical Care										
ACCFocus 10	Ratio: Initial Evaluations with Cardiac Stress Imaging for Symptomatic Patients to Initial Evaluations for Asymptomatic Patients	Effective Clinical Care										
ACCPin 1	Hypertension: Blood Pressure Management	Effective Clinical Care										
ACRad 1	CT Colonongraphy True Positive Rate 	Effective Clinical Care										
ACRad 3	Screening Mammography Cancer Detection Rate (CDR)	Effective Clinical Care										
ACRad 4	Screening Mammography Invasive Cancer Detection Rate (ICDR)	Effective Clinical Care										
ACRad 6	Screening Mammography Positive Predictive Value 2 (PPV2Biopsy Recommended)	Effective Clinical Care										
ACRad 7	Screening Mammography Node Negativity Rate	Effective Clinical Care										
ACRad 8	Screening Mammography Minimal Cancer Rate	Effective Clinical Care										
AGACCSSR 2	Colonoscopy Assessment (Cecum Reached)  Cecal Intubation / Depth of Intubation	Effective Clinical Care										
AGADHRPR 2	Colonoscopy Assessment (Cecum Reached)  Cecal Intubation / Depth of Intubation	Effective Clinical Care										
ASBS 1	Surgeon Assessment for Hereditary Cause of Breast Cancer	Effective Clinical Care										
AQI 5*	Composite Anesthesia Safety	Effective Clinical Care										
CDR 1	Process Measure: Adequate Off-Loading of Diabetic Foot Ulcers at Each Visit 	Effective Clinical Care										
CDR 4	Diabetic Foot & Ankle Care: Comprehensive Diabetic Foot Examination	Effective Clinical Care										
CDR 5	Process Measure: Adequate Compression at Each Visit for Patients with Venous Leg Ulcers (VLU) 	Effective Clinical Care										
CDR 8	Appropriate Use of Hyperbaric Oxygen Therapy for Patients with Diabetic Foot Ulcers 	Effective Clinical Care										
Performance Measure		Domain	Eligible Professional Performance			Benchmark Rate						
			Reporting Mechanism	Number of Eligible Cases	Performance Rate							
Measure Reference	Measure Name	Domain Name	[EHR/Claims/Registry/QCDR]	"#,###"	#.##%	#.##%						
CDR 9	Appropriate use of Cellular or Tissue Based Products (CTP)  for Patients Aged 18 Years or Older with a Diabetic Foot Ulcer (DFU) or Venous Leg Ulcer (VLU)	Effective Clinical Care										
CDR 10	Process Measure: Vascular Assessment of Patients with Chronic Leg Ulcers	Effective Clinical Care										
CDR 11	Process Measure: Wound Bed Preparation through Debridement of Necrotic or Non-Viable Tissue 	Effective Clinical Care										
GIQIC 1	Adenoma Detection Rate	Effective Clinical Care										
GIQIC 2	Adequacy of Bowel Preparation	Effective Clinical Care										
GIQIC 3	Photo Documentation of the Cecum (also known as Cecal Intubation Rate)All Colonoscopies	Effective Clinical Care										
GIQIC 4	Photo Documentation of the Cecum (also known as Cecal Intubation Rate)Screening Colonoscopies	Effective Clinical Care										
GIQIC 9	Documentation of History and Physical RateColonoscopy	Effective Clinical Care										
ICLOPS 12*	Cholecystectomy Outcomes after 90 Days	Effective Clinical Care										
ICLOPS 13*	Unexpected Outcomes for Breast Cancer Surgery	Effective Clinical Care										
ICLOPS 14*	Post-Operative Sepsis Rate	Effective Clinical Care										
MBSAQIP 1*	"Risk Standardized Rate of Patients Who Experienced a Post-Operative Complication within 30 Days Following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy Operation, Performed as a Primary (Not Revisional) Procedure "	Effective Clinical Care										
MBSAQIP 4*	"Risk Standardized Rate of Patients Who Experienced an Anastomotic/Staple Line Leak within 30 Days Following a  Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy Operation, Performed as a Primary (Not Revisional) Procedure"	Effective Clinical Care										
MBSAQIP 5*	"Risk Standardized Rate of Patients Who Experienced a Bleeding/Hemorrhage Event Requiring Transfusion, Intervention/Operation, or Readmission within 30 Days Following a  Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy Operation, Performed as a Primary (Not Revisional) Procedure"	Effective Clinical Care										
MBSAQIP 6*	"Risk Standardized Rate of Patients Who Experienced a Post-Operative Surgical Site Infection (SSI) (Superficial Incisional, Deep Incisional, or Organ/Space SSI) within 30 Days Following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy Operation, Performed as a Primary (Not Revisional) Procedure  "	Effective Clinical Care										
												
												
Performance Measure		Domain	Eligible Professional Performance			Benchmark Rate						
			Reporting Mechanism	Number of Eligible Cases	Performance Rate							
Measure Reference	Measure Name	Domain Name	[EHR/Claims/Registry/QCDR]	"#,###"	#.##%	#.##%						
MBSAQIP 7*	"Risk Standardized Rate of Patients Who Experienced Post-Operative Nausea, Vomiting or Fluid/Electrolyte/Nutritional Depletion within 30 Days Following a  Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy Operation, Performed as a Primary (Not Revisional) Procedure"	Effective Clinical Care										
MBS 4	MBSC Venous Thromboembolism Prophylaxis Adherence Rates for Perioperative Care	Effective Clinical Care										
MBS 5	MBSC Venous Thromboembolism Prophylaxis Adherence Rates for Postoperative Care	Effective Clinical Care										
MBS 6	MBSC Venous Thromboembolism Prophylaxis Adherence Rates for Post-Discharge Care	Effective Clinical Care										
MUSIC 2	Unplanned Hospital Admission within 30 Days of TRUS Biopsy	Effective Clinical Care										
MUSIC 4*	Prostate Cancer: Proportion of Patients with Low-Risk Prostate Cancer Receiving Active Surveillance	Effective Clinical Care										
MUSIC 5	Prostate Cancer: Percentage of Prostate Cancer Cases with a Length of Stay > 2 Days	Effective Clinical Care										
MUSIC 6	Unplanned Hospital Readmission within 30 Days of Radical Prostatectomy	Effective Clinical Care										
NOF 1	Laboratory Investigation for Secondary Causes of Fracture	Effective Clinical Care										
NOF 4	Osteoporosis Management in Women Who Had a Fracture	Effective Clinical Care										
NOF 5	Osteoporosis Testing in Older Women	Effective Clinical Care										
NOF 6*	Hip Fracture Mortality Rate (IQI 19)	Effective Clinical Care										
NOF 7	"Osteoporosis: Percentage of Patients, Regardless of Age, with a Diagnosis of Osteoporosis Who Are Either Receiving Both Calcium and Vitamin D or Had Documented Counseling Regarding Both Calcium and Vitamin D Intake, and Exercise at Least Once within 12 Months"	Effective Clinical Care										
NOF 8	Osteoporosis: Percentage of Patients Aged 50 Years and Older with a Diagnosis of Osteoporosis Who Were Prescribed Pharmacologic Therapy within 12 Months	Effective Clinical Care										
ONSQIR 1	Symptom Assessment	Effective Clinical Care										
ONSQIR 2	Intervention for Psychosocial Distress	Effective Clinical Care										
ONSQIR 3	Intervention for Fatigue	Effective Clinical Care										
ONSQIR 4	Intervention for Sleep-Wake Disturbance	Effective Clinical Care										
ONSQIR 5	Assessment for Chemotherapy Induced Nausea and Vomiting	Effective Clinical Care										
ONSQIR 6	Education on Neutropenia Precautions	Effective Clinical Care										
ONSQIR 7	Post-Treatment Symptom Assessment	Effective Clinical Care										
ONSQIR 8	Post-Treatment Symptom Intervention	Effective Clinical Care										
ONSQIR 9	Post-Treatment Education	Effective Clinical Care										
OQIC 10	PET Utilization in Breast Cancer Surveillance	Effective Clinical Care										
OQIC 11	CEA and Breast Cancer	Effective Clinical Care										
												
Performance Measure		Domain	Eligible Professional Performance			Benchmark Rate						
			Reporting Mechanism	Number of Eligible Cases	Performance Rate							
Measure Reference	Measure Name	Domain Name	[EHR/Claims/Registry/QCDR]	"#,###"	#.##%	#.##%						
OQIC 12	GCSF: Utilization of GCSF in Metastatic Colon Cancer	Effective Clinical Care										
OQIC 13	Appropriate Antiemetic Usage	Effective Clinical Care										
OQIC 14	Appropriate Trastuzumab Use in Women with HER2/neu Gene Overexpression	Effective Clinical Care										
OQIC 15	Metastatic Colon Cancer	Effective Clinical Care										
OQIC 16	Appropriate Use of Late Line Chemotherapy in Metastatic Lung Cancer	Effective Clinical Care										
OQIC 17	Intensity-Modulated Radiation Therapy (IMRT)	Effective Clinical Care										
PInc 11	Aspirin at Arrival	Effective Clinical Care										
PInc 12	Evaluation of LVS Function	Effective Clinical Care										
QOPI 1*	Staging Documented within One Month of First Office Visit	Effective Clinical Care										
QOPI 7	Antiemetic Therapy Prescribed for Highly Emetogenic Chemotherapy 	Effective Clinical Care										
QOPI 8	Antiemetic Therapy Prescribed for Moderately Emetogenic Chemotherapy	Effective Clinical Care										
QOPI 11	Combination Chemotherapy Received within 4 Months of Diagnosis by Women under 70 with AJCC Stage I (T1c) to III ER/PR Negative Breast Cancer 	Effective Clinical Care										
QOPI 12	Test for HER2/NEU Overexpression or Gene Amplification	Effective Clinical Care										
QOPI 13	Trastuzumab Received by Patients with AJCC Stage I (T1c) to III HER2/NEU Positive Breast Cancer 	Effective Clinical Care										
QOPI 14	Tamoxifen or AI Received within 1 Year of Diagnosis by Patients with AJCC Stage I (T1c) to III ER/PR Positive Breast Cancer	Effective Clinical Care										
QOPI 16	Adjuvant Chemotherapy Received within 4 Months of Diagnosis by Patients with AJCC Stage III Colon Cancer	Effective Clinical Care										
QOPI 17	Location of Death Documented (*Paired Measure)	Effective Clinical Care										
RPAQIR 1	Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy	Effective Clinical Care										
RPAQIR 2	Adequacy of Volume Management	Effective Clinical Care										
RPAQIR 3*	ESRD Patients Receiving Dialysis: Hemoglobin Level < 10g/dL	Effective Clinical Care										
RPAQIR 4	Arteriovenous Fistula Rate	Effective Clinical Care										
VAN 4	Preventive Care and Screening: CholesterolFasting Low Density Lipoprotein (LDL-C) Test Performed	Effective Clinical Care										
VAN 5	Cervical Cancer Screening	Effective Clinical Care										
VAN 6	Hemoglobin A1c Test for Pediatric Patients	Effective Clinical Care										
WCHQ 1	Diabetes Care: A1C Blood Sugar Testing (Chronic Care)	Effective Clinical Care										
WCHQ 2*	Diabetes Care: A1C Blood Sugar Control (Chronic Care)	Effective Clinical Care										
WCHQ 3	Diabetes Care: LDL Cholesterol Testing (Chronic Care)	Effective Clinical Care										
WCHQ 4	Diabetes Care: LDL Cholesterol Control (Chronic Care)	Effective Clinical Care										
												
Performance Measure		Domain	Eligible Professional Performance			Benchmark Rate						
			Reporting Mechanism	Number of Eligible Cases	Performance Rate							
Measure Reference	Measure Name	Domain Name	[EHR/Claims/Registry/QCDR]	"#,###"	#.##%	#.##%						
WCHQ 5	Diabetes Care: Kidney Function Monitored (Chronic Care)	Effective Clinical Care										
WCHQ 6*	Diabetes Care: Blood Pressure Control (Chronic Care)	Effective Clinical Care										
WCHQ 8	Diabetes Care: Daily Aspirin or Other Antiplatelet (Chronic Care)	Effective Clinical Care										
WCHQ 9	Diabetes Care: All or None Process MeasureOptimal Testing (Chronic Care)	Effective Clinical Care										
WCHQ 10	Diabetes Care - All or None Process Measure: Optimal Outcomes (Chronic Care)	Effective Clinical Care										
WCHQ 11*	Controlling High Blood Pressure: Blood Pressure Control (Chronic Care)	Effective Clinical Care										
WCHQ 12	Ischemic Vascular Disease Care: Daily Aspirin or Other Antiplatelet Medication Usage (Chronic Care)	Effective Clinical Care										
WCHQ 13*	Ischemic Vascular Disease Care: Blood Pressure Control (Chronic Care)	Effective Clinical Care										
WCHQ 14	Preventive Care: Adults with Pneumococcal Vaccinations (Preventive Care)	Effective Clinical Care										
WCHQ 15	Preventive Care: Screening for Osteoporosis (Preventative Care)	Effective Clinical Care										
WCHQ 18	Preventive Care: Breast Cancer Screening 	Effective Clinical Care										
WCHQ 19	Preventive Care: Cervical Cancer Screening 	Effective Clinical Care										
WCHQ 20	Preventive Care: Colorectal Cancer Screening	Effective Clinical Care										
WCQIC 1	Chronic Wound Care: Assessment of Wound Characteristics in Patients Undergoing Debridement	Effective Clinical Care										
WCQIC 3	Chronic Wound Care: Offloading (Pressure Relief) of Diabetic Foot Ulcers	Effective Clinical Care										
WCQIC 5	Chronic Wound Care: Use of Compression System in Patients with Venous Ulcers	Effective Clinical Care										
WCQIC 7	Peripheral Artery Disease (PAD) Screening	Effective Clinical Care										
50	Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older	Person and Caregiver-Centered Experience and Outcomes 										
109	Osteoarthritis (OA): Function and Pain Assessment	Person and Caregiver-Centered Experience and Outcomes 										
"143
(CMS157v2)"	Oncology: Medical and RadiationPain Intensity Quantified	Person and Caregiver-Centered Experience and Outcomes 										
144	Oncology: Medical and RadiationPlan of Care for Pain	Person and Caregiver-Centered Experience and Outcomes 										
304	Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery	Person and Caregiver-Centered Experience and Outcomes 										
342	Pain Brought Under Control within 48 Hours	Person and Caregiver-Centered Experience and Outcomes 										
358	Patient-Centered Surgical Risk Assessment and Communication	Person and Caregiver-Centered Experience and Outcomes 										
"375
(CMS66v2)"	Functional Status Assessment for Knee Replacement	Person and Caregiver-Centered Experience and Outcomes 										
												
												
Performance Measure		Domain	Eligible Professional Performance			Benchmark Rate						
			Reporting Mechanism	Number of Eligible Cases	Performance Rate							
Measure Reference	Measure Name	Domain Name	[EHR/Claims/Registry/QCDR]	"#,###"	#.##%	#.##%						
"376
(CMS56v2)"	Functional Status Assessment for Hip Replacement	Person and Caregiver-Centered Experience and Outcomes 										
"377
(CMS90v3)"	Functional Status Assessment for Complex Chronic Conditions	Person and Caregiver-Centered Experience and Outcomes 										
AAAAI 10	Documentation of the Consent Process for Subcutaneous Allergy Immunotherapy in the Medical Record	Person and Caregiver-Centered Experience and Outcomes 										
AAAAI 14	Patient Self-Management Plan	Person and Caregiver-Centered Experience and Outcomes 										
AAAAI 16*	Optimal Asthma Care: Control Component	Person and Caregiver-Centered Experience and Outcomes 										
AGADHRPR 8	Sustained Virological Response (SVR) (Quality Improvement Only)	Person and Caregiver-Centered Experience and Outcomes 										
AQI 2*	Prevention of Post-Operative Nausea and Vomiting (PONV)Combination Therapy (Adults)	Person and Caregiver-Centered Experience and Outcomes 										
AQI 3*	Prevention of Post-Operative Vomiting (POV)Combination Therapy (Pediatrics)	Person and Caregiver-Centered Experience and Outcomes 										
AQI 9	Short-Term Pain Management	Person and Caregiver-Centered Experience and Outcomes 										
AQI 11	Composite Patient Experience Measure	Person and Caregiver-Centered Experience and Outcomes 										
ASBS 2*	Surgical Site Infection and Cellulitis After Breast and/or Axillary Surgery	Person and Caregiver-Centered Experience and Outcomes 										
CDR 2*	Outcome Measure: Diabetic Foot Ulcer (DFU) Healing or Closure 	Person and Caregiver-Centered Experience and Outcomes 										
CDR 6*	Venous Leg Ulcer Outcome Measure: Healing or Closure 	Person and Caregiver-Centered Experience and Outcomes 										
CDR 12	Patient Reported Experience of Care: Wound Related Quality of Life	Person and Caregiver-Centered Experience and Outcomes 										
CUHSM 3	"CAHPS Clinician/Group Surveys(Adult Primary Care, Pediatric Care, and Specialist Care Surveys)"	Person and Caregiver-Centered Experience and Outcomes 										
CUHSM 4	CAHPS Health Plan Survey v4.0Adult Questionnaire	Person and Caregiver-Centered Experience and Outcomes 										
ICLOPS 4	Patients Admitted to ICU Who Have Care Preferences Documented	Person and Caregiver-Centered Experience and Outcomes 										
ICLOPS 10	Hospice and Palliative CareTreatment Preferences	Person and Caregiver-Centered Experience and Outcomes 										
ICLOPS 11	Percentage of Hospice Patients with Documentation in the Clinical Record of a Discussion of Spiritual/Religious Concerns or Documentation that the Patient/Caregiver Did Not Want to Discuss	Person and Caregiver-Centered Experience and Outcomes 										
ICLOPS 18 	CG-CAHPS Clinician/Group Survey	Person and Caregiver-Centered Experience and Outcomes 										
OBERD 3	Back Pain: Shared Decision Making	Person and Caregiver-Centered Experience and Outcomes 										
OBERD 8	Orthopedic Pain: Shared Decision Making	Person and Caregiver-Centered Experience and Outcomes 										
OBERD 12 	CG-CAHPS Adult Visit Composite Tracking	Person and Caregiver-Centered Experience and Outcomes 										
OQIC 1*	Hospital Emergency Room Chemotherapy Related Visits	Person and Caregiver-Centered Experience and Outcomes 										
OQIC 2*	Hospital Admissions Related to Complications of Chemotherapy	Person and Caregiver-Centered Experience and Outcomes 										
												
												
Performance Measure		Domain	Eligible Professional Performance			Benchmark Rate						
			Reporting Mechanism	Number of Eligible Cases	Performance Rate							
Measure Reference	Measure Name	Domain Name	[EHR/Claims/Registry/QCDR]	"#,###"	#.##%	#.##%						
OQIC 4	Advance Care Planning in Stage 4 Disease	Person and Caregiver-Centered Experience and Outcomes 										
OQIC 5	Chemotherapy in the Last Two Weeks of Life	Person and Caregiver-Centered Experience and Outcomes 										
OQIC 6	In Hospital Deaths	Person and Caregiver-Centered Experience and Outcomes 										
OQIC 7	In ICU Deaths	Person and Caregiver-Centered Experience and Outcomes 										
OQIC 9	Hospice Admission Rate for Patients Dying with a Cancer Diagnosis	Person and Caregiver-Centered Experience and Outcomes 										
ONSQIR 10	Post-Treatment Goal Setting	Person and Caregiver-Centered Experience and Outcomes 										
ONSQIR 11	Post-Treatment Goal Attainment	Person and Caregiver-Centered Experience and Outcomes 										
ONSQIR 13*	Fatigue Improvement	Person and Caregiver-Centered Experience and Outcomes 										
ONSQIR 14	Psychosocial Distress Improvement	Person and Caregiver-Centered Experience and Outcomes 										
QOPI 2	Pain Intensity Quantified by Second Office Visit	Person and Caregiver-Centered Experience and Outcomes 										
QOPI 3	Chemotherapy Intent Documented	Person and Caregiver-Centered Experience and Outcomes 										
QOPI 9	Pain Intensity Quantified on Either of the Last Two Visits before Death	Person and Caregiver-Centered Experience and Outcomes 										
QOPI 10	Hospice Enrollment and Enrolled More than 3 Days before Death 	Person and Caregiver-Centered Experience and Outcomes 										
QOPI 18	Death from Cancer in Intensive Care Unit (*Paired Measure)	Person and Caregiver-Centered Experience and Outcomes 										
QOPI 19	Chemotherapy Administered within Last 2 Weeks of Life 	Person and Caregiver-Centered Experience and Outcomes 										
QOPI 20	Documentation of Patient's Advance Directives by the Third Office Visit	Person and Caregiver-Centered Experience and Outcomes 										
RPAQIR 6	Advance Care Planning	Person and Caregiver-Centered Experience and Outcomes 										
RPAQIR 7	Advance Directives Completed	Person and Caregiver-Centered Experience and Outcomes 										
RPAQIR 9	Advance Care Planning (Pediatric Kidney Disease)	Person and Caregiver-Centered Experience and Outcomes 										
VAN 7	CG-CAHPS Clinician / Group Survey	Person and Caregiver-Centered Experience and Outcomes 										
WCQIC 2	Chronic Wound Care: Patient Education Regarding Diabetic Foot Care	Person and Caregiver-Centered Experience and Outcomes 										
WCQIC 4	Chronic Wound Care: Patient Education Regarding Long Term Compression Therapy	Person and Caregiver-Centered Experience and Outcomes 										
WCQIC 6	Effective Use of Biologic Dressings	Person and Caregiver-Centered Experience and Outcomes 										
"110
(CMS147v2)"	Preventive Care and Screening: Influenza Immunization	Community/Population Health										
"128
(CMS69v2)"	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up	Community/Population Health										
131	Pain Assessment and Follow-Up	Community/Population Health										
"134
(CMS2v3)"	Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan	Community/Population Health										
173	Preventive Care and Screening: Unhealthy Alcohol UseScreening	Community/Population Health										
183	Hepatitis C: Hepatitis A Vaccination in Patients with Hepatitis C Virus (HCV)	Community/Population Health										
Performance Measure		Domain	Eligible Professional Performance			Benchmark Rate						
			Reporting Mechanism	Number of Eligible Cases	Performance Rate							
Measure Reference	Measure Name	Domain Name	[EHR/Claims/Registry/QCDR]	"#,###"	#.##%	#.##%						
"226
(CMS138v2)"	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Community/Population Health										
"239
(CMS155v2)"	Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents 	Community/Population Health										
"240
(CMS117v2)"	Childhood Immunization Status	Community/Population Health										
"310
(CMS153v2)"	Chlamydia Screening for Women	Community/Population Health										
"317 
(CMS22v2)"	Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	Community/Population Health										
"372
(CMS82v1)"	Maternal Depression Screening	Community/Population Health										
AAAAI 3	Asthma: Tobacco Use: Screening	Community/Population Health										
AAAAI 4	Asthma: Tobacco Use: Intervention	Community/Population Health										
AAAAI 13	Influenza Immunization	Community/Population Health										
AAAAI 15	Body Mass Index	Community/Population Health										
ACCFocus 7*	Disparities in Appropriate Patient Selection for Cardiac Imaging between Men and Women	Community/Population Health										
ACCFocus 8*	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria in Patients Less than 50 Years Old	Community/Population Health										
QOPI 6	Smoking Status/Tobacco Use Documented in Past Year	Community/Population Health										
VAN 2	Childhood Immunization Status	Community/Population Health										
VAN 3	Chlamydia Screening for Women	Community/Population Health										
WCHQ 7	Diabetes Care - Tobacco Free (Chronic Care)	Community/Population Health										
WCHQ 16	Adult Tobacco Use: Screening for Tobacco Use (Preventive Care)	Community/Population Health										
WCHQ 17	Adult Tobacco Use: Screening for Tobacco Use (Preventive Care)	Community/Population Health										
20	Perioperative Care: Timing of Prophylactic Parenteral AntibioticOrdering Physician	Patient Safety										
21	Perioperative Care: Selection of Prophylactic AntibioticFirst OR Second Generation Cephalosporin	Patient Safety										
22	Perioperative Care: Discontinuation of Prophylactic Parenteral Antibiotics (Non-Cardiac Procedures)	Patient Safety										
23	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Patient Safety										
30	Perioperative Care: Timing of Prophylactic AntibioticAdministering Physician 	Patient Safety										
45	Perioperative Care: Discontinuation of Prophylactic Parenteral Antibiotics (Cardiac Procedures)	Patient Safety										
"46
"	Medication Reconciliation: Reconciliation After Discharge from an Inpatient Facility	Patient Safety										
76	Prevention of Catheter-Related Bloodstream Infections (CRBSI): Central Venous Catheter (CVC) Insertion Protocol	Patient Safety										
Performance Measure		Domain	Eligible Professional Performance			Benchmark Rate						
			Reporting Mechanism	Number of Eligible Cases	Performance Rate							
Measure Reference	Measure Name	Domain Name	[EHR/Claims/Registry/QCDR]	"#,###"	#.##%	#.##%						
"130
(CMS68v3)"	Documentation of Current Medications in the Medical Record	Patient Safety										
145	Radiology: Exposure Time Reported for Procedures Using Fluoroscopy	Patient Safety										
154	Falls: Risk Assessment	Patient Safety										
156	Oncology: Radiation Dose Limits to Normal Tissues	Patient Safety										
157	Thoracic Surgery: Recording of Clinical Stage Prior to Lung Cancer or Esophageal Cancer Resection	Patient Safety										
181	Elder Maltreatment Screen and Follow-Up Plan	Patient Safety										
"192*
(CMS132v2)"	Cataracts: Complications Within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures	Patient Safety										
193	Perioperative Temperature Management	Patient Safety										
234	"Thoracic Surgery: Pulmonary Function Tests Before Major Anatomic Lung Resection (Pneumonectomy, Lobectomy or Formal Segmentectomy)"	Patient Safety										
262	Image Confirmation of Successful Excision of Image-Localized Breast Lesion	Patient Safety										
286	Dementia: Counseling Regarding Safety Concerns	Patient Safety										
"318
(CMS139v2)"	Falls: Screening for Future Fall Risk	Patient Safety										
326	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Patient Safety										
335	Maternity Care: Elective Delivery or Early Induction Without Medical Indication at ? 37 and < 39 Weeks	Patient Safety										
351	Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation	Patient Safety										
352	Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet	Patient Safety										
353	Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report	Patient Safety										
360	Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies	Patient Safety										
361	Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry	Patient Safety										
"380
(CMS179v2)"	ADE Prevention and Monitoring: Warfarin Time in Therapeutic Range	Patient Safety										
"382
(CMS177v2)"	Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment	Patient Safety										
AAAAI 5	Allergy Immunotherapy Treatment: Allergen Specific Immunoglobulin E (IgE) Sensitivity Assessed and Documented Prior to Treatment	Patient Safety										
Performance Measure		Domain	Eligible Professional Performance			Benchmark Rate						
			Reporting Mechanism	Number of Eligible Cases	Performance Rate							
Measure Reference	Measure Name	Domain Name	[EHR/Claims/Registry/QCDR]	"#,###"	#.##%	#.##%						
AAAAI 9	Assessment of Asthma Symptoms Prior to Administration of Allergy Immunotherapy Injection(s)	Patient Safety										
ACR 4	Tuberculosis (TB) Test Prior to First Course Biologic Therapy	Patient Safety										
ACRad 9	Median Dose Length Product for CT Head/Brain without Contrast (Single Phase Scan)	Patient Safety										
ACRad 10	Median Size Specific Dose Estimate for CT Chest without Contrast (Single Phase Scan)	Patient Safety										
ACRad 11	Median Dose Length Product for CT Chest without Contrast (Single Phase Scan)	Patient Safety										
ACRad 12	Median Size Specific Dose Estimate for CT Abdomen-Pelvis with Contrast (Single Phase Scan)	Patient Safety										
ACRad 13	Median Dose Length Product for CT Abdomen-Pelvis with Contrast (Single Phase Scan)	Patient Safety										
ACRad 14	Participation in a National Dose Index Registry	Patient Safety										
ACRad 20	CT IV Contrast Extravasation Rate (Low Osmolar Contrast Media)	Patient Safety										
AGACCSSR 1	Colonoscopy Assessment (Procedure Adequacy) - Assessment of Bowel Preparation	Patient Safety										
AGACCSSR 3*	Hospital Visit Rate After Outpatient Colonoscopy	Patient Safety										
AGADHRPR 1*	Colonoscopy Assessment (Procedure Adequacy) - Assessment of Bowel Preparation	Patient Safety										
AGADHRPR 3*	Hospital Visit Rate After Outpatient Colonoscopy	Patient Safety										
AGADHRPR 6	Hepatitis B Vaccination in Patients with HCV	Patient Safety										
AGADHRPR 7	Discontinuation of Antiviral Therapy for Inadequate Viral Response	Patient Safety										
AGADHRPR 9	One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk	Patient Safety										
AGADHRPR 10	Screening for Hepatocellular Carcinoma (HCC) in Patients with Hepatitis C Cirrhosis	Patient Safety										
ASBS 4	Perioperative Care: Timing of Prophylactic Parenteral AntibioticOrdering Physician	Patient Safety										
ASBS 5	Perioperative Care: Selection of Prophylactic AntibioticFirst OR Second Generation Cephalosporin 	Patient Safety										
ASBS 6	Perioperative Care: Discontinuation  of Prophylactic Antibiotic 	Patient Safety										
AQI 6*	Immediate Perioperative Cardiac Arrest Rate	Patient Safety										
AQI 7*	Immediate Perioperative Mortality Rate	Patient Safety										
AQI 8*	PACU Reintubation Rate	Patient Safety										
AQI 10*	Composite Procedural Safety for Central Line Placement	Patient Safety										
												
												
												
Performance Measure		Domain	Eligible Professional Performance			Benchmark Rate						
			Reporting Mechanism	Number of Eligible Cases	Performance Rate							
Measure Reference	Measure Name	Domain Name	[EHR/Claims/Registry/QCDR]	"#,###"	#.##%	#.##%						
GIQIC 5*	Incidence of Perforation	Patient Safety										
ICLOPS 3	Hospitalized Patients Who Die an Expected Death with an ICD that Has Been Deactivated	Patient Safety										
MBSAQIP 8*	"Risk Standardized Rate of Patients Who Experienced Extended Length of Stay (> 7 Days) Following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy Operation, Performed as a Primary (Not Revisional) Procedure "	Patient Safety										
MBS 1*	Medical Complications 	Patient Safety										
MBS 2*	Surgical Site Complications 	Patient Safety										
MBS 3*	Serious Complications	Patient Safety										
MUSIC 1*	Prostate Biopsy: Compliance with AUA Best Practices for Antibiotic Prophylaxis for Transrectal Ultrasound-Guided (TRUS) Biopsy	Patient Safety										
PInc 4*	30 Day Mortality for Acute Myocardial Infarction	Patient Safety										
PInc 5*	30 Day Mortality for Heart Failure	Patient Safety										
PInc 6*	30 Day Mortality for Pneumonia	Patient Safety										
PInc 7	Venous Thromboembolism (VTE) Prophylaxis	Patient Safety										
PInc 10	Elective Delivery	Patient Safety										
PInc 14	Prophylactic Antibiotic Received within 1 Hour Prior to Surgical Incision	Patient Safety										
PInc 15	Prophylactic Antibiotic Selection for Surgical Patients	Patient Safety										
PInc 16	Prophylactic Antibiotics Discontinued within 24 Hours after Surgery End (48 Hours for CABG/Other Cardiac Surgery)	Patient Safety										
PInc 17	Surgery Patients on Beta Blocker Therapy Who Receive a Beta Blocker during the Perioperative Period	Patient Safety										
PInc 18	Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis within 24 Hours Prior to Surgery up to 24 Hours After Surgery End Time	Patient Safety										
PInc 19	Antibiotic Timing	Patient Safety										
PInc 20	Antibiotic Selection	Patient Safety										
VAN 1*	Use of High-Risk Medications in the Elderly	Patient Safety										
24	"Osteoporosis: Communication with the Physician Managing Ongoing Care Post-Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older"	Communication and Care Coordination										
47	Advance Care Plan	Communication and Care Coordination										
81	Adult Kidney Disease: Hemodialysis Adequacy: Solute	Communication and Care Coordination										
82	Adult Kidney Disease: Peritoneal Dialysis Adequacy: Solute	Communication and Care Coordination										
93	Acute Otitis Externa (AOE): Systemic Antimicrobial TherapyAvoidance of Inappropriate Use	Communication and Care Coordination										
138	Melanoma: Coordination of Care	Communication and Care Coordination										
												
												
Performance Measure		Domain	Eligible Professional Performance			Benchmark Rate						
			Reporting Mechanism	Number of Eligible Cases	Performance Rate							
Measure Reference	Measure Name	Domain Name	[EHR/Claims/Registry/QCDR]	"#,###"	#.##%	#.##%						
141	Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care	Communication and Care Coordination										
147	Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy	Communication and Care Coordination										
155	Falls: Plan of Care	Communication and Care Coordination										
180	Rheumatoid Arthritis (RA): Glucocorticoid Management	Communication and Care Coordination										
182	Functional Outcome Assessment	Communication and Care Coordination										
185	Endoscopy & Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous PolypsAvoidance of Inappropriate Use	Communication and Care Coordination										
217	Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Knee Impairments	Communication and Care Coordination										
218	Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Hip Impairments	Communication and Care Coordination										
219	"Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Lower Leg, Foot or Ankle Impairments"	Communication and Care Coordination										
220	Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Lumbar Spine Impairments	Communication and Care Coordination										
221	Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Shoulder Impairments	Communication and Care Coordination										
222	"Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Elbow, Wrist or Hand Impairments"	Communication and Care Coordination										
223	"Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Neck, Cranium, Mandible, Thoracic Spine, Ribs or Other General Orthopedic Impairments"	Communication and Care Coordination										
225	Radiology: Reminder System for Mammograms	Communication and Care Coordination										
258	Rate of Open Repair of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7)	Communication and Care Coordination										
259	Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #2)	Communication and Care Coordination										
260	Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients without Major Complications (Discharged to Home by Post-Operative Day #2)	Communication and Care Coordination										
261	Referral to Otologic Evaluation for Patients with Acute or Chronic Dizziness	Communication and Care Coordination										
265	Biopsy Follow-Up	Communication and Care Coordination										
280	Dementia: Staging of Dementia	Communication and Care Coordination										
Performance Measure		Domain	Eligible Professional Performance			Benchmark Rate						
			Reporting Mechanism	Number of Eligible Cases	Performance Rate							
Measure Reference	Measure Name	Domain Name	[EHR/Claims/Registry/QCDR]	"#,###"	#.##%	#.##%						
320	Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients	Communication and Care Coordination										
336	Maternity Care: Post-Partum Follow-Up and Care Coordination	Communication and Care Coordination										
350	Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-Surgical) Therapy	Communication and Care Coordination										
359	Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computerized Tomography (CT) Imaging Description	Communication and Care Coordination										
362	Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-Up and Comparison Purposes	Communication and Care Coordination										
363	"Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Imaging Studies Through a Secure, Authorized, Media-Free, Shared Archive"	Communication and Care Coordination										
364	Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-Up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines	Communication and Care Coordination										
"374
(CMS50v2)"	Closing the Referral Loop: Receipt of Specialist Report	Communication and Care Coordination										
AAAAI 6	Documentation of Clinical Response to Allergy Immunotherapy within One Year	Communication and Care Coordination										
ACRad 15*	Report Turnaround Time: Radiography	Communication and Care Coordination										
ACRad 16*	Report Turnaround Time: Ultrasound (Excluding Breast US)	Communication and Care Coordination										
ACRad 17*	Report Turnaround Time: MRI	Communication and Care Coordination										
ACRad 18*	Report Turnaround Time:  CT	Communication and Care Coordination										
ACRad 19*	Report Turnaround Time: PET	Communication and Care Coordination										
ASBS 3	Specimen Orientation for Partial Mastectomy or Excisional Breast Biopsy	Communication and Care Coordination										
AQI 1	Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU)	Communication and Care Coordination										
AQI 4	Anesthesiology: Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit	Communication and Care Coordination										
CDR 3	Process Measure: Plan of Care Creation for Diabetic Foot Ulcer (DFU) Patients Not Achieving 30% Closure at 4 Weeks 	Communication and Care Coordination										
CDR 7	Process Measure: Plan of Care for Venous Leg Ulcer Patients Not Achieving 30% Closure at 4 Weeks 	Communication and Care Coordination										
CUHSM 1	Adherence to Statins	Communication and Care Coordination										
CUHSM 2	5 Rates by Therapeutic Category: Proportion of Days Covered (PDC)	Communication and Care Coordination										
CUHSM 5	Care for Older Adults (COA)Medication Review	Communication and Care Coordination										
												
												
Performance Measure		Domain	Eligible Professional Performance			Benchmark Rate						
			Reporting Mechanism	Number of Eligible Cases	Performance Rate							
Measure Reference	Measure Name	Domain Name	[EHR/Claims/Registry/QCDR]	"#,###"	#.##%	#.##%						
GIQIC 6	Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients	Communication and Care Coordination										
GIQIC 10	Appropriate Management of Anticoagulation in the Periprocedural Period RateEGD 	Communication and Care Coordination										
GIQIC 11	Helicobacter pylori (H. pylori) Status Rate	Communication and Care Coordination										
GIQIC 13	Colonoscopy Interval for Patients with a History of Adenomatous PolypsAvoidance of Inappropriate Use	Communication and Care Coordination										
ICLOPS 1	Comfortable Dying: Pain Brought to a Comfortable Level Within 48 Hours of Initial Assessment	Communication and Care Coordination										
ICLOPS 2	Patients Treated with an Opioid Who Are Given a Bowel Regimen	Communication and Care Coordination										
ICLOPS 5	Patients with Advanced Cancer Screened for Pain at Outpatient Visits	Communication and Care Coordination										
ICLOPS 6	Hospice and Palliative CarePain Screening	Communication and Care Coordination										
ICLOPS 7	Hospice and Palliative CarePain Assessment	Communication and Care Coordination										
ICLOPS 8	Hospice and Palliative CareDyspnea Treatment	Communication and Care Coordination										
ICLOPS 9	Hospice and Palliative CareDyspnea Screening	Communication and Care Coordination										
ICLOPS 17	Rate of Follow Up Visits within 7 Days of Discharge (and Physician Response)	Communication and Care Coordination										
MBSAQIP 9	Percentage of Patients Who Had Complete 30 Day Follow-Up Following Any Metabolic and Bariatric Procedure 	Communication and Care Coordination										
NOF 2	Risk Assessment/Treatment After Fracture	Communication and Care Coordination										
NOF 3	Discharge Instructions: Emergency Department	Communication and Care Coordination										
OBERD 1	Back Pain: Mental Health Assessment	Communication and Care Coordination										
OBERD 2	Back Pain: Patient Reassessment	Communication and Care Coordination										
OBERD 4	Pain Assessment and Follow-Up	Communication and Care Coordination										
OBERD 5*	Back Pain: Surgical Timing	Communication and Care Coordination										
OBERD 6	Orthopedic Pain: Mental Health Assessment	Communication and Care Coordination										
OBERD 7	Orthopedic Pain: Patient Reassessment	Communication and Care Coordination										
OBERD 9	Orthopedic Pain: Assessment and Follow-Up	Communication and Care Coordination										
OBERD 10	Quality of Life (VR-12 or Promis Global 10) Monitoring	Communication and Care Coordination										
OBERD 11	Quality of Life (VR-12 or Promis Global 10) Outcomes	Communication and Care Coordination										
OBERD 13	Orthopedic Functional and Pain Level Outcomes	Communication and Care Coordination										
ONSQIR 12	Post-Treatment Follow Up Care	Communication and Care Coordination										
PInc 1*	30 Day Readmission for Acute Myocardial Infarction	Communication and Care Coordination										
PInc 2*	30 Day Readmission for Heart Failure	Communication and Care Coordination										
PInc 3*	30 Day Readmission for Pneumonia	Communication and Care Coordination										
PInc 8	Discharged on Antithrombotic Therapy	Communication and Care Coordination										
PInc 9	Anticoagulation Therapy for Atrial Fibrillation/Flutter	Communication and Care Coordination										
												
Performance Measure		Domain	Eligible Professional Performance			Benchmark Rate						
			Reporting Mechanism	Number of Eligible Cases	Performance Rate							
Measure Reference	Measure Name	Domain Name	[EHR/Claims/Registry/QCDR]	"#,###"	#.##%	#.##%						
PInc 13	Initial Antibiotic Selection for CAP Immunocompetent Patients	Communication and Care Coordination										
RPAQIR 5	Transplant Referral	Communication and Care Coordination										
RPAQIR 8	Referral to Hospice	Communication and Care Coordination										
"65
(CMS154v2)"	Appropriate Treatment for Children with Upper Respiratory Infection (URI)	Efficiency and Cost Reduction										
"66
(CMS146v2)"	Appropriate Testing for Children with Pharyngitis	Efficiency and Cost Reduction										
"102
(CMS129v3)"	Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients	Efficiency and Cost Reduction										
116	Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis 	Efficiency and Cost Reduction										
146*	Radiology: Inappropriate Use of Probably Benign Assessment Category in Mammography Screening	Efficiency and Cost Reduction										
148	Back Pain: Initial Visit	Efficiency and Cost Reduction										
224	Melanoma: Overutilization of Imaging Studies in Melanoma	Efficiency and Cost Reduction										
"312
(CMS166v3)"	Low Back Pain: Use of Imaging Studies	Efficiency and Cost Reduction										
322*	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients	Efficiency and Cost Reduction										
323*	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI)	Efficiency and Cost Reduction										
324*	"Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low Risk Patients"	Efficiency and Cost Reduction										
333	Adult Sinusitis: Computerized Tomography (CT) for Acute	Efficiency and Cost Reduction										
334*	Sinusitis (Overuse)	Efficiency and Cost Reduction										
340	Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse)	Efficiency and Cost Reduction										
341*	HIV Medical Visit Frequency	Efficiency and Cost Reduction										
AAAAI 7	"Documented Rationale to Support Long-Term Aeroallergen Immunotherapy Beyond Five Years, As Indicated"	Efficiency and Cost Reduction										
ACCFocus 1*	"Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Asymptomatic, Low Risk Patients"	Efficiency and Cost Reduction										
ACCFocus 2*	"Cardiac Stress Imaging Not Meeting Appropriate Use Criteria:  Symptomatic, Low Pre-Test Probability Patients Who Can Exercise and Have an Interpretable ECG"	Efficiency and Cost Reduction										
ACCFocus 3*	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Low Risk Surgery Preoperative Testing	Efficiency and Cost Reduction										
ACCFocus 4*	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing after Percutaneous Coronary Intervention (PCI)	Efficiency and Cost Reduction										
												
												
												
Performance Measure		Domain	Eligible Professional Performance			Benchmark Rate						
			Reporting Mechanism	Number of Eligible Cases	Performance Rate							
Measure Reference	Measure Name	Domain Name	[EHR/Claims/Registry/QCDR]	"#,###"	#.##%	#.##%						
ACCFocus 5*	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Surveillance Testing after an Interpretable Prior SPECT MPI or Stress Echo in Asymptomatic Patients	Efficiency and Cost Reduction										
ACCFocus 6*	Ratio: Rarely Appropriate Tests Ordered Per Physician Compared to the National Average	Efficiency and Cost Reduction										
ACRad 2	CT Colonography Clinically Significant Extracolonic Findings	Efficiency and Cost Reduction										
ACRad 5	Screening Mammography Abnormal Interpretation Rate (Recall Rate)	Efficiency and Cost Reduction										
AGACCSSR 4	Performance of Upper Endoscopic Examination with Colonoscopy	Efficiency and Cost Reduction										
AGACCSSR 5*	Unnecessary Screening Colonoscopy in Older Adults	Efficiency and Cost Reduction										
AGADHRPR 4	Performance of Upper Endoscopic Examination with Colonoscopy	Efficiency and Cost Reduction										
AGADHRPR 5*	Unnecessary Screening Colonoscopy in Older Adults	Efficiency and Cost Reduction										
GIQIC 7	Repeat Colonoscopy Recommended Due to Poor Bowel Preparation	Efficiency and Cost Reduction										
GIQIC 8	Age Appropriate Screening Colonoscopy	Efficiency and Cost Reduction										
GIQIC 12	Appropriate Indication for Colonoscopy	Efficiency and Cost Reduction										
ICLOPS 15	Excess Days Rate and Degree of Excess (Including Physician Response)	Efficiency and Cost Reduction										
ICLOPS 16	Re-Admission Rate within 30 Days (Including Physician Response)	Efficiency and Cost Reduction										
MBSAQIP 2*	"Risk Standardized Rate of Patients Who Experienced an Unplanned Readmission (Likely Related to the Initial Operation) to Any Hospital within 30 Days Following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy Operation, Performed as a Primary (Not Revisional) Procedure"	Efficiency and Cost Reduction										
MBSAQIP 3*	"Risk Standardized Rate of Patients Who Experienced a Reoperation (Likely Related to the Initial Operation) within 30 days Following a Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy Operation, Performed as a Primary (Not Revisional) Procedure"	Efficiency and Cost Reduction										
MBS 7	Extended Length of Stay (LOS)	Efficiency and Cost Reduction										
MBS 8*	Unplanned Emergency Room (ER) visits	Efficiency and Cost Reduction										
MBS 9*	Unplanned Hospital Readmission within 30 Days of Principal Procedure	Efficiency and Cost Reduction										
MUSIC 3	Prostate Cancer: Avoidance of Overuse of CT Scan for Staging Low Risk Prostate Cancer Patients 	Efficiency and Cost Reduction										
OQIC 3*	Hospital Days	Efficiency and Cost Reduction										
OQIC 8*	Hospital Days	Efficiency and Cost Reduction										
QOPI 4	Performance Status Documented Prior to Initiating Non-Curative Chemotherapy Regimen 	Efficiency and Cost Reduction										
												
Performance Measure		Domain	Eligible Professional Performance			Benchmark Rate						
			Reporting Mechanism	Number of Eligible Cases	Performance Rate							
Measure Reference	Measure Name	Domain Name	[EHR/Claims/Registry/QCDR]	"#,###"	#.##%	#.##%						
QOPI 5	"Chemotherapy Administered to Patients with Metastatic Solid Tumors and Performance Status of 3, 4, or Undocumented (Lower Score Better)"	Efficiency and Cost Reduction										
QOPI 15	GCSF Administered to Patients Who Received Chemotherapy for Metastatic Cancer (Lower Score Better)	Efficiency and Cost Reduction										
STS 1*	CABG - Prolonged Length of Stay	Efficiency and Cost Reduction										
STS 2	CABG - Short Length of Stay	Efficiency and Cost Reduction										
STS 3*	CABG + Valve Prolonged Length of Stay	Efficiency and Cost Reduction										
STS 4	CABG + Valve Short Length of Stay	Efficiency and Cost Reduction										
STS 5*	Valve - Prolonged Length of Stay	Efficiency and Cost Reduction										
STS 6	Valve - Short Length of Stay	Efficiency and Cost Reduction										
												
												
* Lower performance rates on this measure indicate better performance. 												
 Crosses indicate terms to be defined through the hover-over function.												
