Historical MIPS Quality Measure Benchmark
| Table 2: Historical MIPS Quality Measure Benchmark Results; created using PY2017 data and PY2019 Eligibility Rules | ||||||||||||||||
| Measure_Name | Measure_ID | Collection_Type | Measure_Type | Benchmark | Standard_Deviation | Average | Decile_3 | Decile_4 | Decile_5 | Decile_6 | Decile_7 | Decile_8 | Decile_9 | Decile_10 | TOPPED_OUT | SevenPointCap |
| Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) | 1 | eCQM | Intermediate Outcome | Y | 28.2 | 46.3 | 77.14 – 60.79 | 60.78 – 48.49 | 48.48 – 38.90 | 38.89 – 31.60 | 31.59 – 25.88 | 25.87 – 20.56 | 20.55 – 14.72 | <= 14.71 | No | No |
| Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) | 1 | Medicare Part B Claims | Intermediate Outcome | Y | 24.5 | 24.6 | 44.44 – 29.04 | 29.03 – 19.52 | 19.51 – 14.72 | 14.71 – 11.12 | 11.11 – 8.34 | 8.33 – 5.57 | 5.56 – 2.79 | <= 2.78 | No | No |
| Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) | 1 | MIPS CQM | Intermediate Outcome | Y | 30.1 | 36.5 | 68.31 – 50.63 | 50.62 – 37.51 | 37.50 – 28.70 | 28.69 – 20.01 | 20.00 – 13.60 | 13.59 – 9.03 | 9.02 – 2.71 | <= 2.70 | No | No |
| Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) | 5 | eCQM | Process | Y | 13.8 | 82.8 | 74.19 – 78.56 | 78.57 – 82.13 | 82.14 – 85.18 | 85.19 – 87.92 | 87.93 – 90.90 | 90.91 – 93.74 | 93.75 – 97.72 | >= 97.73 | No | No |
| Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) | 5 | MIPS CQM | Process | Y | 13.5 | 94.1 | 93.33 – 96.96 | 96.97 – 98.40 | 98.41 – 99.99 | — | — | — | — | 100 | Yes | No |
| Coronary Artery Disease (CAD): Antiplatelet Therapy | 6 | MIPS CQM | Process | Y | 13.2 | 89.6 | 84.13 – 87.99 | 88.00 – 90.66 | 90.67 – 92.85 | 92.86 – 95.09 | 95.10 – 97.08 | 97.09 – 99.99 | — | 100 | No | No |
| Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%) | 7 | eCQM | Process | Y | 13.7 | 82.9 | 76.74 – 80.30 | 80.31 – 83.17 | 83.18 – 85.28 | 85.29 – 87.15 | 87.16 – 89.73 | 89.74 – 91.91 | 91.92 – 94.86 | >= 94.87 | No | No |
| Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%) | 7 | MIPS CQM | Process | Y | 8.8 | 96.3 | 96.17 – 98.11 | 98.12 – 99.76 | 99.77 – 99.99 | — | — | — | — | 100 | Yes | No |
| Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) | 8 | eCQM | Process | Y | 11.1 | 87.9 | 80.49 – 85.61 | 85.62 – 88.97 | 88.98 – 91.29 | 91.30 – 93.04 | 93.05 – 94.73 | 94.74 – 96.34 | 96.35 – 99.99 | 100 | No | No |
| Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) | 8 | MIPS CQM | Process | Y | 10.3 | 95.9 | 95.45 – 98.05 | 98.06 – 99.28 | 99.29 – 99.99 | — | — | — | — | 100 | Yes | No |
| Anti-Depressant Medication Management | 9 | eCQM | Process | Y | 32.4 | 53.9 | 16.67 – 31.06 | 31.07 – 42.18 | 42.19 – 53.15 | 53.16 – 71.73 | 71.74 – 82.78 | 82.79 – 88.88 | 88.89 – 94.43 | >= 94.44 | No | No |
| Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation | 12 | eCQM | Process | Y | 20 | 86.2 | 79.11 – 86.57 | 86.58 – 90.61 | 90.62 – 93.87 | 93.88 – 96.31 | 96.32 – 98.01 | 98.02 – 99.10 | 99.11 – 99.99 | 100 | No | No |
| Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation | 12 | Medicare Part B Claims | Process | Y | 9.8 | 97.4 | — | — | — | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation | 12 | MIPS CQM | Process | Y | 9.8 | 96.2 | 96.47 – 99.16 | 99.17 – 99.99 | — | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Age-Related Macular Degeneration (AMD): Dilated Macular Examination | 14 | Medicare Part B Claims | Process | Y | 10.2 | 97.8 | — | — | — | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Age-Related Macular Degeneration (AMD): Dilated Macular Examination | 14 | MIPS CQM | Process | Y | 24.3 | 86.2 | 76.54 – 89.80 | 89.81 – 96.53 | 96.54 – 99.70 | 99.71 – 99.99 | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care | 19 | eCQM | Process | Y | 28.8 | 61.7 | 33.90 – 47.61 | 47.62 – 57.88 | 57.89 – 67.02 | 67.03 – 75.36 | 75.37 – 82.48 | 82.49 – 90.02 | 90.03 – 95.99 | >= 96.00 | No | No |
| Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care | 19 | Medicare Part B Claims | Process | Y | 8.6 | 98.2 | — | — | — | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care | 19 | MIPS CQM | Process | Y | 26.6 | 83.4 | 70.29 – 84.41 | 84.42 – 92.72 | 92.73 – 98.56 | 98.57 – 99.99 | — | — | — | 100 | Yes | No |
| Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin | 21 | Medicare Part B Claims | Process | Y | 22.6 | 92 | 99.17 – 99.99 | — | — | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin | 21 | MIPS CQM | Process | Y | 17.5 | 94.6 | 98.67 – 99.99 | — | — | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) | 23 | Medicare Part B Claims | Process | Y | 19.9 | 94.9 | — | — | — | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) | 23 | MIPS CQM | Process | Y | 17.4 | 95 | 98.68 – 99.99 | — | — | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older | 24 | Medicare Part B Claims | Process | Y | 31.9 | 76.3 | 32.35 – 63.63 | 63.64 – 92.30 | 92.31 – 96.20 | 96.21 – 97.61 | 97.62 – 99.99 | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older | 24 | MIPS CQM | Process | Y | 32.4 | 59.6 | 26.32 – 45.09 | 45.10 – 55.31 | 55.32 – 60.20 | 60.21 – 69.99 | 70.00 – 80.55 | 80.56 – 99.99 | — | 100 | No | No |
| Screening for Osteoporosis for Women Aged 65-85 Years of Age | 39 | Medicare Part B Claims | Process | Y | 26.5 | 56.2 | 32.79 – 42.36 | 42.37 – 49.00 | 49.01 – 55.90 | 55.91 – 62.54 | 62.55 – 70.68 | 70.69 – 82.88 | 82.89 – 95.49 | >= 95.50 | No | No |
| Screening for Osteoporosis for Women Aged 65-85 Years of Age | 39 | MIPS CQM | Process | Y | 31 | 46.2 | 11.38 – 22.43 | 22.44 – 34.71 | 34.72 – 45.25 | 45.26 – 58.10 | 58.11 – 67.97 | 67.98 – 78.45 | 78.46 – 88.23 | >= 88.24 | No | No |
| Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery | 44 | MIPS CQM | Process | Y | 14.7 | 92.7 | 90.35 – 95.89 | 95.90 – 97.38 | 97.39 – 99.99 | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Medication Reconciliation Post-Discharge | 46 | Medicare Part B Claims | Process | Y | 16.3 | 94.2 | 95.74 – 98.40 | 98.41 – 99.99 | — | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Medication Reconciliation Post-Discharge | 46 | MIPS CQM | Process | Y | 17.2 | 93.3 | 94.24 – 97.62 | 97.63 – 99.92 | 99.93 – 99.99 | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Care Plan | 47 | Medicare Part B Claims | Process | Y | 33.1 | 78.4 | 50.32 – 82.60 | 82.61 – 92.88 | 92.89 – 97.45 | 97.46 – 99.30 | 99.31 – 99.99 | — | — | 100 | Yes | No |
| Care Plan | 47 | MIPS CQM | Process | Y | 35.9 | 66.1 | 24.33 – 45.01 | 45.02 – 65.74 | 65.75 – 82.16 | 82.17 – 91.89 | 91.90 – 97.31 | 97.32 – 99.71 | 99.72 – 99.99 | 100 | No | No |
| Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older | 48 | Medicare Part B Claims | Process | Y | 43.1 | 65 | 3.88 – 13.85 | 13.86 – 72.40 | 72.41 – 96.68 | 96.69 – 99.99 | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older | 48 | MIPS CQM | Process | Y | 37.5 | 59.8 | 12.22 – 31.74 | 31.75 – 52.36 | 52.37 – 70.44 | 70.45 – 84.26 | 84.27 – 95.10 | 95.11 – 99.50 | 99.51 – 99.99 | 100 | No | No |
| Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older | 50 | Medicare Part B Claims | Process | Y | 18.2 | 94.4 | 97.30 – 98.87 | 98.88 – 99.99 | — | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older | 50 | MIPS CQM | Process | Y | 26.6 | 71.4 | 47.22 – 59.99 | 60.00 – 68.98 | 68.99 – 75.63 | 75.64 – 85.49 | 85.50 – 92.58 | 92.59 – 99.65 | 99.66 – 99.99 | 100 | No | No |
| Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation | 51 | Medicare Part B Claims | Process | Y | 33.7 | 77 | 38.10 – 77.26 | 77.27 – 92.44 | 92.45 – 98.75 | 98.76 – 99.99 | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation | 51 | MIPS CQM | Process | Y | 33.4 | 64.9 | 25.00 – 45.44 | 45.45 – 60.42 | 60.43 – 75.75 | 75.76 – 86.45 | 86.46 – 93.82 | 93.83 – 99.35 | 99.36 – 99.99 | 100 | No | No |
| Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy | 52 | Medicare Part B Claims | Process | Y | 21.9 | 89.9 | 90.14 – 98.14 | 98.15 – 99.99 | — | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy | 52 | MIPS CQM | Process | Y | 13.4 | 93.1 | 90.16 – 95.21 | 95.22 – 96.48 | 96.49 – 98.85 | 98.86 – 99.99 | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Appropriate Treatment for Children with Upper Respiratory Infection (URI) | 65 | eCQM | Process | Y | 15.8 | 88.1 | 80.95 – 88.36 | 88.37 – 91.76 | 91.77 – 93.87 | 93.88 – 95.60 | 95.61 – 96.87 | 96.88 – 98.21 | 98.22 – 99.99 | 100 | No | No |
| Appropriate Treatment for Children with Upper Respiratory Infection (URI) | 65 | MIPS CQM | Process | Y | 13.9 | 93.2 | 91.49 – 95.01 | 95.02 – 97.02 | 97.03 – 97.84 | 97.85 – 98.69 | 98.70 – 99.19 | 99.20 – 99.74 | 99.75 – 99.99 | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Appropriate Testing for Children with Pharyngitis | 66 | eCQM | Process | Y | 29.6 | 66.7 | 36.71 – 60.04 | 60.05 – 72.40 | 72.41 – 78.37 | 78.38 – 83.32 | 83.33 – 87.62 | 87.63 – 91.42 | 91.43 – 94.58 | >= 94.59 | No | No |
| Appropriate Testing for Children with Pharyngitis | 66 | MIPS CQM | Process | Y | 17.5 | 77.4 | 64.57 – 69.60 | 69.61 – 75.41 | 75.42 – 81.74 | 81.75 – 85.50 | 85.51 – 87.95 | 87.96 – 91.77 | 91.78 – 97.54 | >= 97.55 | No | No |
| Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow | 67 | MIPS CQM | Process | Y | 38.1 | 42.9 | 8.00 – 12.49 | 12.50 – 22.72 | 22.73 – 28.52 | 28.53 – 34.61 | 34.62 – 78.78 | 78.79 – 99.99 | — | 100 | No | No |
| Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy | 68 | MIPS CQM | Process | N | — | — | — | — | — | — | — | — | — | — | — | No |
| Hematology: Multiple Myeloma: Treatment with Bisphosphonates | 69 | MIPS CQM | Process | Y | 21.1 | 61.5 | 42.86 – 47.49 | 47.50 – 64.51 | 64.52 – 66.66 | 66.67 – 71.42 | 71.43 – 71.87 | 71.88 – 76.91 | 76.92 – 92.30 | >= 92.31 | No | No |
| Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry | 70 | MIPS CQM | Process | Y | 36.5 | 53.1 | 16.67 – 23.20 | 23.21 – 32.25 | 32.26 – 35.94 | 35.95 – 67.85 | 67.86 – 95.44 | 95.45 – 99.99 | — | 100 | No | No |
| Prevention of Central Venous Catheter (CVC) – Related Bloodstream Infections | 76 | Medicare Part B Claims | Process | Y | 17.3 | 93.7 | 95.24 – 98.60 | 98.61 – 99.99 | — | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Prevention of Central Venous Catheter (CVC) – Related Bloodstream Infections | 76 | MIPS CQM | Process | Y | 15.7 | 94.2 | 95.67 – 99.08 | 99.09 – 99.99 | — | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Acute Otitis Externa (AOE): Topical Therapy | 91 | Medicare Part B Claims | Process | Y | 32.6 | 78.5 | 43.36 – 86.60 | 86.61 – 93.21 | 93.22 – 99.65 | 99.66 – 99.99 | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Acute Otitis Externa (AOE): Topical Therapy | 91 | MIPS CQM | Process | Y | 20 | 83.2 | 67.34 – 78.76 | 78.77 – 86.33 | 86.34 – 91.32 | 91.33 – 95.23 | 95.24 – 97.36 | 97.37 – 99.99 | — | 100 | No | No |
| Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use | 93 | Medicare Part B Claims | Process | Y | 21.6 | 88.7 | 89.12 – 93.50 | 93.51 – 96.35 | 96.36 – 97.82 | 97.83 – 99.92 | 99.93 – 99.99 | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use | 93 | MIPS CQM | Process | Y | 23.7 | 80.1 | 63.16 – 77.35 | 77.36 – 83.96 | 83.97 – 89.65 | 89.66 – 93.32 | 93.33 – 96.14 | 96.15 – 99.99 | — | 100 | No | No |
| Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients | 102 | eCQM | Process | Y | 29.8 | 78.3 | 59.34 – 75.73 | 75.74 – 83.90 | 83.91 – 91.99 | 92.00 – 98.30 | 98.31 – 99.99 | — | — | 100 | No | No |
| Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients | 102 | MIPS CQM | Process | N | — | — | — | — | — | — | — | — | — | — | — | No |
| Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate Cancer | 104 | MIPS CQM | Process | Y | 30.6 | 69 | 39.65 – 48.16 | 48.17 – 55.05 | 55.06 – 76.22 | 76.23 – 93.25 | 93.26 – 99.59 | 99.60 – 99.99 | — | 100 | No | No |
| Adult Major Depressive Disorder (MDD): Suicide Risk Assessment | 107 | eCQM | Process | Y | 36 | 33.9 | 1.51 – 3.56 | 3.57 – 8.10 | 8.11 – 17.48 | 17.49 – 30.28 | 30.29 – 54.72 | 54.73 – 77.56 | 77.57 – 96.66 | >= 96.67 | No | No |
| Osteoarthritis (OA): Function and Pain Assessment | 109 | Medicare Part B Claims | Process | Y | 22.9 | 89.2 | 87.28 – 95.71 | 95.72 – 98.71 | 98.72 – 99.88 | 99.89 – 99.99 | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Osteoarthritis (OA): Function and Pain Assessment | 109 | MIPS CQM | Process | Y | 35 | 73.7 | 34.62 – 63.00 | 63.01 – 86.63 | 86.64 – 94.37 | 94.38 – 99.99 | — | — | — | 100 | No | No |
| Preventive Care and Screening: Influenza Immunization | 110 | eCQM | Process | Y | 28.1 | 42 | 15.50 – 23.63 | 23.64 – 31.20 | 31.21 – 38.65 | 38.66 – 46.76 | 46.77 – 56.01 | 56.02 – 67.49 | 67.50 – 84.98 | >= 84.99 | No | No |
| Preventive Care and Screening: Influenza Immunization | 110 | Medicare Part B Claims | Process | Y | 32.3 | 64.2 | 29.52 – 41.41 | 41.42 – 56.31 | 56.32 – 71.18 | 71.19 – 82.88 | 82.89 – 94.14 | 94.15 – 99.41 | 99.42 – 99.99 | 100 | No | No |
| Preventive Care and Screening: Influenza Immunization | 110 | MIPS CQM | Process | Y | 31.4 | 61.8 | 29.85 – 41.42 | 41.43 – 53.84 | 53.85 – 66.02 | 66.03 – 76.93 | 76.94 – 87.80 | 87.81 – 96.40 | 96.41 – 99.99 | 100 | No | No |
| Pneumococcal Vaccination Status for Older Adults | 111 | eCQM | Process | Y | 30.1 | 50.8 | 19.01 – 31.06 | 31.07 – 42.70 | 42.71 – 53.43 | 53.44 – 62.85 | 62.86 – 71.81 | 71.82 – 80.42 | 80.43 – 90.40 | >= 90.41 | No | No |
| Pneumococcal Vaccination Status for Older Adults | 111 | Medicare Part B Claims | Process | Y | 24.8 | 71.6 | 49.76 – 61.10 | 61.11 – 70.10 | 70.11 – 77.31 | 77.32 – 82.95 | 82.96 – 89.43 | 89.44 – 95.66 | 95.67 – 99.99 | 100 | No | No |
| Pneumococcal Vaccination Status for Older Adults | 111 | MIPS CQM | Process | Y | 28.4 | 58.4 | 30.23 – 44.52 | 44.53 – 55.55 | 55.56 – 63.63 | 63.64 – 70.42 | 70.43 – 76.37 | 76.38 – 83.76 | 83.77 – 95.44 | >= 95.45 | No | No |
| Breast Cancer Screening | 112 | eCQM | Process | Y | 26.7 | 48.4 | 22.28 – 32.74 | 32.75 – 42.31 | 42.32 – 51.05 | 51.06 – 58.43 | 58.44 – 65.67 | 65.68 – 73.43 | 73.44 – 82.30 | >= 82.31 | No | No |
| Breast Cancer Screening | 112 | Medicare Part B Claims | Process | Y | 24.7 | 64.6 | 44.44 – 52.07 | 52.08 – 58.44 | 58.45 – 64.28 | 64.29 – 70.96 | 70.97 – 79.84 | 79.85 – 90.23 | 90.24 – 99.99 | 100 | No | No |
| Breast Cancer Screening | 112 | MIPS CQM | Process | Y | 29.3 | 62.9 | 35.99 – 48.25 | 48.26 – 57.57 | 57.58 – 67.38 | 67.39 – 75.24 | 75.25 – 85.30 | 85.31 – 93.44 | 93.45 – 99.99 | 100 | No | No |
| Colorectal Cancer Screening | 113 | eCQM | Process | Y | 28.9 | 44.4 | 13.49 – 24.00 | 24.01 – 33.96 | 33.97 – 44.38 | 44.39 – 54.79 | 54.80 – 64.00 | 64.01 – 73.37 | 73.38 – 83.50 | >= 83.51 | No | No |
| Colorectal Cancer Screening | 113 | Medicare Part B Claims | Process | Y | 28.9 | 66.3 | 36.60 – 50.99 | 51.00 – 62.49 | 62.50 – 71.22 | 71.23 – 79.99 | 80.00 – 88.63 | 88.64 – 97.72 | 97.73 – 99.99 | 100 | No | No |
| Colorectal Cancer Screening | 113 | MIPS CQM | Process | Y | 30.4 | 65.3 | 35.90 – 49.50 | 49.51 – 60.82 | 60.83 – 70.87 | 70.88 – 80.61 | 80.62 – 90.40 | 90.41 – 96.97 | 96.98 – 99.99 | 100 | No | No |
| Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis | 116 | MIPS CQM | Process | Y | 27.8 | 72.6 | 44.27 – 57.07 | 57.08 – 72.02 | 72.03 – 83.77 | 83.78 – 90.98 | 90.99 – 95.56 | 95.57 – 97.54 | 97.55 – 99.99 | 100 | No | No |
| Diabetes: Eye Exam | 117 | eCQM | Process | Y | 35.8 | 60.7 | 20.61 – 31.99 | 32.00 – 45.52 | 45.53 – 66.01 | 66.02 – 89.11 | 89.12 – 95.64 | 95.65 – 98.25 | 98.26 – 99.72 | >= 99.73 | No | No |
| Diabetes: Eye Exam | 117 | Medicare Part B Claims | Process | Y | 24.9 | 86.9 | 72.00 – 96.87 | 96.88 – 99.99 | — | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Diabetes: Eye Exam | 117 | MIPS CQM | Process | Y | 24.7 | 85.8 | 77.26 – 89.99 | 90.00 – 95.81 | 95.82 – 98.48 | 98.49 – 99.99 | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy – Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%) | 118 | MIPS CQM | Process | Y | 11.1 | 83.3 | 76.00 – 78.56 | 78.57 – 81.07 | 81.08 – 83.90 | 83.91 – 86.35 | 86.36 – 88.72 | 88.73 – 92.25 | 92.26 – 98.17 | >= 98.18 | No | No |
| Diabetes: Medical Attention for Nephropathy | 119 | eCQM | Process | Y | 19.7 | 79 | 67.86 – 74.79 | 74.80 – 79.99 | 80.00 – 84.13 | 84.14 – 87.73 | 87.74 – 91.10 | 91.11 – 94.62 | 94.63 – 98.38 | >= 98.39 | No | No |
| Diabetes: Medical Attention for Nephropathy | 119 | MIPS CQM | Process | Y | 20.1 | 85.1 | 74.38 – 82.85 | 82.86 – 87.70 | 87.71 – 91.93 | 91.94 – 97.23 | 97.24 – 99.99 | — | — | 100 | No | No |
| Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation | 126 | MIPS CQM | Process | Y | 29.3 | 82.5 | 66.15 – 85.22 | 85.23 – 96.42 | 96.43 – 99.99 | — | — | — | — | 100 | Yes | No |
| Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear | 127 | MIPS CQM | Process | Y | 27.9 | 84.8 | 70.59 – 92.85 | 92.86 – 99.45 | 99.46 – 99.99 | — | — | — | — | 100 | Yes | No |
| Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan | 128 | eCQM | Process | Y | 28.5 | 45.4 | 21.15 – 24.58 | 24.59 – 28.51 | 28.52 – 34.20 | 34.21 – 43.84 | 43.85 – 60.30 | 60.31 – 78.24 | 78.25 – 93.28 | >= 93.29 | No | No |
| Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan | 128 | Medicare Part B Claims | Process | Y | 30.3 | 74.2 | 37.52 – 47.77 | 47.78 – 74.47 | 74.48 – 95.19 | 95.20 – 99.26 | 99.27 – 99.99 | — | — | 100 | Yes | No |
| Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan | 128 | MIPS CQM | Process | Y | 31.8 | 72.6 | 34.35 – 54.25 | 54.26 – 74.56 | 74.57 – 90.59 | 90.60 – 97.55 | 97.56 – 99.86 | 99.87 – 99.99 | — | 100 | No | No |
| Documentation of Current Medications in the Medical Record | 130 | eCQM | Process | Y | 18.5 | 90.3 | 87.55 – 93.48 | 93.49 – 96.28 | 96.29 – 97.98 | 97.99 – 98.99 | 99.00 – 99.57 | 99.58 – 99.88 | 99.89 – 99.99 | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Documentation of Current Medications in the Medical Record | 130 | Medicare Part B Claims | Process | Y | 13.1 | 96.1 | 97.95 – 99.51 | 99.52 – 99.91 | 99.92 – 99.99 | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Documentation of Current Medications in the Medical Record | 130 | MIPS CQM | Process | Y | 30.5 | 82.6 | 68.06 – 90.27 | 90.28 – 97.23 | 97.24 – 99.50 | 99.51 – 99.99 | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Pain Assessment and Follow-Up | 131 | Medicare Part B Claims | Process | Y | 25 | 87.9 | 80.57 – 96.91 | 96.92 – 99.63 | 99.64 – 99.99 | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Pain Assessment and Follow-Up | 131 | MIPS CQM | Process | Y | 38.2 | 65.1 | 15.80 – 39.99 | 40.00 – 62.78 | 62.79 – 84.05 | 84.06 – 95.25 | 95.26 – 99.54 | 99.55 – 99.99 | — | 100 | No | No |
| Preventive Care and Screening: Screening for Depression and Follow-Up Plan | 134 | eCQM | Process | Y | 32.2 | 37.1 | 4.88 – 10.17 | 10.18 – 17.59 | 17.60 – 28.28 | 28.29 – 42.29 | 42.30 – 56.82 | 56.83 – 73.29 | 73.30 – 87.49 | >= 87.50 | No | No |
| Preventive Care and Screening: Screening for Depression and Follow-Up Plan | 134 | Medicare Part B Claims | Process | Y | 39.6 | 69.3 | 12.94 – 53.91 | 53.92 – 80.22 | 80.23 – 96.98 | 96.99 – 99.99 | — | — | — | 100 | Yes | No |
| Preventive Care and Screening: Screening for Depression and Follow-Up Plan | 134 | MIPS CQM | Process | Y | 38.5 | 67.7 | 17.11 – 45.64 | 45.65 – 73.81 | 73.82 – 90.05 | 90.06 – 98.49 | 98.50 – 99.99 | — | — | 100 | No | No |
| Melanoma: Continuity of Care – Recall System | 137 | MIPS CQM | Structure | Y | 23 | 88.6 | 83.83 – 94.33 | 94.34 – 98.79 | 98.80 – 99.99 | — | — | — | — | 100 | No | No |
| Melanoma: Coordination of Care | 138 | MIPS CQM | Process | Y | 30.2 | 75.8 | 49.44 – 63.63 | 63.64 – 78.25 | 78.26 – 92.58 | 92.59 – 99.99 | — | — | — | 100 | No | No |
| Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care | 141 | Medicare Part B Claims | Outcome | Y | 10.8 | 97.6 | — | — | — | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care | 141 | MIPS CQM | Outcome | Y | 26.4 | 84.8 | 73.85 – 87.49 | 87.50 – 96.29 | 96.30 – 99.30 | 99.31 – 99.99 | — | — | — | 100 | No | No |
| Oncology: Medical and Radiation – Pain Intensity Quantified | 143 | eCQM | Process | Y | 25.4 | 84.9 | 77.21 – 87.78 | 87.79 – 94.91 | 94.92 – 97.26 | 97.27 – 98.34 | 98.35 – 99.45 | 99.46 – 99.99 | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Oncology: Medical and Radiation – Pain Intensity Quantified | 143 | MIPS CQM | Process | Y | 17.1 | 91.9 | 90.31 – 95.39 | 95.40 – 97.12 | 97.13 – 98.56 | 98.57 – 99.25 | 99.26 – 99.99 | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Oncology: Medical and Radiation – Plan of Care for Pain | 144 | MIPS CQM | Process | N | — | — | — | — | — | — | — | — | — | — | — | No |
| Radiology: Exposure Dose or Time Reported for Procedures Using Fluoroscopy | 145 | Medicare Part B Claims | Process | Y | 26.5 | 81.9 | 66.41 – 82.92 | 82.93 – 90.90 | 90.91 – 95.17 | 95.18 – 97.39 | 97.40 – 99.06 | 99.07 – 99.99 | — | 100 | Yes | No |
| Radiology: Exposure Dose or Time Reported for Procedures Using Fluoroscopy | 145 | MIPS CQM | Process | Y | 24.9 | 85.1 | 73.10 – 88.03 | 88.04 – 94.91 | 94.92 – 98.15 | 98.16 – 99.53 | 99.54 – 99.99 | — | — | 100 | Yes | No |
| Radiology: Inappropriate Use of “Probably Benign” Assessment Category in Screening Mammograms | 146 | Medicare Part B Claims | Process | Y | 1.2 | 0.3 | 0.23 – 0.01 | — | — | — | — | — | — | 0 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Radiology: Inappropriate Use of “Probably Benign” Assessment Category in Screening Mammograms | 146 | MIPS CQM | Process | Y | 3.5 | 0.5 | 0.24 – 0.12 | 0.11 – 0.05 | 0.04 – 0.01 | — | — | — | — | 0 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy | 147 | Medicare Part B Claims | Process | Y | 22.3 | 86.2 | 76.47 – 87.17 | 87.18 – 94.05 | 94.06 – 97.00 | 97.01 – 99.99 | — | — | — | 100 | Yes | No |
| Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy | 147 | MIPS CQM | Process | Y | 13.7 | 94.1 | 93.04 – 97.96 | 97.97 – 99.99 | — | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Falls: Risk Assessment | 154 | Medicare Part B Claims | Process | Y | 18.3 | 94 | 96.95 – 99.99 | — | — | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Falls: Risk Assessment | 154 | MIPS CQM | Process | Y | 35.4 | 73.2 | 28.63 – 60.81 | 60.82 – 84.99 | 85.00 – 95.96 | 95.97 – 99.73 | 99.74 – 99.99 | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Falls: Plan of Care | 155 | Medicare Part B Claims | Process | Y | 30.8 | 81.4 | 55.81 – 84.61 | 84.62 – 99.20 | 99.21 – 99.99 | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Falls: Plan of Care | 155 | MIPS CQM | Process | Y | 28.8 | 82.7 | 67.86 – 86.78 | 86.79 – 94.99 | 95.00 – 98.21 | 98.22 – 99.99 | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis | 160 | eCQM | Process | N | — | — | — | — | — | — | — | — | — | — | — | No |
| Coronary Artery Bypass Graft (CABG): Prolonged Intubation | 164 | MIPS CQM | Outcome | Y | 5.9 | 7.6 | 11.40 – 9.10 | 9.09 – 7.70 | 7.69 – 6.81 | 6.80 – 5.56 | 5.55 – 4.29 | 4.28 – 3.09 | 3.08 – 1.55 | <= 1.54 | No | No |
| Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate | 165 | MIPS CQM | Outcome | Y | 1.1 | 0.5 | 0.84 – 0.01 | — | — | — | — | — | — | 0 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Coronary Artery Bypass Graft (CABG): Stroke | 166 | MIPS CQM | Outcome | Y | 1.6 | 1.3 | 2.38 – 1.80 | 1.79 – 1.27 | 1.26 – 0.72 | 0.71 – 0.01 | — | — | — | 0 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure | 167 | MIPS CQM | Outcome | Y | 2.6 | 2.2 | 3.51 – 2.71 | 2.70 – 2.16 | 2.15 – 1.86 | 1.85 – 1.29 | 1.28 – 0.89 | 0.88 – 0.01 | — | 0 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration | 168 | MIPS CQM | Outcome | Y | 2.6 | 2.4 | 3.95 – 3.14 | 3.13 – 2.64 | 2.63 – 1.80 | 1.79 – 1.28 | 1.27 – 0.88 | 0.87 – 0.01 | — | 0 | Yes | No |
| Rheumatoid Arthritis (RA): Tuberculosis Screening | 176 | MIPS CQM | Process | Y | 31 | 65.4 | 32.00 – 48.14 | 48.15 – 55.55 | 55.56 – 68.00 | 68.01 – 80.42 | 80.43 – 99.03 | 99.04 – 99.99 | — | 100 | No | No |
| Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity | 177 | MIPS CQM | Process | Y | 29.4 | 79 | 57.23 – 74.99 | 75.00 – 88.23 | 88.24 – 96.01 | 96.02 – 99.99 | — | — | — | 100 | Yes | No |
| Rheumatoid Arthritis (RA): Functional Status Assessment | 178 | MIPS CQM | Process | Y | 27.2 | 82 | 67.61 – 81.39 | 81.40 – 90.58 | 90.59 – 95.94 | 95.95 – 99.99 | — | — | — | 100 | Yes | No |
| Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis | 179 | MIPS CQM | Process | Y | 30.9 | 76.7 | 44.53 – 67.88 | 67.89 – 85.30 | 85.31 – 95.21 | 95.22 – 99.99 | — | — | — | 100 | Yes | No |
| Rheumatoid Arthritis (RA): Glucocorticoid Management | 180 | MIPS CQM | Process | Y | 28.6 | 79.3 | 52.68 – 75.78 | 75.79 – 87.95 | 87.96 – 95.05 | 95.06 – 99.57 | 99.58 – 99.99 | — | — | 100 | Yes | No |
| Elder Maltreatment Screen and Follow-Up Plan | 181 | Medicare Part B Claims | Process | Y | 34.6 | 80.9 | 55.38 – 97.31 | 97.32 – 99.55 | 99.56 – 99.99 | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Elder Maltreatment Screen and Follow-Up Plan | 181 | MIPS CQM | Process | Y | 29.9 | 75.6 | 50.65 – 66.03 | 66.04 – 77.77 | 77.78 – 89.28 | 89.29 – 96.78 | 96.79 – 99.99 | — | — | 100 | No | No |
| Functional Outcome Assessment | 182 | Medicare Part B Claims | Process | Y | 14.7 | 96.7 | — | — | — | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Functional Outcome Assessment | 182 | MIPS CQM | Process | N | — | — | — | — | — | — | — | — | — | — | — | No |
| Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use | 185 | Medicare Part B Claims | Process | Y | 8.5 | 97.8 | 98.57 – 99.99 | — | — | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use | 185 | MIPS CQM | Process | Y | 25.8 | 82 | 61.64 – 84.99 | 85.00 – 90.53 | 90.54 – 95.41 | 95.42 – 98.40 | 98.41 – 99.99 | — | — | 100 | Yes | No |
| Stroke and Stroke Rehabilitation: Thrombolytic Therapy | 187 | MIPS CQM | Process | Y | 20.5 | 90.1 | 88.89 – 96.48 | 96.49 – 99.99 | — | — | — | — | — | 100 | Yes | No |
| Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery | 191 | eCQM | Outcome | Y | 18.4 | 88.5 | 85.25 – 90.62 | 90.63 – 93.40 | 93.41 – 95.58 | 95.59 – 96.87 | 96.88 – 97.82 | 97.83 – 98.77 | 98.78 – 99.99 | 100 | No | No |
| Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery | 191 | MIPS CQM | Outcome | Y | 9.3 | 96.1 | 94.37 – 96.87 | 96.88 – 98.97 | 98.98 – 99.99 | — | — | — | — | 100 | Yes | No |
| Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures | 192 | eCQM | Outcome | Y | 0.9 | 0.2 | — | — | — | — | — | — | — | 0 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures | 192 | MIPS CQM | Outcome | Y | 6.5 | 0.9 | — | — | — | — | — | — | — | 0 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Radiology: Stenosis Measurement in Carotid Imaging Reports | 195 | Medicare Part B Claims | Process | Y | 16.1 | 92.7 | 91.72 – 96.22 | 96.23 – 98.17 | 98.18 – 99.99 | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Radiology: Stenosis Measurement in Carotid Imaging Reports | 195 | MIPS CQM | Process | Y | 10.7 | 96.6 | 97.81 – 99.84 | 99.85 – 99.99 | — | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis | 205 | MIPS CQM | Process | N | — | — | — | — | — | — | — | — | — | — | — | No |
| Functional Status Change for Patients with Knee Impairments | 217 | MIPS CQM | Patient Reported Outcome | N | — | — | — | — | — | — | — | — | — | — | — | No |
| Functional Status Change for Patients with Hip Impairments | 218 | MIPS CQM | Patient Reported Outcome | N | — | — | — | — | — | — | — | — | — | — | — | No |
| Functional Status Change for Patients with Foot or Ankle Impairments | 219 | MIPS CQM | Patient Reported Outcome | N | — | — | — | — | — | — | — | — | — | — | — | No |
| Functional Status Change for Patients with Lumbar Impairments | 220 | MIPS CQM | Patient Reported Outcome | N | — | — | — | — | — | — | — | — | — | — | — | No |
| Functional Status Change for Patients with Shoulder Impairments | 221 | MIPS CQM | Patient Reported Outcome | N | — | — | — | — | — | — | — | — | — | — | — | No |
| Functional Status Change for Patients with Elbow, Wrist or Hand Impairments | 222 | MIPS CQM | Patient Reported Outcome | N | — | — | — | — | — | — | — | — | — | — | — | No |
| Functional Status Change for Patients with Other General Orthopaedic Impairments | 223 | MIPS CQM | Patient Reported Outcome | N | — | — | — | — | — | — | — | — | — | — | — | No |
| Radiology: Reminder System for Screening Mammograms | 225 | Medicare Part B Claims | Structure | Y | 19.3 | 94.3 | 99.36 – 99.99 | — | — | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Radiology: Reminder System for Screening Mammograms | 225 | MIPS CQM | Structure | Y | 13.8 | 97.4 | — | — | — | — | — | — | — | 100 | Yes | No |
| Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | 226 | Medicare Part B Claims | Process | N | — | — | — | — | — | — | — | — | — | — | — | No |
| Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | 226 | eCQM | Process | N | — | — | — | — | — | — | — | — | — | — | — | No |
| Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | 226 | MIPS CQM | Process | N | — | — | — | — | — | — | — | — | — | — | — | No |
| Controlling High Blood Pressure | 236 | eCQM | Intermediate Outcome | Y | 16.6 | 63 | 51.46 – 56.82 | 56.83 – 60.94 | 60.95 – 64.67 | 64.68 – 68.17 | 68.18 – 72.00 | 72.01 – 76.25 | 76.26 – 82.20 | >= 82.21 | No | No |
| Controlling High Blood Pressure | 236 | Medicare Part B Claims | Intermediate Outcome | Y | 18.6 | 72.2 | 58.57 – 63.97 | 63.98 – 68.82 | 68.83 – 73.90 | 73.91 – 78.56 | 78.57 – 83.32 | 83.33 – 88.31 | 88.32 – 94.88 | >= 94.89 | No | No |
| Controlling High Blood Pressure | 236 | MIPS CQM | Intermediate Outcome | Y | 24.1 | 69.3 | 52.41 – 60.04 | 60.05 – 65.67 | 65.68 – 70.61 | 70.62 – 76.82 | 76.83 – 84.61 | 84.62 – 93.39 | 93.40 – 99.99 | 100 | No | No |
| Use of High-Risk Medications in the Elderly | 238 | eCQM | Process | Y | 9 | 4.7 | 8.04 – 4.75 | 4.74 – 2.68 | 2.67 – 1.32 | 1.31 – 0.54 | 0.53 – 0.05 | 0.04 – 0.01 | — | 0 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Use of High-Risk Medications in the Elderly | 238 | MIPS CQM | Process | Y | 6.6 | 1.7 | 0.68 – 0.29 | 0.28 – 0.14 | 0.13 – 0.01 | — | — | — | — | 0 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents | 239 | eCQM | Process | Y | 19.9 | 37.6 | 26.23 – 29.51 | 29.52 – 31.47 | 31.48 – 32.79 | 32.80 – 33.85 | 33.86 – 38.72 | 38.73 – 47.76 | 47.77 – 65.52 | >= 65.53 | No | No |
| Childhood Immunization Status | 240 | eCQM | Process | Y | 17.3 | 26.9 | 9.30 – 14.80 | 14.81 – 20.49 | 20.50 – 26.67 | 26.68 – 30.66 | 30.67 – 37.22 | 37.23 – 42.41 | 42.42 – 50.88 | >= 50.89 | No | No |
| Cardiac Rehabilitation Patient Referral from an Outpatient Setting | 243 | MIPS CQM | Process | Y | 20.1 | 22.2 | 8.11 – 11.87 | 11.88 – 14.62 | 14.63 – 17.22 | 17.23 – 20.77 | 20.78 – 24.31 | 24.32 – 30.68 | 30.69 – 44.43 | >= 44.44 | No | No |
| Barrett’s Esophagus | 249 | Medicare Part B Claims | Process | Y | 0.2 | 100 | — | — | — | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Barrett’s Esophagus | 249 | MIPS CQM | Process | Y | 4.1 | 99.5 | — | — | — | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Radical Prostatectomy Pathology Reporting | 250 | Medicare Part B Claims | Process | Y | 0.7 | 99.9 | — | — | — | — | — | — | — | 100 | Yes | No |
| Radical Prostatectomy Pathology Reporting | 250 | MIPS CQM | Process | Y | 1.5 | 99.7 | — | — | — | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain | 254 | MIPS CQM | Process | Y | 15.3 | 85.1 | 74.42 – 80.94 | 80.95 – 85.36 | 85.37 – 88.88 | 88.89 – 91.99 | 92.00 – 95.23 | 95.24 – 97.66 | 97.67 – 99.99 | 100 | No | No |
| Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain | 254 | Medicare Part B Claims | Process | N | — | — | — | — | — | — | — | — | — | — | — | No |
| Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure | 255 | Medicare Part B Claims | Process | N | — | — | — | — | — | — | — | — | — | — | — | No |
| Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure | 255 | MIPS CQM | Process | N | — | — | — | — | — | — | — | — | — | — | — | No |
| Rate of Open Repair of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7) | 258 | MIPS CQM | Outcome | N | — | — | — | — | — | — | — | — | — | — | — | No |
| 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 | MIPS CQM | Outcome | N | — | — | — | — | — | — | — | — | — | — | — | No |
| Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2) | 260 | MIPS CQM | Outcome | N | — | — | — | — | — | — | — | — | — | — | — | No |
| Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness | 261 | Medicare Part B Claims | Process | N | — | — | — | — | — | — | — | — | — | — | — | No |
| Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness | 261 | MIPS CQM | Process | N | — | — | — | — | — | — | — | — | — | — | — | No |
| Image Confirmation of Successful Excision of Image-Localized Breast Lesion | 262 | MIPS CQM | Process | Y | 0.2 | 100 | — | — | — | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Sentinel Lymph Node Biopsy for Invasive Breast Cancer | 264 | MIPS CQM | Process | Y | 6.1 | 98 | 97.96 – 99.21 | 99.22 – 99.99 | — | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Biopsy Follow-Up | 265 | MIPS CQM | Process | Y | 29.5 | 81.8 | 61.23 – 83.62 | 83.63 – 95.64 | 95.65 – 99.37 | 99.38 – 99.99 | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy | 268 | MIPS CQM | Process | Y | 35.9 | 65 | 32.00 – 45.34 | 45.35 – 57.13 | 57.14 – 78.56 | 78.57 – 95.99 | 96.00 – 99.06 | 99.07 – 99.99 | — | 100 | No | No |
| Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy | 268 | Medicare Part B Claims | Process | N | — | — | — | — | — | — | — | — | — | — | — | No |
| Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury – Bone Loss Assessment | 271 | MIPS CQM | Process | N | — | — | — | — | — | — | — | — | — | — | — | No |
| Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy | 275 | MIPS CQM | Process | N | — | — | — | — | — | — | — | — | — | — | — | No |
| Sleep Apnea: Severity Assessment at Initial Diagnosis | 277 | MIPS CQM | Process | Y | 26.9 | 82.1 | 69.01 – 81.02 | 81.03 – 90.62 | 90.63 – 99.70 | 99.71 – 99.99 | — | — | — | 100 | Yes | No |
| Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy | 279 | MIPS CQM | Process | Y | 17.8 | 92 | 90.08 – 96.26 | 96.27 – 99.16 | 99.17 – 99.99 | — | — | — | — | 100 | Yes | No |
| Dementia: Cognitive Assessment | 281 | eCQM | Process | Y | 35.7 | 46.1 | 5.88 – 12.89 | 12.90 – 26.08 | 26.09 – 44.99 | 45.00 – 59.25 | 59.26 – 73.32 | 73.33 – 88.56 | 88.57 – 96.76 | >= 96.77 | No | No |
| Dementia: Functional Status Assessment | 282 | MIPS CQM | Process | Y | 32.2 | 79.2 | 57.14 – 78.94 | 78.95 – 95.27 | 95.28 – 99.12 | 99.13 – 99.99 | — | — | — | 100 | Yes | No |
| Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management | 283 | MIPS CQM | Process | Y | 29.9 | 81.3 | 58.14 – 83.07 | 83.08 – 96.66 | 96.67 – 99.81 | 99.82 – 99.99 | — | — | — | 100 | Yes | No |
| Dementia: Safety Concerns Screening and Mitigation Recommendations or Referral for Patients with Dementia | 286 | MIPS CQM | Process | Y | 27.3 | 82 | 62.86 – 78.68 | 78.69 – 89.88 | 89.89 – 98.20 | 98.21 – 99.99 | — | — | — | 100 | Yes | No |
| Dementia: Caregiver Education and Support | 288 | MIPS CQM | Process | Y | 27.9 | 80.9 | 59.26 – 77.32 | 77.33 – 89.32 | 89.33 – 97.53 | 97.54 – 99.99 | — | — | — | 100 | Yes | No |
| Parkinson’s Disease: Psychiatric Symptoms Assessment for Patients with Parkinson’s Disease | 290 | MIPS CQM | Process | Y | 19.2 | 89.7 | 85.09 – 92.55 | 92.56 – 96.91 | 96.92 – 99.22 | 99.23 – 99.99 | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment | 291 | MIPS CQM | Process | Y | 13.1 | 93.3 | 86.49 – 94.99 | 95.00 – 99.99 | — | — | — | — | — | 100 | Yes | No |
| Parkinson’s Disease: Rehabilitative Therapy Options | 293 | MIPS CQM | Process | Y | 19.8 | 86.6 | 67.03 – 82.94 | 82.95 – 94.28 | 94.29 – 99.99 | — | — | — | — | 100 | Yes | No |
| Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery | 303 | MIPS CQM | Patient Reported Outcome | Y | 30.5 | 74 | 45.11 – 70.87 | 70.88 – 78.76 | 78.77 – 84.90 | 84.91 – 91.77 | 91.78 – 98.79 | 98.80 – 99.99 | — | 100 | No | No |
| Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery | 304 | MIPS CQM | Patient Engagement Experience | Y | 28.4 | 76.6 | 50.00 – 72.21 | 72.22 – 80.29 | 80.30 – 87.08 | 87.09 – 95.41 | 95.42 – 99.11 | 99.12 – 99.99 | — | 100 | No | No |
| Initiation and Engagement of Alcohol and Other Drug Dependence Treatment | 305 | eCQM | Process | Y | 6.2 | 3.3 | 0.31 – 0.41 | 0.42 – 0.67 | 0.68 – 1.02 | 1.03 – 1.34 | 1.35 – 2.23 | 2.24 – 3.84 | 3.85 – 6.90 | >= 6.91 | No | No |
| Cervical Cancer Screening | 309 | eCQM | Process | Y | 25.6 | 35.1 | 9.83 – 16.79 | 16.80 – 23.65 | 23.66 – 31.53 | 31.54 – 39.71 | 39.72 – 48.30 | 48.31 – 57.62 | 57.63 – 72.60 | >= 72.61 | No | No |
| Chlamydia Screening for Women | 310 | eCQM | Process | Y | 20.2 | 35.2 | 16.67 – 22.30 | 22.31 – 28.04 | 28.05 – 33.32 | 33.33 – 39.12 | 39.13 – 44.77 | 44.78 – 53.13 | 53.14 – 63.77 | >= 63.78 | No | No |
| Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 317 | eCQM | Process | Y | 23.6 | 37.3 | 19.56 – 24.13 | 24.14 – 28.18 | 28.19 – 32.30 | 32.31 – 36.66 | 36.67 – 42.11 | 42.12 – 50.69 | 50.70 – 74.54 | >= 74.55 | No | No |
| Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 317 | Medicare Part B Claims | Process | Y | 30.1 | 68 | 34.25 – 45.47 | 45.48 – 58.48 | 58.49 – 73.28 | 73.29 – 89.40 | 89.41 – 98.06 | 98.07 – 99.99 | — | 100 | No | No |
| Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 317 | MIPS CQM | Process | Y | 32.7 | 54.1 | 25.75 – 30.80 | 30.81 – 35.46 | 35.47 – 42.56 | 42.57 – 59.14 | 59.15 – 83.48 | 83.49 – 97.31 | 97.32 – 99.99 | 100 | No | No |
| Falls: Screening for Future Fall Risk | 318 | eCQM | Process | Y | 35.4 | 49.8 | 7.24 – 20.26 | 20.27 – 36.40 | 36.41 – 52.24 | 52.25 – 66.72 | 66.73 – 78.59 | 78.60 – 88.50 | 88.51 – 96.55 | >= 96.56 | No | No |
| Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients | 320 | Medicare Part B Claims | Process | Y | 21.1 | 91.8 | 95.24 – 97.72 | 97.73 – 99.99 | — | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients | 320 | MIPS CQM | Process | Y | 19.5 | 88.9 | 85.00 – 89.73 | 89.74 – 93.60 | 93.61 – 95.94 | 95.95 – 97.72 | 97.73 – 98.95 | 98.96 – 99.99 | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients | 322 | MIPS CQM | Efficiency | Y | 16.9 | 4.1 | 1.90 – 0.01 | — | — | — | — | — | — | 0 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI) | 323 | MIPS CQM | Efficiency | Y | 16.9 | 4.4 | 2.44 – 0.01 | — | — | — | — | — | — | 0 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients | 324 | MIPS CQM | Efficiency | Y | 13.4 | 5.1 | 6.25 – 2.02 | 2.01 – 0.01 | — | — | — | — | — | 0 | Yes | No |
| Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions | 325 | MIPS CQM | Process | N | — | — | — | — | — | — | — | — | — | — | — | No |
| Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy | 326 | Medicare Part B Claims | Process | Y | 20.6 | 89.5 | 84.13 – 95.28 | 95.29 – 98.79 | 98.80 – 99.99 | — | — | — | — | 100 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy | 326 | MIPS CQM | Process | Y | 18 | 81.2 | 69.54 – 75.10 | 75.11 – 78.89 | 78.90 – 83.08 | 83.09 – 88.16 | 88.17 – 94.93 | 94.94 – 99.99 | — | 100 | No | No |
| Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level < 10g/dL | 328 | MIPS CQM | Intermediate Outcome | N | — | — | — | — | — | — | — | — | — | — | — | No |
| Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis | 329 | MIPS CQM | Outcome | N | — | — | — | — | — | — | — | — | — | — | — | No |
| Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days | 330 | MIPS CQM | Outcome | N | — | — | — | — | — | — | — | — | — | — | — | No |
| Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse) | 331 | MIPS CQM | Process | Y | 34.5 | 61.5 | 92.15 – 87.51 | 87.50 – 82.89 | 82.88 – 75.37 | 75.36 – 64.36 | 64.35 – 46.68 | 46.67 – 20.00 | 19.99 – 0.01 | 0 | No | No |
| Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use) | 332 | MIPS CQM | Process | Y | 15.4 | 93.2 | 93.55 – 96.19 | 96.20 – 97.58 | 97.59 – 98.39 | 98.40 – 99.35 | 99.36 – 99.99 | — | — | 100 | Yes | No |
| Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse) | 333 | MIPS CQM | Efficiency | Y | 6.7 | 2.2 | 2.50 – 0.91 | 0.90 – 0.27 | 0.26 – 0.01 | — | — | — | — | 0 | Yes | Yes – see “Scoring Examples” tab of spreadsheet |
| Maternity Care: Elective Delivery or Early Induction Without Medical Indication at >= 37 and < 39 Weeks (Overuse) | 335 | MIPS CQM | Outcome | N | — | — | — | — | — | — | — | — | — | — | — | No |
| Maternity Care: Post-Partum Follow-Up and Care Coordination | 336 | MIPS CQM | Process | N | — | — | — | — | — | — | — | — | — | — | — | No |
| Psoriasis: Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier | 337 | MIPS CQM | Process | Y | 30 | 72.1 | 47.06 – 60.60 | 60.61 – 73.62 | 73.63 – 82.50 | 82.51 – 89.99 | 90.00 – 96.42 | 96.43 – 99.99 | — | 100 | No | No |
| HIV Viral Load Suppression | 338 | MIPS CQM | Outcome | Y | 24.2 | 80.9 | 74.47 – 78.56 | 78.57 – 83.99 | 84.00 – 87.93 | 87.94 – 93.99 | 94.00 – 97.23 | 97.24 – 99.99 | — | 100 | No | No |
| HIV Medical Visit Frequency | 340 | MIPS CQM | Process | Y | 25.8 | 71.5 | 48.97 – 52.85 | 52.86 – 61.08 | 61.09 – 82.68 | 82.69 – 87.99 | 88.00 – 92.85 | 92.86 – 95.91 | 95.92 – 99.99 | 100 | No | No |
| Pain Brought Under Control Within 48 Hours | 342 | MIPS CQM | Ou |
