#	Measure Title	Submission Methods
001	Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)	Claims, Electronic Health Record, Cms Web Interface, Registry
005	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)	Electronic Health Record, Registry
006	Coronary Artery Disease (CAD): Antiplatelet Therapy	Registry
007	Coronary Artery Disease (CAD): Beta-Blocker Therapy - Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%)	Electronic Health Record, Registry
008	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)	Electronic Health Record, Registry
009	Anti-Depressant Medication Management	Electronic Health Record, Registry
012	Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation	Claims, Electronic Health Record, Registry
014	Age-Related Macular Degeneration (AMD): Dilated Macular Examination	Claims, Registry
018	Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy	Electronic Health Record, Registry
019	Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care	Claims, Electronic Health Record, Registry
021	Perioperative Care: Selection of Prophylactic Antibiotic - First OR Second Generation Cephalosporin	Claims, Registry
023	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Claims, Registry
024	Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older	Claims, Registry
039	Screening for Osteoporosis for Women Aged 65-85 Years of Age	Claims, Registry
043	Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery	Registry
044	Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery	Registry
046	Medication Reconciliation Post-Discharge	Claims, Cms Web Interface, Registry
047	Care Plan	Claims, Registry
048	Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older	Claims, Registry
050	Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older	Claims, Registry
051	Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation	Claims, Registry
052	Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy	Claims, Registry
065	Appropriate Treatment for Children with Upper Respiratory Infection (URI)	Electronic Health Record, Registry
066	Appropriate Testing for Children with Pharyngitis	Electronic Health Record, Registry
067	Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow	Registry
068	Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy	Registry
069	Hematology: Multiple Myeloma: Treatment with Bisphosphonates	Registry
070	Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry	Registry
076	Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections	Claims, Registry
091	Acute Otitis Externa (AOE): Topical Therapy	Claims, Registry
093	Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy - Avoidance of Inappropriate Use	Claims, Registry
099	Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade	Claims, Registry
100	Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade	Claims, Registry
102	Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients	Electronic Health Record, Registry
104	Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate Cancer	Registry
107	Adult Major Depressive Disorder (MDD): Suicide Risk Assessment	Electronic Health Record, Registry
109	Osteoarthritis (OA): Function and Pain Assessment	Claims, Registry
110	Preventive Care and Screening: Influenza Immunization	Claims, Electronic Health Record, Cms Web Interface, Registry
111	Pneumococcal Vaccination Status for Older Adults	Claims, Electronic Health Record, Cms Web Interface, Registry
112	Breast Cancer Screening	Claims, Electronic Health Record, Cms Web Interface, Registry
113	Colorectal Cancer Screening	Claims, Electronic Health Record, Cms Web Interface, Registry
116	Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis	Registry
117	Diabetes: Eye Exam	Claims, Electronic Health Record, Cms Web Interface, Registry
118	Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)	Registry
119	Diabetes: Medical Attention for Nephropathy	Electronic Health Record, Registry
122	Adult Kidney Disease: Blood Pressure Management	Registry
126	Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy - Neurological Evaluation	Registry
127	Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention - Evaluation of Footwear	Registry
128	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Claims, Electronic Health Record, Cms Web Interface, Registry
130	Documentation of Current Medications in the Medical Record	Claims, Electronic Health Record, Registry
131	Pain Assessment and Follow-Up	Claims, Registry
134	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	Claims, Electronic Health Record, Cms Web Interface, Registry
137	Melanoma: Continuity of Care - Recall System	Registry
138	Melanoma: Coordination of Care	Registry
140	Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement	Claims, Registry
141	Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care	Claims, Registry
143	Oncology: Medical and Radiation - Pain Intensity Quantified	Electronic Health Record, Registry
144	Oncology: Medical and Radiation - Plan of Care for Pain	Registry
145	Radiology: Exposure Dose or Time Reported for Procedures Using Fluoroscopy	Claims, Registry
146	Radiology: Inappropriate Use of "Probably Benign" Assessment Category in Screening Mammograms	Claims, Registry
147	Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy	Claims, Registry
154	Falls: Risk Assessment	Claims, Registry
155	Falls: Plan of Care	Claims, Registry
156	Oncology: Radiation Dose Limits to Normal Tissues	Claims, Registry
160	HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis	Electronic Health Record, Registry
163	Diabetes: Foot Exam	Electronic Health Record, Registry
164	Coronary Artery Bypass Graft (CABG): Prolonged Intubation	Registry
165	Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate	Registry
166	Coronary Artery Bypass Graft (CABG): Stroke	Registry
167	Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure	Registry
168	Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration	Registry
176	Rheumatoid Arthritis (RA): Tuberculosis Screening	Registry
177	Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity	Registry
178	Rheumatoid Arthritis (RA): Functional Status Assessment	Registry
179	Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis	Registry
180	Rheumatoid Arthritis (RA): Glucocorticoid Management	Registry
181	Elder Maltreatment Screen and Follow-Up Plan	Claims, Registry
182	Functional Outcome Assessment	Claims, Registry
185	Colonoscopy Interval for Patients with a History of Adenomatous Polyps - Avoidance of Inappropriate Use	Claims, Registry
187	Stroke and Stroke Rehabilitation: Thrombolytic Therapy	Registry
191	Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery	Electronic Health Record, Registry
192	Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures	Electronic Health Record, Registry
195	Radiology: Stenosis Measurement in Carotid Imaging Reports	Claims, Registry
204	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet	Claims, Electronic Health Record, Cms Web Interface, Registry
205	HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis	Registry
217	Functional Status Change for Patients with Knee Impairments	Registry
218	Functional Status Change for Patients with Hip Impairments	Registry
219	Functional Status Change for Patients with Foot or Ankle Impairments	Registry
220	Functional Status Change for Patients with Lumbar Impairments	Registry
221	Functional Status Change for Patients with Shoulder Impairments	Registry
222	Functional Status Change for Patients with Elbow, Wrist or Hand Impairments	Registry
223	Functional Status Change for Patients with Other General Orthopaedic Impairments	Registry
224	Melanoma: Overutilization of Imaging Studies in Melanoma	Registry
225	Radiology: Reminder System for Screening Mammograms	Claims, Registry
226	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Claims, Electronic Health Record, Cms Web Interface, Registry
236	Controlling High Blood Pressure	Claims, Electronic Health Record, Cms Web Interface, Registry
238	Use of High-Risk Medications in the Elderly	Electronic Health Record, Registry
239	Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents	Electronic Health Record, Registry
240	Childhood Immunization Status	Electronic Health Record, Registry
243	Cardiac Rehabilitation Patient Referral from an Outpatient Setting	Registry
249	Barrett's Esophagus	Claims, Registry
250	Radical Prostatectomy Pathology Reporting	Claims, Registry
251	Quantitative Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) for Breast Cancer Patients	Claims, Registry
254	Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain	Claims, Registry
255	Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure	Claims, Registry
257	Statin Therapy at Discharge after Lower Extremity Bypass (LEB)	Registry
258	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)	Registry
259	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)	Registry
260	Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2)	Registry
261	Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness	Claims, Registry
262	Image Confirmation of Successful Excision of Image-Localized Breast Lesion	Registry
263	Preoperative Diagnosis of Breast Cancer	Registry
264	Sentinel Lymph Node Biopsy for Invasive Breast Cancer	Registry
265	Biopsy Follow-Up	Registry
268	Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy	Claims, Registry
271	Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury - Bone Loss Assessment	Registry
275	Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy	Registry
276	Sleep Apnea: Assessment of Sleep Symptoms	Registry
277	Sleep Apnea: Severity Assessment at Initial Diagnosis	Registry
278	Sleep Apnea: Positive Airway Pressure Therapy Prescribed	Registry
279	Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy	Registry
281	Dementia: Cognitive Assessment	Electronic Health Record, Registry
282	Dementia: Functional Status Assessment	Registry
283	Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management	Registry
286	Dementia: Safety Concerns Screening and Mitigation Recommendations or Referral for Patients with Dementia	Registry
288	Dementia: Caregiver Education and Support	Registry
290	Parkinson's Disease: Psychiatric Symptoms Assessment for Patients with Parkinson's Disease	Registry
291	Parkinson's Disease: Cognitive Impairment or Dysfunction Assessment	Registry
293	Parkinson's Disease: Rehabilitative Therapy Options	Registry
303	Cataracts: Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery	Registry
304	Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery	Registry
305	Initiation and Engagement of Alcohol and Other Drug Dependence Treatment	Electronic Health Record, Registry
309	Cervical Cancer Screening	Electronic Health Record, Registry
310	Chlamydia Screening for Women	Electronic Health Record, Registry
317	Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	Claims, Electronic Health Record, Registry
318	Falls: Screening for Future Fall Risk	Electronic Health Record, Cms Web Interface, Registry
320	Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients	Claims, Registry
321	CAHPS for MIPs Clinician/Group Survey	Certified Survey Vendor
322	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients	Registry
323	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI)	Registry
324	Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients	Registry
325	Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions	Registry
326	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Claims, Registry
327	Pediatric Kidney Disease: Adequacy of Volume Management	Registry
328	Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level < 10g/dL	Registry
329	Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis	Registry
330	Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days	Registry
331	Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse)	Registry
332	Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use)	Registry
333	Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse)	Registry
334	Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse)	Registry
335	Maternity Care: Elective Delivery or Early Induction Without Medical Indication at >= 37 and < 39 Weeks (Overuse)	Registry
336	Maternity Care: Post-Partum Follow-Up and Care Coordination	Registry
337	Psoriasis: Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier	Registry
338	HIV Viral Load Suppression	Registry
340	HIV Medical Visit Frequency	Registry
342	Pain Brought Under Control Within 48 Hours	Registry
343	Screening Colonoscopy Adenoma Detection Rate	Registry
344	Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)	Registry
345	Rate of Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS) Who Are Stroke Free or Discharged Alive	Registry
346	Rate of Asymptomatic Patients Undergoing Carotid Endarterectomy (CEA) Who Are Stroke Free or Discharged Alive	Registry
347	Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) Who Are Discharged Alive	Registry
348	HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate	Registry
350	Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy	Registry
351	Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation	Registry
352	Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet	Registry
353	Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report	Registry
354	Anastomotic Leak Intervention	Registry
355	Unplanned Reoperation within the 30 Day Postoperative Period	Registry
356	Unplanned Hospital Readmission within 30 Days of Principal Procedure	Registry
357	Surgical Site Infection (SSI)	Registry
358	Patient-Centered Surgical Risk Assessment and Communication	Registry
359	Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging Description	Registry
360	Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies	Registry
361	Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry	Registry
362	Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison	Registry
363	Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Studies Through a Secure, Authorized, Media-Free, Shared Archive	Registry
364	Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines	Registry
366	Follow-Up Care for Children Prescribed ADHD Medication (ADD)	Electronic Health Record, Registry
367	Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance use	Electronic Health Record, Registry
369	Pregnant women that had HBsAg testing	Electronic Health Record, Registry
370	Depression Remission at Twelve Months	Electronic Health Record, Cms Web Interface, Registry
371	Depression Utilization of the PHQ-9 Tool	Electronic Health Record, Registry
372	Maternal Depression Screening	Electronic Health Record, Registry
373	Hypertension: Improvement in Blood Pressure	Electronic Health Record, Registry
374	Closing the Referral Loop: Receipt of Specialist Report	Electronic Health Record, Registry
375	Functional Status Assessment for Total Knee Replacement	Electronic Health Record, Registry
376	Functional Status Assessment for Total Hip Replacement	Electronic Health Record, Registry
377	Functional Status Assessments for Congestive Heart Failure	Electronic Health Record, Registry
378	Children Who Have Dental Decay or Cavities	Electronic Health Record, Registry
379	Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists	Electronic Health Record, Registry
382	Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment	Electronic Health Record, Registry
383	Adherence to Antipsychotic Medications For Individuals with Schizophrenia	Registry
384	Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery	Registry
385	Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery	Registry
386	Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences	Registry
387	Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users	Registry
388	Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy)	Registry
389	Cataract Surgery: Difference Between Planned and Final Refraction	Registry
390	Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options	Registry
391	Follow-Up After Hospitalization for Mental Illness (FUH)	Registry
392	HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation	Registry
393	HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision	Registry
394	Immunizations for Adolescents	Registry
395	Lung Cancer Reporting (Biopsy/Cytology Specimens)	Claims, Registry
396	Lung Cancer Reporting (Resection Specimens)	Claims, Registry
397	Melanoma Reporting	Claims, Registry
398	Optimal Asthma Control	Registry
400	One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk	Registry
401	Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis	Registry
402	Tobacco Use and Help with Quitting Among Adolescents	Registry
403	Adult Kidney Disease: Referral to Hospice	Registry
404	Anesthesiology Smoking Abstinence	Registry
405	Appropriate Follow-up Imaging for Incidental Abdominal Lesions	Claims, Registry
406	Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients	Claims, Registry
407	Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia	Claims, Registry
408	Opioid Therapy Follow-up Evaluation	Registry
409	Clinical Outcome Post Endovascular Stroke Treatment	Registry
410	Psoriasis: Clinical Response to Oral Systemic or Biologic Medications	Registry
411	Depression Remission at Six Months	Registry
412	Documentation of Signed Opioid Treatment Agreement	Registry
413	Door to Puncture Time for Endovascular Stroke Treatment	Registry
414	Evaluation or Interview for Risk of Opioid Misuse	Registry
415	Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older	Claims, Registry
416	Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years	Claims, Registry
417	Rate of Open Repair of Small or Moderate Abdominal Aortic Aneurysms (AAA) Where Patients Are Discharged Alive	Registry
418	Osteoporosis Management in Women Who Had a Fracture	Claims, Registry
419	Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination	Claims, Registry
420	Varicose Vein Treatment with Saphenous Ablation: Outcome Survey	Registry
421	Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal	Registry
422	Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury	Claims, Registry
423	Perioperative Anti-platelet Therapy for Patients Undergoing Carotid Endarterectomy	Claims, Registry
424	Perioperative Temperature Management	Registry
425	Photodocumentation of Cecal Intubation	Claims, Registry
426	Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU)	Registry
427	Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU)	Registry
428	Pelvic Organ Prolapse: Preoperative Assessment of Occult Stress Urinary Incontinence	Registry
429	Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy	Claims, Registry
430	Prevention of Post-Operative Nausea and Vomiting (PONV) - Combination Therapy	Registry
431	Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling	Registry
432	Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair	Registry
433	Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair	Registry
434	Proportion of Patients Sustaining a Ureter Injury at the Time of any Pelvic Organ Prolapse Repair	Registry
435	Quality of Life Assessment For Patients With Primary Headache Disorders	Claims, Registry
436	Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques	Claims, Registry
437	Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure	Claims, Registry
438	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Electronic Health Record, Cms Web Interface, Registry
439	Age Appropriate Screening Colonoscopy	Registry
440	Basal Cell Carcinoma (BCC)/Squamous Cell Carcinoma (SCC): Biopsy Reporting Time - Pathologist to Clinician	Registry
441	Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control)	Registry
442	Persistence of Beta-Blocker Treatment After a Heart Attack	Registry
443	Non-Recommended Cervical Cancer Screening in Adolescent Females	Registry
444	Medication Management for People with Asthma	Registry
445	Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG)	Registry
446	Operative Mortality Stratified by the Five STS-EACTS Mortality Categories	Registry
447	Chlamydia Screening and Follow Up	Registry
448	Appropriate Work Up Prior to Endometrial Ablation	Registry
449	HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment with HER2-Targeted Therapies	Registry
450	Trastuzumab Received By Patients With AJCC Stage I (T1c) - III And HER2 Positive Breast Cancer Receiving Adjuvant Chemotherapy	Registry
451	RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy	Registry
452	Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) 4 with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies	Registry
453	Proportion Receiving Chemotherapy in the Last 14 Days of Life	Registry
454	Proportion of Patients who Died from Cancer with more than One Emergency Department Visit in the Last 30 Days of Life	Registry
455	Proportion Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life	Registry
456	Proportion Not Admitted To Hospice	Registry
457	Proportion Admitted to Hospice for less than 3 days	Registry
458	All-cause Hospital Readmission	Administrative Claims
459	Average Change in Back Pain following Lumbar Discectomy / Laminotomy	Registry
460	Average Change in Back Pain following Lumbar Fusion	Registry
461	Average Change in Leg Pain following Lumbar Discectomy and/or Laminotomy	Registry
462	Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy	Electronic Health Record, Registry
463	Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics)	Registry
464	Otitis Media with Effusion (OME): Systemic Antimicrobials- Avoidance of Inappropriate Use	Registry
465	Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian Arteries	Registry
467	Developmental Screening in the First Three Years of Life	Registry
PI_INFBLO_1	Prevention of Information Blocking Attestation
PI_ONCDIR_1	ONC Direct Review Attestation
PI_ONCACB_1	ONC-ACB Surveillance Attestation (Optional)
PI_IACEHRT_1	PI bonus for submission of eligible Improvement Activities using CEHRT
PI_LVPP_1	E-Prescribing Exclusion
PI_TRANS_LVPP_1	E-Prescribing Exclusion
PI_LVOTC_1	Send a Summary of Care Exclusion
PI_TRANS_LVOTC_1	Health Information Exchange Exclusion
PI_LVITC_1	Request/Accept Summary of Care Exclusion
PI_PHCDRR_5	Clinical Data Registry Reporting
PI_PHCDRR_5_MULTI	Clinical Data Registry Reporting for Multiple Registry Engagement
PI_HIE_3	Clinical Information Reconciliation
PI_PHCDRR_3	Electronic Case Reporting
PI_PHCDRR_3_MULTI	Electronic Case Reporting for Multiple Registry Engagement
PI_EP_1	e-Prescribing
PI_PHCDRR_1	Immunization Registry Reporting
PI_PHCDRR_1_MULTI	Immunization Registry Reporting for Multiple Registry Engagement
PI_CCTPE_3	Patient-Generated Health Data
PI_PEA_2	Patient-Specific Education
PI_PEA_1	Provide Patient Access
PI_PHCDRR_4	Public Health Registry Reporting
PI_PHCDRR_4_MULTI	Public Health Registry Reporting for Multiple Registry Engagement
PI_HIE_2	Request/Accept Summary of Care
PI_CCTPE_2	Secure Messaging
PI_PPHI_1	Security Risk Analysis
PI_HIE_1	Send a Summary of Care
PI_PHCDRR_2	Syndromic Surveillance Reporting
PI_PHCDRR_2_MULTI	Syndromic Surveillance Reporting for Multiple Registry Engagement
PI_CCTPE_1	View, Download and Transmit (VDT)
PI_TRANS_EP_1	e-Prescribing
PI_TRANS_HIE_1	Health Information Exchange
PI_TRANS_PHCDRR_1	Immunization Registry Reporting
PI_TRANS_PHCDRR_1_MULTI	Immunization Registry Reporting for Multiple Registry Engagement
PI_TRANS_MR_1	Medication Reconciliation
PI_TRANS_PSE_1	Patient-Specific Education
PI_TRANS_PEA_1	Provide Patient Access
PI_TRANS_SM_1	Secure Messaging
PI_TRANS_PPHI_1	Security Risk Analysis
PI_TRANS_PHCDRR_3	Specialized Registry Reporting
PI_TRANS_PHCDRR_3_MULTI	Specialized Registry Reporting for Multiple Registry Engagement
PI_TRANS_PHCDRR_2	Syndromic Surveillance Reporting
PI_TRANS_PHCDRR_2_MULTI	Syndromic Surveillance Reporting for Multiple Registry Engagement
PI_TRANS_PEA_2	View, Download, or Transmit (VDT)
IA_AHE_1	Engagement of New Medicaid Patients and Follow-up
IA_AHE_2	Leveraging a QCDR to standardize processes for screening
IA_AHE_3	Promote Use of Patient-Reported Outcome Tools
IA_AHE_4	Leveraging a QCDR for use of standard questionnaires
IA_AHE_5	MIPS Eligible Clinician Leadership in Clinical Trials or CBPR
IA_AHE_6	Provide Education Opportunities for New Clinicians
IA_BE_1	Use of certified EHR to capture patient reported outcomes
IA_BE_10	Participation in a QCDR, that promotes implementation of patient self-action plans.
IA_BE_11	Participation in a QCDR, that promotes use of processes and tools that engage patients for adherence to treatment plan.
IA_BE_12	Use evidence-based decision aids to support shared decision-making.
IA_BE_13	Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms.
IA_BE_14	Engage Patients and Families to Guide Improvement in the System of Care
IA_BE_15	Engagement of Patients, Family, and Caregivers in Developing a Plan of Care
IA_BE_16	Evidenced-based techniques to promote self-management into usual care
IA_BE_17	Use of tools to assist patient self-management
IA_BE_18	Provide peer-led support for self-management.
IA_BE_19	Use group visits for common chronic conditions (e.g., diabetes).
IA_BE_2	Use of QCDR to support clinical decision making
IA_BE_20	Implementation of condition-specific chronic disease self-management support programs
IA_BE_21	Improved Practices that Disseminate Appropriate Self-Management Materials
IA_BE_22	Improved Practices that Engage Patients Pre-Visit
IA_BE_23	Integration of patient coaching practices between visits
IA_BE_3	Engagement with QIN-QIO to implement self-management training programs
IA_BE_4	Engagement of patients through implementation of improvements in patient portal
IA_BE_5	Enhancements/regular updates to practice websites/tools that also include considerations for patients with cognitive disabilities
IA_BE_6	Collection and follow-up on patient experience and satisfaction data on beneficiary engagement
IA_BE_7	Participation in a QCDR, that promotes use of patient engagement tools.
IA_BE_8	Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive.
IA_BE_9	Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement.
IA_BMH_1	Diabetes screening
IA_BMH_2	Tobacco use
IA_BMH_3	Unhealthy alcohol use
IA_BMH_4	Depression screening
IA_BMH_5	MDD prevention and treatment interventions
IA_BMH_6	Implementation of co-location PCP and MH services
IA_BMH_7	Implementation of Integrated Patient Centered Behavioral Health Model
IA_BMH_8	Electronic Health Record Enhancements for BH data capture
IA_BMH_9	Unhealthy Alcohol Use for Patients with Co-occurring Conditions of Mental Health and Substance Abuse and Ambulatory Care Patients
IA_CC_1	Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop
IA_CC_10	Care transition documentation practice improvements
IA_CC_11	Care transition standard operational improvements
IA_CC_12	Care coordination agreements that promote improvements in patient tracking across settings
IA_CC_13	Practice Improvements for Bilateral Exchange of Patient Information
IA_CC_14	Practice Improvements that Engage Community Resources to Support Patient Health Goals
IA_CC_15	PSH Care Coordination
IA_CC_16	Primary Care Physician and Behavioral Health Bilateral Electronic Exchange of Information for Shared Patients
IA_CC_17	Patient Navigator Program
IA_CC_2	Implementation of improvements that contribute to more timely communication of test results
IA_CC_3	Implementation of additional activity as a result of TA for improving care coordination
IA_CC_4	TCPI Participation
IA_CC_5	CMS partner in Patients Hospital Engagement Network
IA_CC_6	Use of QCDR to promote standard practices, tools and processes in practice for improvement in care coordination
IA_CC_7	Regular training in care coordination
IA_CC_8	Implementation of documentation improvements for practice/process improvements
IA_CC_9	Implementation of practices/processes for developing regular individual care plans
IA_EPA_1	Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record
IA_EPA_2	Use of telehealth services that expand practice access
IA_EPA_3	Collection and use of patient experience and satisfaction data on access
IA_EPA_4	Additional improvements in access as a result of QIN/QIO TA
IA_EPA_5	Participation in User Testing of the Quality Payment Program Website (https://qpp.cms.gov/)
IA_ERP_1	Participation on Disaster Medical Assistance Team, registered for 6 months.
IA_ERP_2	Participation in a 60-day or greater effort to support domestic or international humanitarian needs.
IA_PCMH	Electronic submission of Patient Centered Medical Home accreditation
IA_PM_1	Participation in Systematic Anticoagulation Program
IA_PM_10	Use of QCDR data for quality improvement such as comparative analysis reports across patient populations
IA_PM_11	Regular Review Practices in Place on Targeted Patient Population Needs
IA_PM_12	Population empanelment
IA_PM_13	Chronic Care and Preventative Care Management for Empaneled Patients
IA_PM_14	Implementation of methodologies for improvements in longitudinal care management for high risk patients
IA_PM_15	Implementation of episodic care management practice improvements
IA_PM_16	Implementation of medication management practice improvements
IA_PM_17	Participation in Population Health Research
IA_PM_18	Provide Clinical-Community Linkages
IA_PM_19	Glycemic Screening Services
IA_PM_2	Anticoagulant Management Improvements
IA_PM_20	Glycemic Referring Services
IA_PM_21	Advance Care Planning
IA_PM_3	RHC, IHS or FQHC quality improvement activities
IA_PM_4	Glycemic management services
IA_PM_5	Engagement of community for health status improvement
IA_PM_6	Use of toolsets or other resources to close healthcare disparities across communities
IA_PM_7	Use of QCDR for feedback reports that incorporate population health
IA_PM_9	Participation in population health research
IA_PSPA_1	Participation in an AHRQ-listed patient safety organization.
IA_PSPA_10	Completion of training and receipt of approved waiver for provision opioid medication-assisted treatments
IA_PSPA_11	Participation in CAHPS or other supplemental questionnaire
IA_PSPA_12	Participation in private payer CPIA
IA_PSPA_13	Participation in Joint Commission Evaluation Initiative
IA_PSPA_14	Participation in Quality Improvement Initiatives
IA_PSPA_15	Implementation of an ASP
IA_PSPA_16	Use of decision support and standardized treatment protocols
IA_PSPA_17	Implementation of analytic capabilities to manage total cost of care for practice population
IA_PSPA_18	Measurement and Improvement at the Practice and Panel Level
IA_PSPA_19	Implementation of formal quality improvement methods, practice changes, or other practice improvement processes
IA_PSPA_2	Participation in MOC Part IV
IA_PSPA_20	Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes
IA_PSPA_21	Implementation of fall screening and assessment programs
IA_PSPA_22	CDC Training on CDC’s Guideline for Prescribing Opioids for Chronic Pain
IA_PSPA_23	Completion of CDC Training on Antibiotic Stewardship
IA_PSPA_24	Initiate CDC Training on Antibiotic Stewardship
IA_PSPA_25	Cost Display for Laboratory and Radiographic Orders
IA_PSPA_26	Communication of Unscheduled Visit for Adverse Drug Event and Nature of Event
IA_PSPA_27	Invasive Procedure or Surgery Anticoagulation Medication Management
IA_PSPA_28	Completion of an Accredited Safety or Quality Improvement Program
IA_PSPA_29	Consulting AUC Using Clinical Decision Support when Ordering Advanced
IA_PSPA_3	Participate in IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS® or Other Similar Activity
IA_PSPA_30	PCI Bleeding Campaign
IA_PSPA_4	Administration of the AHRQ Survey of Patient Safety Culture
IA_PSPA_5	Annual registration in the Prescription Drug Monitoring Program
IA_PSPA_6	Consultation of the Prescription Drug Monitoring Program
IA_PSPA_7	Use of QCDR data for ongoing practice assessment and improvements
IA_PSPA_8	Use of Patient Safety Tools
IA_PSPA_9	Completion of the AMA STEPS Forward program
MSPB_1	Medicare Spending Per Beneficiary (MSPB)	Administrative Claims
TPCC_1	Total Per Capita Costs (TPCC)	Administrative Claims
CAHPS_1	CAHPS for MIPS SSM: Getting Timely Care, Appointments and Information	Certified Survey Vendor
CAHPS_ACO_1	CAHPS for ACO SSM: Getting Timely Care, Appointments and Information	Certified Survey Vendor
CAHPS_2	CAHPS for MIPS SSM: How Well Providers Communicate	Certified Survey Vendor
CAHPS_ACO_2	CAHPS for ACO SSM: How Well Providers Communicate	Certified Survey Vendor
CAHPS_3	CAHPS for MIPS SSM: Patient’s Rating of Provider	Certified Survey Vendor
CAHPS_ACO_3	CAHPS for ACO SSM: Patient’s Rating of Provider	Certified Survey Vendor
CAHPS_4	CAHPS for MIPS SSM: Access to Specialists	Certified Survey Vendor
CAHPS_ACO_4	CAHPS for ACO SSM: Access to Specialists	Certified Survey Vendor
CAHPS_5	CAHPS for MIPS SSM: Health Promotion and Education	Certified Survey Vendor
CAHPS_ACO_5	CAHPS for ACO SSM: Health Promotion and Education	Certified Survey Vendor
CAHPS_6	CAHPS for MIPS SSM: Shared Decision-Making	Certified Survey Vendor
CAHPS_ACO_6	CAHPS for ACO SSM: Shared Decision-Making	Certified Survey Vendor
CAHPS_7	CAHPS for MIPS SSM: Health Status and Functional Status	Certified Survey Vendor
CAHPS_ACO_7	CAHPS for ACO SSM: Health Status and Functional Status	Certified Survey Vendor
CAHPS_8	CAHPS for MIPS SSM: Care Coordination	Certified Survey Vendor
CAHPS_9	CAHPS for MIPS SSM: Courteous and Helpful Office Staff	Certified Survey Vendor
CAHPS_11	CAHPS for MIPS SSM: Stewardship of Patient Resources	Certified Survey Vendor
CAHPS_ACO_34	CAHPS for ACO SSM: Stewardship of Patient Resources	Certified Survey Vendor
ACO321	CAHPS for ACOs Clinician/Group Survey	Certified Survey Vendor
dmComposite	Diabetes Mellitus (DM) Composite (All or Nothing Scoring)	Cms Web Interface
AAAAI11	Asthma Assessment and Classification	Registry
AAAAI12	Lung Function/Spirometry Evaluation	Registry
AAAAI17	Asthma Control: Minimal Important Difference Improvement	Registry
AAAAI18	Penicillin Allergy: Appropriate Removal or Confirmation	Registry
AAAAI2	Asthma: Assessment of Asthma Control – Ambulatory Care Setting	Registry
AAAAI6	Documentation of Clinical Response to Allergen Immunotherapy within One Year	Registry
AAAAI8	Achievement of Projected Effective Dose of Standardized Allergens for Patient Treated With Allergen Immunotherapy for at Least One Year	Registry
AAAAI9	Assessment of Asthma Symptoms Prior to Administration of Allergen Immunotherapy Injection(s)	Registry
AAD1	Psoriasis: Assessment of Psoriasis Disease Activity	Registry
AAD2	Psoriasis: Screening for Psoriatic Arthritis	Registry
AAD3	Basal Cell Carcinoma/Squamous Cell Carcinoma: Mohs Surgery for Superficial Basal Cell Carcinoma of the Trunk for Immune Competent Patients	Registry
AAD4	Basal Cell Carcinoma/Squamous Cell Carcinoma: Mohs Surgery for Squamous Cell Carcinoma in Situ or Keratoacanthoma Type Squamous Cell Carcinoma 1 cm or Smaller on the Trunk	Registry
AAD5	Biopsy: Reporting Time - Clinician to Patient	Registry
AAN1	Diabetes/Pre-Diabetes Screening for Patients with DSP	Registry
AAN10	Falls screening (aggregation of AAN disease specific falls measures)	Registry
AAN11	Overuse of barbiturate and opioid containing medications for primary headache disorders	Registry
AAN12	Quality of Life Assessment for Patients with Epilepsy	Registry
AAN14	Current MS Disability Scale Score	Registry
AAN15	Quality of Life Assessment	Registry
AAN16	Falls Outcome for Patients with Parkinson's Disease	Registry
AAN18	First line treatment for infantile spasms (IS)	Registry
AAN19	Botulinum Toxin Serotype A (BoNT-A) for spasticity or dystonia	Registry
AAN2	DSP Screening for Unhealthy Alcohol Use	Registry
AAN20	Querying for co-morbid conditions of tic disorder (TD) and Tourette syndrome (TS)	Registry
AAN4	Screening for Psychiatric or Behavioral Health Disorders	Registry
AAN5	MEDICATION PRESCRIBED FOR ACUTE MIGRAINE ATTACK	Registry
AAN8	Exercise and Appropriate Physical Activity Counseling for Patients with MS	Registry
AAN9	Querying About Symptoms of Autonomic Dysfunction for Patients with Parkinson's Disease	Registry
AAO11	Otitis Media with Effusion: Avoidance of Topical Intranasal Corticosteroids	Registry
AAO12	Topical Ear Drop Monotherapy for Children with Acute Tympanostomy Tube Otorrhea	Registry
AAO13	Inappropriate Use of Magnetic Resonance Imaging or Computed Tomography Scan for Bell’s Palsy (Inverse Measure)	Registry
AAO14	Inappropriate Use of Antiviral Monotherapy for Bell’s Palsy (Inverse Measure)	Registry
AAO15	Percentage of patients with cerumen impaction and a suggestive history of a non-intact tympanic membrane who receive just manual removal.	Registry
AAO16	Audiometric Evaluation for Older Adults with Hearing Loss	Registry
AAO17	Advanced Diagnostic Imaging of Bilateral Presbycusis or Symmetric Sensorineural Hearing Loss-Avoidance of Inappropriate Use	Registry
AAO18	Percentage of visits with patients with hearing aids where otoscopy is routinely performed	Registry
AAO19	Shared Decision Making for Treatment Options for Bilateral Presbycusis or Symmetric Sensorineural Hearing Loss	Registry
AAO20	Otitis Media with Effusion: Hearing Testing	Registry
AAO21	Audiometry for Chronic Otitis Media with Effusion in Children	Registry
AAO22	Percentage of patients with allergic rhinitis who do not receive sinonasal imaging for allergic rhinitis	Registry
AAO23	Percentage of patients with allergic rhinitis who are offered intranasal corticosteroids or oral antihistamines	Registry
AAO24	Percentage of patients with allergic rhinitis who do not receive leukotriene inhibitors	Registry
AAO25	Percentage of patients with allergic rhinitis who do not receive IgG-based immunoglobulin testing	Registry
AAO26	Otitis Media with Effusion: Diagnostic Evaluation - Assessment of Tympanic Membrane Mobility	Registry
AAO27	Otitis Media with Effusion: Resolution of Otitis Media with Effusion in Children	Registry
AAO28	Otitis Media with Effusion: Resolution of Otitis Media with Effusion in Adults	Registry
AAO8	Otitis Media with Effusion: Antihistamines or Decongestants – Avoidance of Inappropriate Use	Registry
ABFM1	All Patients Who Die an Expected Death with an ICD that Has Been Deactivated	Registry
ABFM2	Patients Admitted to ICU who Have Care Preferences Documented	Registry
ABFM3	Patients Treated with an Opioid Who Are Given a Bowel Regimen	Registry
ABFM4	Palliative Care – Spiritual Assessment	Registry
ABFM5	Palliative Care—Treatment Preferences	Registry
ABFM6	Palliative Care Timely Dyspnea Screening & Treatment	Registry
ABFM7	Pain Brought Under Control within the first three visits	Registry
ABFM8	Measuring the Value-Functions of Primary Care: Provider Level Continuity Measure	Registry
ABG1	Intra-operative anesthesia safety	Registry
ABG16	Planned use of difficult airway equipment	Registry
ABG21	Pre-operative OSA assessment	Registry
ABG28	Pre-Operative Screening for GERD	Registry
ABG29	Pre-Operative Screening for Glaucoma	Registry
ABG30	Pre-Operative Screening for PONV Risk	Registry
ABG31	Pre-Operative Screening for Excessive Alcohol and Recreational Drug Use	Registry
ABG32	Pain Related Quality of Life Interference	Registry
ABG33	Lower Body Functional Impairment (LBI)	Registry
ABG34	Mood Assessment Screening and treatment	Registry
ABG35	Preoperative Assessment of Frailty	Registry
ABG36	Corneal Abrasion	Registry
ABG7	Immediate Adult Post-Operative Pain Management	Registry
ACCPIN3	ACCPin3 Heart Failure: Patient Self Care Education	Registry
ACEP19	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older	Registry
ACEP20	Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years	Registry
ACEP21	Coagulation Studies in Patients Presenting with Chest Pain with No Coagulopathy or Bleeding	Registry
ACEP22	Appropriate Emergency Department Utilization of CT for Pulmonary Embolism	Registry
ACEP24	Pregnancy Test for Female Abdominal Pain Patients	Registry
ACEP25	Tobacco Use: Screening and Cessation Intervention for Patients with Asthma and COPD	Registry
ACEP29	Sepsis Management: Septic Shock: Repeat Lactate Level Measurement	Registry
ACEP30	Sepsis Management: Septic Shock: Lactate Clearance Rate of >=10%	Registry
ACEP31	Appropriate Foley Catheter Use in the Emergency Department	Registry
ACEP32	ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients	Registry
ACEP33	ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Supercenter EDs (80k +)	Registry
ACEP35	ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in High Volume EDs (60k-79,999)	Registry
ACEP36	ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Average Volume EDs (40k-59,999)	Registry
ACEP37	ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Moderate Volume EDs (20k-39,999)	Registry
ACEP38	ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Low Volume EDs (19,999 and less)	Registry
ACEP39	ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Freestanding Ends	Registry
ACEP40	ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients	Registry
ACEP41	ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Supercenter EDs (80k +)	Registry
ACEP43	ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in High Volume EDs (60k-79,999)	Registry
ACEP44	ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Average Volume EDs (40k-59,999)	Registry
ACEP45	ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Moderate Volume EDs (20k-39,999)	Registry
ACEP46	ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Low Volume EDs (19,999 and less)	Registry
ACEP47	ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Freestanding EDs	Registry
ACEP48	Sepsis Management: Septic Shock: Lactate Level Management, Antibiotics Ordered, and Fluid Resuscitation	Registry
ACMT1	Screening for risk of opioid misuse/overuse	Registry
ACMT2	Pregnancy test in women who receive a toxicologic consult	Registry
ACMT3	EKG assessment in acute overdoses	Registry
ACMT4	Appropriate treatment for acetaminophen ingestions	Registry
ACMT5	Assessment of suspected ethylene glycol or methanol exposures	Registry
ACMT6	Repeat assessment of salicylate concentrations in overdose patients	Registry
ACPGR1	High Risk Pneumococcal Vaccination	Registry
ACPGR2	Tdap (Tetanus, Diphtheria, Acellular Pertussis) Vaccination	Registry
ACPGR3	Fixed-dose Combination of Hydralazine and Isosorbide Dinitrate Therapy for Self-identified Black or African American Patients with Heart Failure and LVEF <40% on ACEI or ARB and Beta-blocker Therapy	Registry
ACQR1	COPD Exacerbation Requiring Hospital Admission: Palliative Care Evaluation	Registry
ACQR2	COPD Exacerbation: % of patients discharged from inpatient status on Long Acting Beta Agonist (LABA) bronchodilator	Registry
ACQR3	COPD: Steroids for no more than 5 days in COPD Exacerbation	Registry
ACQR4	CHF Exacerbation Requiring Hospital Admission: Palliative Care Evaluation	Registry
ACQR5	CHF: Document AHA/ACC staging of CHF (A-D)	Registry
ACQR6	POLST Utilization: POLST form reviewed or completed for any patients with limited code status (i.e. any status other than, "Attempt Resuscitation" if unresponsive, pulseless and not breathing; and "Full Treatment" if patient is pulseless and breathing)	Registry
ACQR7	Sepsis Management: Septic Shock: Repeat Lactate Level Measurement within 6 hours	Registry
ACQR8	Stroke/TIA: % of patients discharged on antithrombotic therapy	Registry
ACR7	Gout: Serum Urate Target	Registry
ACRAD1	CT Colonography True Positive Rate	Registry
ACRAD15	Report Turnaround Time: Radiography (modified)	Registry
ACRAD16	Report Turnaround Time: Ultrasound (Excluding Breast US)	Registry
ACRAD17	Report Turnaround Time: MRI	Registry
ACRAD18	Report Turnaround Time: CT	Registry
ACRAD19	Report Turnaround Time: PET	Registry
ACRAD21	Lung Cancer Screening Cancer Detection Rate (CDR)	Registry
ACRAD22	Lung Cancer Screening Positive Predictive Value (PPV)	Registry
ACRAD23	Lung Cancer Screening Abnormal Interpretation Rate	Registry
ACRAD25	Report Turnaround Time: Mammography	Registry
ACRAD26	Appropriate venous access for hemodialysis	Registry
ACRAD28	Rate of early peristomal infection following fluoroscopically guided gastrostomy tube placement	Registry
ACRAD29	Rate of percutaneous nephrostomy tube replacement within 30 days secondary to dislodgement	Registry
ACRAD3	Screening Mammography Cancer Detection Rate (CDR)	Registry
ACRAD30	Rate of Inadequate Percutaneous Image-Guided Biopsy	Registry
ACRAD31	Percent of CT Abdomen-pelvis exams with contrast (single phase scan) for which Dose Length Product is at or below the size-specific diagnostic reference level.	Registry
ACRAD32	Percent of CT Chest exams without contrast (single phase scan) for which Dose Length Product is at or below the size-specific diagnostic reference level.	Registry
ACRAD33	Percent of CT Head/Brain exams without contrast (single phase scan) for which Dose Length Product is at or below the size-specific diagnostic reference level	Registry
ACRAD5	Screening Mammography Abnormal Interpretation Rate (Recall Rate)	Registry
ACRAD6	Screening Mammography Positive Predictive Value 2 (PPV2 - Biopsy Recommended)	Registry
ACRAD7	Screening Mammography Node Negativity Rate	Registry
ACRAD8	Screening Mammography Minimal Cancer Rate	Registry
ACS15	Preoperative Composite	Registry
ACS16	Preventative Care and Screening: Tobacco Screening and Cessation Intervention	Registry
ACS17	Preoperative Key Medications Review for Anticoagulation Medication	Registry
ACS18	Patient Frailty Evaluation	Registry
ACS19	Intraoperative Composite	Registry
ACS20	Optimal Postoperative Communication Plan and Patient Care Coordination Composite	Registry
ACS21	Post-Acute Recovery Composite	Registry
ACS22	Unplanned Reoperation within the 30 Day Postoperative Period	Registry
ACS23	Unplanned Hospital Readmission within 30 Days of Principal Procedure	Registry
ACS24	Surgical Phases of Care Patient-Reported Outcome Composite Measure	Registry
ACS25	Surgical Site Infection (SSI)	Registry
ACSTRAUMA1	Trauma Initial Assessment Composite	Registry
ACSTRAUMA2	Mortality Rate Following Blunt Traumatic Injury to the Chest and/or Abdomen	Registry
ACSTRAUMA3	Mortality Rate Following Penetrating Traumatic Injury to the Chest and/or Abdomen	Registry
ACSTRAUMA4	Splenic Salvage Rate	Registry
ACSTRAUMA5	Optimal Timing of Surgical or Procedural Intervention for Hemorrhage in Trauma	Registry
ACSTRAUMA6	Optimal Ratio of Blood Product Transfusion	Registry
ACSTRAUMA7	Timely Initiation of VTE Prophylaxis in Trauma Patients	Registry
AHSQC1	Ventral Hernia Repair: Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period	Registry
AHSQC2	Unplanned Hospital Readmission or Observation Visit within the 30 Day Postoperative Period	Registry
AHSQC6	Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period	Registry
AHSQC8	Ventral Hernia Repair: Biologic Mesh Prosthesis Use in Low Risk Patients	Registry
AHSQC9	Ventral Hernia Repair: Pain and Functional Status Assessment	Registry
AJRR1	Hip Arthroplasty: Postoperative Complications within 90 Days Following the Procedure	Registry
AJRR3	Hip Arthroplasty: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy	Registry
AJRR4	Hip Arthroplasty: Venous Thromboembolic and Cardiovascular Risk Evaluation	Registry
APMA1	Comprehensive Diabetic Foot Examination	Registry
AQI18	Coronary Artery Bypass Graft (CABG): Prolonged Intubation – Inverse Measure	Registry
AQI41	Coronary Artery Bypass Graft (CABG): Stroke – Inverse Measure	Registry
AQI42	Coronary Artery Bypass Graft (CABG): Post-Operative Renal Failure – Inverse Measure	Registry
AQI48	Patient-Reported Experience with Anesthesia	Registry
AQI49	Adherence to Blood Conservation Guidelines for Cardiac Operations using Cardiopulmonary Bypass (CPB) – Composite	Registry
AQI50	Application of Lung-Protective Ventilation during General Anesthesia	Registry
AQI51	Assessment of Patients for Obstructive Sleep Apnea	Registry
AQI53	Documentation of Anticoagulant and Antiplatelet Medications when Performing Neuraxial Anesthesia/Analgesia or Interventional Pain Procedures	Registry
AQI54	Use of Pencil-Point Needle for Spinal Anesthesia	Registry
AQI55	Team-Based Implementation of a Care-and-Communication Bundle for ICU Patients	Registry
AQI56	Use of Neuraxial Techniques and/or Peripheral Nerve Blocks for Total Knee Arthroplasty (TKA)	Registry
AQI57	Safe Opioid Prescribing Practices	Registry
AQI58	Infection Control Practices for Open Interventional Pain Procedures	Registry
AQI59	Multimodal Pain Management	Registry
AQI60	New Corneal Injury Not Diagnosed Prior to Discharge	Registry
AQUA12	Benign Prostate Hyperplasia: IPSS improvement after diagnosis	Registry
AQUA13	Stress Urinary Incontinence (SUI): Revision surgery within 12 months of incontinence procedure	Registry
AQUA14	Stones: Repeat Shock Wave Lithotripsy (SWL) within 6 months of treatment	Registry
AQUA15	Stones: Urinalysis documented 30 days before surgical stone procedures	Registry
AQUA16	Non-Muscle Invasive Bladder Cancer: Repeat Transurethral Resection of Bladder Tumor (TURBT) for T1 disease	Registry
AQUA17	Non-Muscle Invasive Bladder Cancer: Initiation of BCG 3 months of diagnosis of high-grade T1 bladder cancer and/or CIS	Registry
AQUA18	Non-Muscle Invasive Bladder Cancer: Early surveillance cystoscopy within 4 months of initial diagnosis	Registry
AQUA19	Diagnosis of Type of Azoospermia and Diagnostic Testing for Obstructive Azoospermia	Registry
AQUA20	Genetic Testing of the Azoospermic Male	Registry
AQUA21	Appropriate Management of Obstructive Azoospermia	Registry
AQUA22	Bone imaging and soft tissue imaging at the time of diagnosis of metastatic CRPC	Registry
AQUA23	Blood work for patients receiving abiraterone	Registry
AQUA24	Testosterone and PSA levels checked for CRPC patients	Registry
AQUA25	Use of Prednisone for CRPC patients on abiraterone	Registry
AQUA26	Benign Prostate Hyperplasia Care: Benign Prostate Hyperplasia	Registry
AQUA27	Appropriate Testing for Vasectomy Patients	Registry
AQUA28	Hypogonadism: Testosterone and hematocrit within 6 months of starting testosterone replacement	Registry
AQUA29	Prostate Cancer: Patient Report of Urinary function after treatment	Registry
AQUA3	Cryptorchidism: Inappropriate use of scrotal/groin ultrasound on boys	Registry
AQUA30	Prostate Cancer: Patient Report of Sexual function after treatment	Registry
AQUA8	Hospital admissions/complications within 30 days of TRUS Biopsy	Registry
ARCO10	Risk Standardized Mortality Rate within 30 days following Trauma Operation	Registry
ARCO11	Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke Patients who Received Head CT or MRI Scan Interpretation within 45 minutes of ED Arrival	Registry
ARCO12	STK-01: Venous Thromboembolism (VTE) Prophylaxis	Registry
ARCO13	STK 02: Ischemic stroke patients management -	Registry
ARCO15	Diabetes: Nutritional, Weight Loss Counseling, Reduction of Sedentary Behavior	Registry
ARCO16	Dyspnea or Heart Failure: Use of BNP or NT- pro BNP screening	Registry
ARCO17	Heart Failure: Use of Aldosterone Antagonists and Diuretics for Symptom Control	Registry
ARCO18	Heart Failure: Counseling on Self-care, Including Monitoring Blood Pressure, Weight, Sodium Intake, and Physical Activity	Registry
ARCO19	Promoting self-care for prevention and management of chronic conditions	Registry
ARCO20	Percentage of patients using self-monitoring with mobile technology or eHealth solutions to manage their diabetes, hypertension, sodium intake, nutritional status, physical activity, tobacco use, alcohol use, and sedentary behaviors	Registry
ARCO3	Antipsychotic Use in Persons with Dementia	Registry
ASBS1	Surgeon assessment for hereditary cause of breast cancer	Registry
ASBS10	Management of the axilla in breast cancer patients undergoing breast conserving surgery with a positive sentinel node biopsy	Registry
ASBS12	Return to the operating room for re-excision of previous microscopically negative margins in invasive breast cancer patients undergoing breast conserving therapy	Registry
ASBS13	Sentinel Node Biopsy for Patients with Ductal Carcinoma in Situ Alone	Registry
ASBS14	Recommendation of Neoadjuvant Chemotherapy for Her2Neu positive invasive breast cancers that are >2.0cm in size and/or have needle biopsy proven axillary metastases.	Registry
ASBS7	Unplanned 30 day re-operation after mastectomy	Registry
ASNC1	Cardiac Stress Nuclear Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients	Registry
ASNC19	Imaging Protocols for SPECT and PET MPI studies - Use of stress only protocol	Registry
ASNC2	Cardiac Stress Nuclear Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI)	Registry
ASNC20	SPECT-MPI studies performed without the use of thallium	Registry
ASNC21	SPECT-MPI study appropriate imaging protocol selection for morbidly obese patients	Registry
ASNC22	SPECT and PET MPI studies reporting Left Ventricular Ejection Fraction	Registry
ASNC23	SPECT-MPI study clinical utilization of Attenuation Correction image acquisition	Registry
ASNC24	SPECT-MPI study utilization of exercise as a stressor	Registry
ASNC25	SPECT-MPI study adequate exercise testing performed	Registry
ASNC26	SPECT and PET MPI studies meeting appropriate use criteria	Registry
ASNC27	SPECT and PET MPI studies not Equivocal	Registry
ASNC28	Effective dose less than or equal to 9 millisieverts as per ASNC guideline recommendations	Registry
ASNC29	SPECT and PET MPI study documentation of stress perfusion defects	Registry
ASNC3	Cardiac Stress Nuclear Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients	Registry
ASNC30	Transthoracic Echo (TTE) studies meeting appropriate use criteria	Registry
ASNC31	Transthoracic Echo (TTE) studies reporting pulmonary artery pressures, 100% views, contrast use	Registry
ASPIRE18	Avoiding myocardial Injury	Registry
ASPIRE19	Avoiding acute kidney injury	Registry
ASPIRE2	Train of Four Monitor Documented After Last Dose of Non-depolarizing Neuromuscular Blocker	Registry
ASPIRE6	Application of Lung-Protective Ventilation during General Anesthesia	Registry
ASPS10	Patient Satisfaction with Information Provided during Breast Reconstruction	Registry
ASPS11	Operative Time for Autologous Breast Reconstruction	Registry
ASPS12	Unplanned hospital admission after panniculectomy	Registry
ASPS13	Wound disruption rate after primary panniculectomy in patients with BMI > or = to 35	Registry
ASPS14	Wound disruption rate after primary panniculectomy in patients with BMI < 35	Registry
ASPS15	Seroma rate after primary panniculectomy	Registry
ASPS5	Breast Reconstruction: Return to OR	Registry
ASPS6	Breast Reconstruction: Flap Loss	Registry
ASPS7	Rate of Blood Transfusion for Patients Undergoing Autologous Breast Reconstruction	Registry
ASPS8	Coordination of Care for Patients Undergoing Breast Reconstruction	Registry
ASPS9	Length of Stay Following Autologous Breast Reconstruction	Registry
AUGS1	Complete assessment and evaluation of patient’s pelvic organ prolapse prior to surgical repair	Registry
AUGS10	Documentation of offering a preoperative pessary for Pelvic Organ Prolapse	Registry
AUGS11	Documentation that a trial of conservative management was offered prior to use of procedure based therapy for urgency urinary incontinence	Registry
AUGS3	Preoperative assessment of sexual function prior to pelvic organ prolapse repair	Registry
AUGS4	Performing an intraoperative rectal examination at the time of prolapse repair	Registry
AUGS5	Performing vaginal apical suspension at the time of hysterectomy to address pelvic organ prolapse	Registry
AUGS6	Route of Hysterectomy	Registry
AUGS7	Documentation that conservative management was offered prior to fecal incontinence surgery or procedures	Registry
AUGS8	Documentation of weight loss counseling prior to surgery for stress urinary incontinence procedures for obese women	Registry
AUGS9	Over-utilization of synthetic mesh in the posterior compartment	Registry
BIVARUS27	Patient Reported Comprehensive Assessment of Safety	Registry
BIVARUS28	Patient Reported Experience and Care Coordination	Registry
BIVARUS32	Patient Reported Care Team Communication	Registry
BIVARUS33	Patient Reported Procedure Readiness and Care	Registry
CAP1	Turn-Around Time (TAT) - Standard biopsies	Registry
CAP2	Cancer Protocol Elements for Carcinoma and Carcinosarcoma of the Endometrium	Registry
CAP3	Cancer Protocol Elements for Invasive Carcinoma of Renal Tubular Origin	Registry
CAP4	Cancer Protocol Elements for Carcinoma of the Intrahepatic Bile Ducts Completed	Registry
CAP5	Cancer Protocol Elements for Hepatocellular Carcinoma Completed	Registry
CAP6	Cancer Protocol Elements for Carcinoma of the Pancreas Completed	Registry
CAP7	Helicobacter pylori documentation rate	Registry
CAP8	Turn-Around Time (TAT) - Lactate	Registry
CAP9	Turn-Around Time (TAT) - Troponin	Registry
CCOME1	1-Year Patient-Reported Pain and Function Improvement after Total Knee Arthroplasty	Registry
CCOME2	1-Year Patient-Reported Pain and Function Improvement after Total Hip Arthroplasty	Registry
CCOME3	1-Year Patient-Reported Pain and Function Improvement after Total Shoulder Arthroplasty	Registry
CCOME4	1-Year Patient-Reported Pain and Function Improvement after ACLR Surgery	Registry
CCOME5	Extent of Osteoarthritis Observed in Arthroscopic Partial Meniscectomy	Registry
CCOME6	1-Year Patient-Reported Pain and Function Improvement after APM Surgery	Registry
CDR1	Adequate Off-loading of Diabetic Foot Ulcer at each visit	Registry
CDR2	Diabetic Foot Ulcer (DFU) Healing or Closure	Registry
CDR3	Plan of Care Creation for Diabetic Foot Ulcer (DFU) Patients not Achieving 30% Closure at 4 Weeks AND Plan of Care Creation for Venous Leg Ulcer (VLU) Patients not Achieving 30% Closure at 4 Weeks	Registry
CDR5	Adequate Compression at each visit for Patients with VLUs	Registry
CDR6	Venous Leg Ulcer (VLU) outcome measure: Healing or Closure	Registry
CDR8	Appropriate Use of hyperbaric oxygen therapy for patients with diabetic foot ulcers	Registry
CDR9	Appropriate Use of Cellular and/or Tissue Based Product (CTP) in diabetic foot ulcers (DFUs) or venous leg ulcer (VLUs) among patients 18 years or older	Registry
CESQIP1	Post operative hypocalcemia after thyroidectomy surgery	Registry
CESQIP2	Related readmission for thyroid or parathyroid related problems	Registry
CESQIP3	Pre operative ultrasound exam of patients with thyroid cancer	Registry
CESQIP4	Persistent hypercalcemia	Registry
CESQIP5	Related readmission for adrenal related problems	Registry
CESQIP7	Vocal cord dysfunction following thyroidectomy	Registry
CESQIP8	Hematoma requiring evacuation following thyroidectomy	Registry
CLLC1	Back Pain: Use of EMG & CNS	Registry
CLLC2	Morton's Neuroma - Avoidance of Alcohol Injections	Registry
CLLC3	Cancer Patients - Survivorship Care Plan	Registry
CLLC4	Foot Bone Infection Diagnosis Without MRI	Registry
CODE1	Improved Global Physical Health Outcome Assessment for Shoulder Replacement	Registry
CODE10	Improved Global Physical Health Outcome Assessment for Shoulder Arthroscopy	Registry
CODE11	Improved Functional Outcome Assessment for Knee Arthroscopy	Registry
CODE12	Improved Functional Outcome Assessment for Hip Arthroscopy	Registry
CODE2	Improved Functional Outcome Assessment for ACL Repair	Registry
CODE3	Improved Functional Outcome Assessment for Foot/Ankle Repair	Registry
CODE5	Improved Global Physical Health Outcome Assessment for Spine Surgery	Registry
CODE6	Improved Functional Outcome Assessment for Hip Replacement	Registry
CODE7	Improved Functional Outcome Assessment for Knee Replacement	Registry
CODE8	Improved Global Physical Health Outcome Assessment for Cervical Surgery	Registry
CODE9	Improved Global Physical Health Outcome Assessment for Hand/Wrist/Elbow Repair	Registry
CUHSM3	CAHPS Clinician/Group Surveys - (Adult Primary Care, Pediatric Care, and Specialist Care Surveys)	Registry
CUHSM4	CAHPS Health Plan Survey v 4.0 - Adult questionnaire	Registry
CUHSM6	Adherence to Mood Stabilizers for Individuals with Bipolar I Disorder	Registry
CUHSM8	Cardiovascular Health Screening for People With Schizophrenia or Bipolar Disorder Who Are Prescribed Antipsychotic Medications	Registry
CURE1	CureOneEGFR	Registry
CURE10	CureOneNSCLCBRAFTTP	Registry
CURE11	CureOneMelBRAFTTP	Registry
CURE2	CureOneALK	Registry
CURE3	CureOneROS1	Registry
CURE4	CureOneNSCLCBRAF	Registry
CURE5	CureOnePDL1	Registry
CURE6	CureOneMelBRAF	Registry
CURE7	CureOneEGFRTTP	Registry
CURE8	CureOneALKTTP	Registry
CURE9	CureOneROS1TTP	Registry
ECPR11	Three Day All Cause Return ED Visit Rate	Registry
ECPR2	Door to Diagnostic Evaluation by a Provider – Emergency Department (ED) Patients	Registry
ECPR39	Avoid Head CT for Patients with Uncomplicated Syncope	Registry
ECPR40	Initiation of the Initial Sepsis Bundle	Registry
ECPR41	Rh Status Evaluation and Treatment of Pregnant Women at Risk of Fetal Blood Exposure	Registry
ECPR42	Restrictive Use of Blood Transfusions	Registry
ECPR45	Avoidance of Creatine Kinase-MB (CK-MB) Testing for Non-traumatic Chest Pain	Registry
ECPR46	Avoidance of Opiate Prescriptions for Low Back Pain or Migraines	Registry
ECPR47	Avoidance of Opiate Prescriptions for Greater Than 3 Days Duration for Acute Pain	Registry
ECPR48	Avoidance of Long-Acting (LA) or Extended-Release (ER) Opiate Prescriptions	Registry
ECPR49	Avoidance of Tramadol or Codeine for Children	Registry
ECPR5	Mean Time from Emergency Department (ED) Arrival to ED Departure for Discharged Lower Acuity ED Patients	Registry
ECPR50	Door to Diagnostic Evaluation by a Provider Within 30 Minutes – Urgent Care Patients	Registry
ECPR6	Mean Time from Emergency Department (ED) Arrival to ED Departure for Discharged Higher Acuity ED Patients	Registry
EPREOP28	Preoperative Frailty Assessment	Registry
EPREOP29	Preoperative Assessment for Opioid Dependence Risk	Registry
EPREOP4	Short-term Pain Management/Maximum Pain Score	Registry
FORCE20	Review of Functional Status Assessment for Patients with Osteoarthritis	Registry
FORCE21	Review of Pain Status Assessment for Patients with Osteoarthritis	Registry
FORCE22	Improvement in Pain after Knee Replacement	Registry
FORCE23	Improvement in Pain after Hip Replacement	Registry
GIQIC10	Appropriate management of anticoagulation in the peri-procedural period rate – EGD	Registry
GIQIC12	Appropriate indication for colonoscopy	Registry
GIQIC15	Appropriate follow-up interval of 3 years recommended based on pathology findings from screening colonoscopy in average-risk patients	Registry
GIQIC17	Appropriate follow-up interval of 5 years for colonoscopies with findings of sessile serrated polyps < 10 mm without dysplasia	Registry
GIQIC18	Appropriate follow-up interval of not less than 5 years for colonoscopies with findings of 1-2 tubular adenomas < 10 mm	Registry
GIQIC19	Appropriate indication for esophagogastroduodenoscopy (EGD)	Registry
GIQIC20	Appropriate follow-up interval of 10 years for colonoscopies with only hyperplastic polyp findings	Registry
HADV1	HAdv1 - Use of high risk sleep medications in the elderly	Registry
HADV2	HAdv2 - Atrial Fibrillation Prevention and Treatment – Lifestyle and Disease Factor Assessment	Registry
HCPR13	Stroke Venous Thromboembolism (VTE) Prophylaxis	Registry
HCPR14	Venous Thromboembolism (VTE) Prophylaxis	Registry
HCPR16	Physician’s Orders for Life-Sustaining Treatment (POLST) Form	Registry
HCPR17	Pressure Ulcers - Risk Assessment and Plan of Care	Registry
HCPR18	Unintentional Weight Loss - Risk Assessment and Plan of Care	Registry
HCPR19	30 Day All-Cause Readmission Rate for Discharged Inpatients	Registry
HCPR20	Clostridium Difficile - Risk Assessment and Plan of Care	Registry
HCPR21	Appropriate Use of Telemetry for Admission or Observation Placement	Registry
HCPR22	Critical Care Transfer of Care - Use of Verbal Checklist or Protocol	Registry
HCPR3	Mean Length of Stay for Inpatients – Pneumonia	Registry
HCPR4	Mean Length of Stay for Inpatients – CHF	Registry
HCPR5	Mean Length of Stay for Inpatients – COPD	Registry
HEF1	Exclusive Breast Milk Feeding	Registry
HF2	Surgical Reconstruction for Anterior Cruciate Ligament (ACL) Injury	Registry
HF3	Shoulder Instability - Labral Reconstruction: Change in Validated Shoulder Patient Reported Outcome Measure Following Labral Reconstruction for Shoulder	Registry
HF4	Shoulder Arthroscopy: Measure of Change in a Validated Shoulder Patient Reported Outcome Following Shoulder Arthroscopy	Registry
HF5	Shoulder Arthroplasty: Change in a Validated Shoulder Patient Reported Outcome Measure Following Shoulder Arthroplasty	Registry
HF6	Knee Arthroscopy for Meniscal Repair: Change in a Validated Knee Patient Reported Outcome Measure Following Knee Arthroscopy for Meniscal Repair	Registry
HF7	Surgical Repair for Rotator Cuff Tear: Change in a Validated Shoulder Patient Reported Outcome Measure Following Surgical Rotator Cuff Repair	Registry
HM1	ACE/ARB use	Registry
HM2	A1C treatment	Registry
HM3	A1C in good control	Registry
IQSS1	Hypogonadism: Serum T, CBC, PSA, IPSS within 6 months of Rx	Registry
IQSS2	Prostate Cancer: Newly diagnosed with document T, PSA, Gleason and Prostate Cancer: Initial Eval. Document T, PSA, Gleason	Registry
IQSS3	Prostate Cancer: Treatment Options Counseling	Registry
IQSS4	BPH: Anticholinergics	Registry
IQSS5	Counseling SUI	Registry
IRIS1	Endothelial Keratoplasty: Post-operative improvement in best corrected visual acuity to 20/40 or greater	Registry
IRIS10	Exudative Age-Related Macular Degeneration - Loss of Visual Acuity	Registry
IRIS11	Nonexudative Age-Related Macular Degeneration - Loss of Visual Acuity	Registry
IRIS13	Diabetic Macular Edema - Loss of Visual Acuity	Registry
IRIS16	Acute Anterior Uveitis - Post-treatment visual acuity	Registry
IRIS17	Acute Anterior Uveitis - Post-treatment Grade 0 anterior chamber cells	Registry
IRIS18	Chronic Anterior Uveitis - Post-treatment visual acuity	Registry
IRIS2	Glaucoma - Intraocular Pressure (IOP) Reduction	Registry
IRIS20	Idiopathic Intracranial Hypertension: No worsening or improvement of mean deviation	Registry
IRIS21	Ocular Myasthenia Gravis: Improvement of ocular deviation or absence of diplopia or functional improvement	Registry
IRIS22	Giant Cell Arteritis: Absence of fellow eye involvement after treatment	Registry
IRIS23	Refractive Surgery: Postoperative Improvement in Uncorrected Visual Acuity of 20/20 or better	Registry
IRIS24	Refractive Surgery: Postoperative correction within + 0.5 Diopter of the Intended Correction	Registry
IRIS25	Adenoviral Conjunctivitis: Avoidance of Antibiotics	Registry
IRIS26	Intravitreal Injections: Avoidance of Routine Antibiotic Use	Registry
IRIS27	Adverse Events After Cataract Surgery	Registry
IRIS28	Regaining Vision After Cataract Surgery	Registry
IRIS29	Improved visual acuity after epiretinal membrane treatment within 90 days	Registry
IRIS3	Glaucoma - Visual Field Progression	Registry
IRIS30	Return to OR within 90 days after epiretinal membrane surgical treatment	Registry
IRIS31	Avoidance of Genetic Testing for Age-related Macular Degeneration	Registry
IRIS32	Evidence of anatomic closure of macular hole within 90 days after surgery as documented by OCT.	Registry
IRIS33	Return to OR within 90 days after macular hole surgery	Registry
IRIS34	Age-Related Macular Degeneration: Disease Progression	Registry
IRIS4	Glaucoma - Intraocular Pressure Reduction Following Laser Trabeculoplasty	Registry
IRIS5	Surgery for Acquired Involutional Ptosis - Patients with an Improvement of Marginal Reflex Distance	Registry
IRIS6	Acquired Involutional Entropion - Normalized Lid Position After Surgical Repair	Registry
IRIS7	Amblyopia - Interocular Visual Acuity	Registry
IRIS8	Surgical Esotropia - Postoperative Alignment	Registry
IRIS9	Diabetic Retinopathy - Documentation of the Presence or Absence of Macular Edema and the Level of Severity of Retinopathy	Registry
IROMS1	Functional Improvement in hip, leg or ankle rehabilitation in patients with lower extremity injury measured via the validated Lower Extremity Function Scale (LEFS) score.	Registry
IROMS10	Functional Improvement in low back rehabilitation of non-surgical patients with low pack pain measured via the validated Modified Low Back Pain Disability Questionnaire (MDQ).	Registry
IROMS2	Functional Improvement in knee rehabilitation of patients with knee injury measured via their validated Knee Outcome Survey (KOS) score.	Registry
IROMS8	Functional Improvement in arm, shoulder, and hand rehabilitation in surgical patients with musculotendinous injury measured via the validated Disability of Arm Shoulder and Hand (DASH) score.	Registry
IROMS9	Functional Improvement in neck pain/injury patients rehabilitation measured via the validated Neck Disability Index (NDI).	Registry
M2S1	M2S 1: Procedures with statin and antiplatelet agents prescribed at discharge	Registry
M2S10	M2S 10: Survival at least 9 months after elective repair of small thoracic aortic aneurysms	Registry
M2S11	M2S 11: Imaging-based maximum aortic diameter assessed at least 9 months following Endovascular AAA Repair procedures	Registry
M2S12	M2S 12: Survival at least 9 months after elective repair Endovascular AAA Repair of small abdominal aortic aneurysms	Registry
M2S13	M2S 13: Survival at least 9 months after elective Open AAA repair of small abdominal aortic aneurysms	Registry
M2S16	Absence of unplanned reoperation after closed lower extremity major amputation	Registry
M2S17	M2S 17: Absence of serious technical complications during peripheral arterial intervention	Registry
M2S19	M2S 19: Proper patient selection for perforator vein ablation	Registry
M2S2	M2S 2: Amputation-free survival assessed at least 9 months following Infra-Inguinal Bypass for intermittent claudication	Registry
M2S5	M2S 5: Amputation-free survival at assessed at least 9 months following Peripheral Vascular Intervention for intermittent claudication	Registry
M2S7	M2S 7: Ipsilateral stroke-free survival at assessed at least 9 months following Carotid Artery Stenting for asymptomatic procedures	Registry
M2S8	M2S 8: Ipsilateral stroke-free survival assessed at least 9 months following isolated Carotid Endarterectomy for asymptomatic procedures	Registry
M2S9	M2S 9: Imaging-based maximum aortic diameter assessed at least 9 months following Thoracic and Complex EVAR procedures	Registry
MA1	Case Delay	Registry
MA3	Corneal Abrasion	Registry
MBHR1	Anxiety Utilization of the GAD-7 Tool	Registry
MBHR2	Anxiety Response at 6-months	Registry
MBSAQIP10	Risk standardized rate of patients who experienced a postoperative escalation in care event following a primary Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation	Registry
MBSAQIP11	Risk standardized rate of patients who experienced a pulmonary complication following a primary Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy	Registry
MBSAQIP12	Risk standardized rate of patients who experienced a postoperative complication following a primary Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation	Registry
MBSAQIP7	Risk standardized rate of patients who experienced postoperative nausea, vomiting or fluid/electrolyte/nutritional depletion following a primary Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation	Registry
MBSAQIP8	Risk standardized rate of patients who experienced an extended length of stay (> 3 days) following a primary Laparoscopic Roux-en-Y Gastric Bypass or Laparoscopic Sleeve Gastrectomy operation	Registry
MEDNAX52	Use of a “PEG Test” to Manage Patients Receiving Opioids	Registry
MEX1	MEX1: Heel Pain Treatment Outcomes for Adults	Registry
MEX10	Vascular Testing Outcome Measure Supervised Programs	Registry
MEX11	MEX2018-19: Non-Invasive Vascular Testing in Patients with Abnormal CVI Screening That Completed Hyperbaric Oxygen Therapy	Registry
MEX12	Peripheral Vascular Assessment % of Diabetic Patients 50+	Registry
MEX13	MEX2018-22: Patients with Lower Limb Ulceration with a Previously Abnormal Vascular Study Receiving Negative Pressure Wound Therapy	Registry
MEX2	MEX2: Heel Pain Treatment Outcomes for Pediatric Patients	Registry
MEX3	MEX3: Identification of Flat Foot in Pediatric Patients	Registry
MEX4	MEX2018-2: Bunion Outcome - Adult and Adolescent	Registry
MEX5	MEX2018-3: Hammer Toe Outcome	Registry
MEX6	MEX2018-11: Peripheral Vascular Assessment - Patients 70+	Registry
MEX7	MEX2018-6: Foot Wound Outcome	Registry
MEX8	MEX2018-20: Non-Invasive Vascular Testing Follow-up in Patients After Revascularization	Registry
MEX9	MEX2018-16: Non-Invasive Vascular Testing in Patients Diagnosed with Intermittent Claudication Who Use Cilostazol or Pentoxifylline	Registry
MHAN3	Plan All Cause Readmissions	Registry
MICS1	General Health Postoperative Improvement	Registry
MICS2	Surgery Specific Postoperative Improvement in Pain Levels	Registry
MICS3	Surgery Specific Postoperative Improvement in Function Levels	Registry
MIRAMED16	Perioperative Pain Plan	Registry
MIRAMED17	Rate of witnessed gastric aspiration	Registry
MIRAMED18	Unplanned Conversion to General Anesthesia from Regional or MAC for all scheduled cases	Registry
MIRAMED19	Onset atrial fibrillation or dysrthymia requiring unanticipated therapy	Registry
MIRAMED20	Perioperative cognitive function test in elderly	Registry
MNCM5	Ischemic Vascular Disease Use of Aspirin or Anti-platelet Medication	Registry
MNCM6	Diabetes A1c Control (<8.0)	Registry
MOA1	Objectifying pain and/or functionality to determine manipulative medicine efficacy with correlative treatment adjustment	Registry
MOA12	Treatment of spinal stenosis with manipulative medicine and alternative medicine modalities	Registry
MOA13	Urine Drug Screen Utilization in Pain Management and Substance Use Disorders; no less than quarterly for pain and no less than monthly for substance use disorders	Registry
MOA14	Addressing anxiety in pain patients with SNRI and SSRIs and reducing/eliminating benzodiazepines for chronic anxiety	Registry
MOA15	Weight loss in pain patients with BMI > = 30 with opiate utilization for weight related pain conditions rather than opiate dose escalation for improved pain control	Registry
MOA2	Appropriate use of advanced imaging by ordering provider with glucocorticoid management to spare motor neuron loss when physical findings suggest neuropathic etiology	Registry
MOA7	Appropriate controlled substance prescribing (definitive diagnosis(es)) via adherence to Controlled Substance Agreements (CSA) or (OA's) with corrective action taken for pain and/or substance use disorder patients when violations occur	Registry
MSSIC1	Pre-surgical screening for depression	Registry
MSSIC10	Percent of patients achieving MCID for pain-related disability (ODI/NDI)	Registry
MSSIC11	Percent Satisfied with Result	Registry
MSSIC12	Risk-adjusted rate of hospital readmission	Registry
MSSIC13	Risk-adjusted rate of surgical site infection	Registry
MSSIC14	Risk-adjusted rate of urinary retention	Registry
MSSIC16	Percent of patients achieving MCID for myelopathy	Registry
MSSIC6	Percent same-day ambulation	Registry
MSSIC7	Rate of use of Pre-op skin preparation/wash	Registry
MSSIC8	Percent of patients achieving MCID for back or neck pain	Registry
MSSIC9	Percent of patients achieving MCID for leg or arm pain	Registry
MUSIC1	Prostate Biopsy Antibiotic Compliance	Registry
MUSIC10	Prostate Cancer: Confirmation Testing in low risk AS eligible patients	Registry
MUSIC11	Prostate Cancer: Follow-Up Testing for patients on active surveillance for at least 30 months	Registry
MUSIC3	Prostate Cancer: Avoidance of Overuse of CT Scan for Staging Low Risk Prostate Cancer Patients	Registry
MUSIC4	Prostate Cancer: Active Surveillance/Watchful Waiting for Low Risk Prostate Cancer Patients	Registry
MUSIC5	Prostate Cancer: Radical Prostatectomy Cases LOS	Registry
MUSIC9	Prostate Biopsy: Repeat Biopsy for Patients with Atypical Small Acinar Proliferation (ASAP)	Registry
NHBPC10	Telephone Contact, Virtual, or In-person Visit Within 48 Hours of Hospital Discharge of Home-Based Primary Care and Palliative Care Patients	Registry
NHBPC13	Interdisciplinary Team Assessment for Home-Based Primary care and Palliative Care Patients	Registry
NHBPC14	Cognitive Assessment for Home-Based Primary Care and Palliative Care Patients	Registry
NHBPC15	A Functional Assessment (Basic and Instrumental Activities of Daily Living [ADL]) for Home-Based Primary Care and Palliative Care Patients (Multiperformance Measure)	Registry
NHBPC16	Patient Reported Outcome for Home-Based Primary Care and Palliative Care Practices	Registry
NHBPC17	Screening for Depression and Follow-up Plan in Home-Based Primary Care and Palliative Care Patients	Registry
NHBPC2	Alcohol Problem Use Assessment for Home-Based Primary Care and Palliative Care Patients	Registry
NHBPC6	Screen for Risk of Future Fall for Home-Based Primary Care and Palliative Care Patients	Registry
NHBPC7	Delirium Assessment in Home-Based Primary Care and Palliative Care Patients: Medication List Reviewed & Offending Medications Discontinued (Multiperformance-Rate Measure)	Registry
NHBPC9	Referral to Hospice for Appropriate Home-Based Primary Care and Palliative Care Patients	Registry
NHCR4	NHCR4: Repeat screening or surveillance colonoscopy recommended within one year due to inadequate/poor bowel preparation	Registry
NHCR5	NHCR5: Repeat colonoscopy recommended due to piecemeal resection	Registry
NHCR9	Appropriate indication for colonoscopy	Registry
NIPM10	COMMUNICATING CONCURRENT OPIOID AND BENZODIAZEPINE PRESCRIBING TO OTHER PRESCRIBERS	Registry
NIPM11	PATIENT COUNSELING REGARDING RISKS OF CO-PRESCRIBED OPIOIDS AND BENZODIAZEPINES	Registry
NIPM12	FUNCTIONAL STATUS ASSESSMENT FOR SPINAL CORD STIMULATOR IMPLANTATION	Registry
NIPM13	FUNCTIONAL STATUS ASSESSMENT FOR LUMBAR MEDIAL BRANCH RADIOFREQUENCY ABLATION	Registry
NIPM14	FUNCTIONAL STATUS ASSESSMENT FOR CERVICAL MEDIAL BRANCH RADIOFREQUENCY ABLATION	Registry
NIPM15	REDUCTION IN PATIENT REPORTED PAIN FOLLOWING SPINAL CORD STIMULATOR IMPLANTATION FOR FAILED BACK SURGERY SYNDROME	Registry
NIPM16	REDUCTION IN PATIENT REPORTED PAIN FOLLOWING LUMBAR MEDIAL BRANCH RADIOFREQUENCY ABLATION	Registry
NIPM17	REDUCTION IN PATIENT REPORTED PAIN FOLLOWING CERVICAL/THORACIC MEDIAL BRANCH RADIOFREQUENCY ABLATION	Registry
NIPM4	APPROPRIATE PATIENT SELECTION FOR DIAGNOSTIC FACET JOINT PROCEDURES	Registry
NIPM8	AVOIDING EXCESSIVE USE OF EPIDURAL INJECTIONS IN MANAGING CHRONIC PAIN ORIGINATING IN THE CERVICAL AND THORACIC SPINE	Registry
NIPM9	AVOIDING EXCESSIVE USE OF THERAPEUTIC FACET JOINT INTERVENTIONS IN MANAGING CHRONIC CERVICAL AND THORACIC SPINAL PAIN	Registry
NJIISMD1	Critical Result: Pulmonary Embolism	Registry
NJIISMD10	Critical Result: Ruptured Ectopic Pregnancy	Registry
NJIISMD11	Critical Result: New Deep Venous Thrombosis (DVT)	Registry
NJIISMD12	Critical Result: Ectopic Pregnancy	Registry
NJIISMD17	Result Requiring Follow Up Protocol	Registry
NJIISMD19	Critical Result: Cord Compression	Registry
NJIISMD2	Critical Result: ICH	Registry
NJIISMD20	Critical Result: CTA of GI bleed	Registry
NJIISMD21	Critical Result: Positive bleeding scan	Registry
NJIISMD22	Critical Result: Acute Ocular injury	Registry
NJIISMD3	Critical Result: Aortic Dissection	Registry
NJIISMD8	Critical Result: Occlusive Intracranial Stroke	Registry
NJIISMD9	Critical Result: Placental abruption	Registry
NNEPTN1	Substance Use Screening	Registry
NNEPTN2	Transforming Clinical Practice Initiative Common Measure Name: Substance Use Screening and Intervention Composite	Registry
NNEPTN3	Transforming Clinical Practice Initiative Common Measure Name: TCP01: Documentation of a Comprehensive Health and Life Plan Developed Collaboratively by the Patient and the Health Professional Team	Registry
NOF12	Median Time to Pain Management for Long Bone Fracture	Registry
NOF13	Osteoporosis: Management Following Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older	Registry
NOF6	Hip Fracture Mortality Rate (IQI 19)	Registry
NOF7	Osteoporosis: percentage of patients, any age, with a diagnosis of osteoporosis who are either receiving both calcium & vitamin D intake, & exercise at least once within 12 months.	Registry
NPA11	Unplanned Readmission Following Spine Procedure within the 30-Day Postoperative Period	Registry
NPA12	Selection of Prophylactic Antibiotic Prior to Spine Procedure	Registry
NPA14	Medicine Reconciliation Following Spine Related Procedure	Registry
NPA15	Risk Assessment for Elective Spine Procedure	Registry
NPA16	Depression and Anxiety Assessment Prior to Spine-Related Therapies	Registry
NPA17	Narcotic Pain Medicine Management Following Elective Spine Procedure	Registry
NPA18	Smoking Assessment and Cessation Coincident With Spine-Related Therapies	Registry
NPA19	Body Mass Assessment and Follow-up Coincident With Spine-Related Therapies	Registry
NPA20	Unhealthy Alcohol Use Assessment Coincident With Spine Care	Registry
NPA23	Spine/Extremity Pain Assessment	Registry
NPA3	Functional Outcome Assessment for Spine Intervention	Registry
NPA4	Quality-of-Life Assessment for Spine Intervention	Registry
NPA5	Patient Satisfaction With Spine Care	Registry
NPA6	Spine-Related Procedure Site Infection	Registry
NPAGSC10	Spine/Extremity Pain Assessment	Registry
NPAGSC3	Functional Outcome Assessment for Spine Intervention	Registry
NPAGSC4	Quality-of-Life Assessment for Spine Intervention	Registry
NPAGSC5	Patient Satisfaction with Spine Care	Registry
NPAGSC6	Depression and Anxiety Assessment Prior to Spine-Related Therapies	Registry
NPAGSC7	Narcotic Pain Medicine Management Prior to and Following Spine Therapy	Registry
NPAGSC8	Complication Following Percutaneous Spine-Related Procedure	Registry
NPAGSC9	Unplanned Admission to Hospital Following Percutaneous Spine Procedure within the 30-Day Post-procedure Period	Registry
NPQR1	Notification to the ordering provider requesting myoglobin or CK-MB in the diagnosis of suspected acute myocardial infarction (AMI).	Registry
NPQR10	Rate of amended pathology reports with a major discrepancy	Registry
NPQR11	Rate of communicating results of an amended report with a major discrepancy to the responsible provider	Registry
NPQR12	Rate of cytopathology case review	Registry
NPQR13	Rate of notification to clinical provider of a new diagnosis of malignancy	Registry
NPQR14	Frozen section diagnosis within 20 minutes of receipt in lab (single block frozen section)	Registry
NPQR2	Notification to the ordering provider requesting thyroid screening tests other than only a Thyroid Stimulating Hormone (TSH) test in the initial screening of a patient with a suspected thyroid disorder	Registry
NPQR3	Notification to the ordering provider requesting amylase testing in the diagnosis of suspected acute pancreatitis	Registry
NPQR4	Time interval: critical value reporting for chemistry	Registry
NPQR5	Time interval: critical value reporting for cerebrospinal fluid - white blood cell (CSF - WBC)	Registry
NPQR6	Time interval: critical value reporting for toxicology	Registry
NPQR7	Time interval: critical value reporting for troponin	Registry
NPQR8	Rate of review of slides with high-grade squamous intraepithelial lesion (HSIL) with negative cervical biopsies	Registry
NPQR9	Rate of follow up letter after high-grade squamous intraepithelial lesion (HSIL) pap test	Registry
OBERD22	Post Stroke Outcome and Follow-Up	Registry
OBERD23	Health Related Quality of Life: Patient Defined Outcomes	Registry
OBERD25	Tracking Satisfaction Improvement with CG-CAHPS	Registry
OBERD26	Cervical Spine Functional Outcomes	Registry
OBERD27	Foot/Ankle Functional Outcomes	Registry
OBERD28	Hip Functional Outcomes	Registry
OBERD29	Knee Functional Outcomes	Registry
OBERD30	Lumbar Spine Functional Outcomes	Registry
OBERD31	Quality of Life-Mental Health Outcomes	Registry
OBERD32	Quality of Life - Physical Health Outcomes	Registry
OBERD33	Patient Acceptable Symptom State Outcomes	Registry
OBERD34	Upper Extremity Functional Outcomes	Registry
OEIS2	Emergent transfer from an outpatient, ambulatory surgical center, or office setting	Registry
OEIS3	Antiplatelet Therapy	Registry
OEIS4	Lipid-Lowering Medications for Patients with PAD	Registry
OEIS6	Appropriate non-invasive arterial testing for patients with intermittent claudication who are undergoing a LE peripheral vascular intervention	Registry
ONSQIR18	Goal Setting and Attainment for Cancer Survivors	Registry
ONSQIR20	Fatigue Improvement	Registry
PIMSH1	Advance Care Planning in Stage 4 Disease	Registry
PIMSH2	Utilization of GCSF in Metastatic Colon Cancer	Registry
PIMSH3	Combination chemotherapy is recommended or administered within 4 months (120 days) of diagnosis for women under 70 with AJCC T1cN0M0 or Stage IB-III hormone receptor negative breast cancer	Registry
PINC1	Risk-adjusted 30 day Readmission for Acute Myocardial Infarction	Registry
PINC2	Risk-adjusted 30 day Readmission for Heart Failure	Registry
PINC3	Risk-adjusted 30 day Readmission for Pneumonia	Registry
PINC33	Risk-Adjusted Average Length of Inpatient Hospital Stay for Acute Myocardial Infarction	Registry
PINC34	Risk-Adjusted Average Length of Inpatient Hospital Stay for Heart Failure	Registry
PINC35	Risk-Adjusted Average Length of Inpatient Hospital Stay for Pneumonia	Registry
PINC4	Risk-adjusted 30 day Inpatient Mortality for Acute Myocardial Infarction	Registry
PINC5	Risk-adjusted 30 day Inpatient Mortality for Heart Failure	Registry
PINC6	Risk-adjusted 30 day Inpatient Mortality for Pneumonia	Registry
PP1	Annual Monitoring for Patients on Persistent Medications (MPM)	Registry
PP2	Follow-Up After Hospitalization for Schizophrenia (7- and 30-day)	Registry
PP3	ADHD: Symptom Reduction in Follow up Period	Registry
PP4	Risky Behavior Assessment or Counseling by Age 18 Years	Registry
PP5	Bipolar disorder: the percentage of patients diagnosed and treated for bipolar disorder who are monitored for change in their symptom complex within 12 weeks of initiating treatment; AND if there is no change or deterioration in symptoms, a revised care plan is documented following the 12 week monitoring phase	Registry
PP6	Pharmacological Treatment of Dementia	Registry
PP7	Use of Multiple Concurrent Antipsychotics in Children and Adolescents (APC)	Registry
PPRNET13	Chronic Kidney Disease (CKD): eGFR Monitoring	Registry
PPRNET14	Chronic Kidney Disease (CKD): Hemoglobin Monitoring	Registry
PPRNET24	Appropriate Treatment for Adults with Upper Respiratory Infection	Registry
PPRNET28	NSAID or Cox 2 Inhibitor Use in Patients with Heart Failure (HF), Hypertension (HTN), or Chronic Kidney Disease (CKD)	Registry
PPRNET29	Monitoring Serum Creatinine	Registry
PPRNET31	Screening for Type 2 Diabetes	Registry
PPRNET32	Screening for albuminuria in patients at risk for CKD (DM and/or HTN)	Registry
PPRNET33	Avoiding Use of CNS Depressants in Patients on Long-Term Opioids	Registry
PPRNET34	Zoster (Shingles) Vaccination	Registry
PPRNET8	Antiplatelet Medication for High Risk Patients	Registry
QOPI11	Combination chemotherapy received within 4 months of diagnosis by women under 70 with AJCC stage IA (T1c) to III ER/PR negative breast cancer	Registry
QOPI15	GCSF administered to patients who received chemotherapy for metastatic cancer (Lower Score -Better)	Registry
QOPI21	Oncology: Treatment Summary Communication – Radiation Oncology	Registry
QOPI22	External Beam Radiotherapy for Bone Metastases	Registry
QOPI5	Chemotherapy administered to patients with metastatic solid tumor with performance status of 3, 4, or undocumented (Lower Score - Better)	Registry
QUANTUM31	Central Line Ultrasound Guidance	Registry
QUANTUM41	Case Cancellation on Day of Surgery	Registry
RCOIR1	CKD 3-5 Patients Seen at the Recommended Frequency Levels	Registry
RCOIR10	Upper Extremity Edema Improvement	Registry
RCOIR11	Optimal End Stage Renal Disease (ESRD) Starts	Registry
RCOIR3	CKD 3-5 Patients with a Urine ACR or Urine PCR Lab Test	Registry
RCOIR4	CKD 4-5 Patients with Transplant Referral	Registry
RCOIR5	ESRD Prevalence of Home Dialysis or Self-Care	Registry
RCOIR7	Improved Access Site Bleeding	Registry
RCOIR8	Post Procedure Bleeding	Registry
RPAQIR1	Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy	Registry
RPAQIR11	Hospitalization Rate Following Procedures Performed under Procedure Sedation Analgesia	Registry
RPAQIR12	Arterial Complication Rate Following Arteriovenous Access Intervention	Registry
RPAQIR13	Rate of Timely Documentation Transmission to Dialysis Unit/Referring Physician	Registry
RPAQIR14	Arteriovenous Graft Thrombectomy Success Rate	Registry
RPAQIR15	Arteriovenous Fistulae Thrombectomy Success Rate	Registry
RPAQIR16	Peritoneal Dialysis Catheter Success Rate	Registry
RPAQIR17	Peritoneal Dialysis Catheter Exit Site Infection Rate	Registry
RPAQIR18	Advance Directives Completed	Registry
RPAQIR2	Adequacy of Volume Management	Registry
RPAQIR4	Arteriovenous Fistula Rate	Registry
RPAQIR5	Transplant Referral	Registry
RPAQIR9	Advance Care Planning (Pediatric Kidney Disease)	Registry
SCG05	Improvement in Quality of Life from Partial Foot, Prosthetics	Registry
SCG1	SCG1 Evaluation of High Risk Pain Medications for MME	Registry
SCG2	SCG2 Outcome Assessment for Patients Prescribed Ankle Orthosis for Ambulation and Functional Improvement	Registry
SCG3	Outcome Assessment for Patients Prescribed Foot Orthosis for Ambulation and Functional Improvement	Registry
SCG4	Prevention of Antibiotic or Herbal Supplement Impairment of Anesthesia	Registry
SCG6	Outcome of High Risk Pain Medications Prescribed in Last 6 Months	Registry
SDPAD1	Education of patients with inflammatory diseases regarding increased cardiovascular risk and the need for PCP evaluation	Registry
SDPAD2	HCV testing in Lichen Planus	Registry
SDPAD3	Avoiding antibiotic use in rupture epidermal inclusion cyst	Registry
SDPAD4	Appropriate Testing and Treatment of Nail tinea infection	Registry
SMD23	Urgent Result: Breast Specimen Radiography	Registry
SMD24	Critical Result: Testicular Torsion	Registry
SMD25	Critical Result: Subdural hematoma	Registry
SMD26	GI Radiography Result Notification •Critical Result: Bowel Obstruction •Critical Result: Sigmoid Volvulus	Registry
SMD27	Chest Imaging Result Notification: •Critical Result: Pneumothorax •Critical Result: Tension Pneumothorax •Follow Up Result: Suspicious Lung Nodule	Registry
SMD28	Musculoskeletal Radiology Result Notification: •Critical Result: Fracture C-Spine •Urgent Result: Osteomyelitis •Urgent Result: Meniscal Tear	Registry
SMX1	Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia	Registry
SMX2	Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications	Registry
SMX3	SMX1004: Use of Multiple Concurrent Antipsychotics in Children and Adolescents	Registry
SMX5	Medication Adherence for Diabetes Medication	Registry
SMX6	Screening for Psychiatric or Behavioral Health Disorders	Registry
SMX7	Medication Adherence for Hypertension	Registry
SMX8	Assessment and Intervention for Psychosocial Distress in Adults Receiving Cancer Treatment	Registry
SMX9	Mental Health Assessment for Patients with orthopedic conditions	Registry
SPINEIQ3	Repeated X-ray Imaging	Registry
SPINEIQ5	Change in Functional Outcomes	Registry
SPINEIQ6	Change in Pain Intensity	Registry
SPINEIQ7	MRI of the lumbar spine without prior conservative care	Registry
SPINETRACK1	Percent of patients meeting MCID thresholds for back or neck pain	Registry
SPINETRACK2	Percent of patients meeting MCID thresholds for leg or arm pain	Registry
SPINETRACK3	Percent of patients meeting MCID thresholds for pain-related disability (ODI/NDI)	Registry
SPINETRACK4	Percent of patients meeting SCB thresholds for back or neck pain	Registry
SPINETRACK5	Percent of patients meeting SCB thresholds for leg or arm pain	Registry
SPINETRACK6	Percent of patients meeting SCB thresholds for pain-related disability (ODI/NDI)	Registry
SQOD1	Assessment and Management of Muscle Spasticity--Inpatient	Registry
SQOD2	Management of Muscle Spasticity--Outpatient	Registry
SQOD3	Post-Acute Brain Injury: Depression Screening and Follow-Up Plan of Care	Registry
SQOD4	Family Training—Inpatient Rehabilitation/Skilled Nursing Facility-Discharged to Home	Registry
SQOD5	Functional Assessment to Determine Rehabilitation Needs	Registry
STS1	Prolonged Length of Stay Following Coronary Artery Bypass Grafting	Registry
STS10	Operative Mortality for Lobectomy	Registry
STS11	Lobectomy – Air Leak Greater than 5 Days	Registry
STS12	Lobectomy – Unplanned Return to OR	Registry
STS13	Recording Performance Status Prior to Lung Cancer Resection	Registry
STS3	Prolonged Length of Stay for Coronary Artery Bypass Grafting (CABG) + Valve Replacement	Registry
STS5	Prolonged Length of Stay following Valve Surgery	Registry
STS7	Patient Centered Surgical Risk Assessment and Communication for Cardiac Surgery	Registry
STS8	Operative Mortality for Esophageal Resection	Registry
STS9	Recording Performance Status prior to Esophageal Cancer Resection	Registry
UREQA1	UR002 - Ankylosing Spondylitis: Controlled Disease	Registry
UREQA2	UR003 - Ankylosing Spondylitis: Appropriate Pharmacologic Therapy	Registry
UREQA3	UR008 - Controlled Gout for Patients on Urate-Lowering Pharmacologic Therapy	Registry
UREQA4	UR007 - Folic or Folinic Acid Therapy for Patients Treated with Methotrexate	Registry
UREQA5	UR006 - Regular Evaluation of Psoriatic Arthritis (PsA)	Registry
USWR13	Patient Vital Sign Assessment and Blood Glucose Check Prior to HBOT Treatment	Registry
USWR16	Major Amputation in Wagner 3, 4, or 5 Diabetic Foot Ulcers (DFUs) Treated with HBOT	Registry
USWR20	Nutritional Screening and Intervention Plan in Patients with Chronic Wounds and Ulcers	Registry
USWR22	Patient Reported Nutritional Assessment in Patients with Wounds and Ulcers	Registry
USWR23	Non Invasive Arterial Assessment of patients with lower extremity wounds or ulcers for determination of healing potential	Registry
USWR24	Patient Reported Experience of Care: Wound Outcome	Registry
VCMAHEMR1	Advance Care planning: Electronic submission of new POLST/MOLST/POST/MOST ("orders for life-sustaining treatment" or "orders for scope of treatment") into an eRegistry powered by Medcordance	Registry
WCHQ10	Diabetes Care All or None Outcome Measure: Optimal Control	Registry
WCHQ15	Screening For Osteoporosis	Registry
WCHQ32	Controlling High Blood Pressure: eGFR Test Annually	Registry
WCHQ9	Diabetes Care All or None Process Measure: Optimal Testing	Registry