#	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
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
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
044	Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery	Registry
046	Medication Reconciliation Post-Discharge	Claims, Registry
047	Advance 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
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
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, 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, 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
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, 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
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 Moderate to Severe Pain	Registry
145	Radiology: Exposure Dose Indices or Exposure Time and Number of Images 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
160	HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis	Electronic Health Record
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	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
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 Lower Leg, Foot or Ankle Impairments	Registry
220	Functional Status Change for Patients with Low Back 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 General Orthopedic Impairments	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
240	Childhood Immunization Status	Electronic Health Record
243	Cardiac Rehabilitation Patient Referral from an Outpatient Setting	Registry
249	Barrett's Esophagus	Claims, Registry
250	Radical Prostatectomy Pathology Reporting	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
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
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
277	Sleep Apnea: Severity Assessment at Initial Diagnosis	Registry
279	Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy	Registry
281	Dementia: Cognitive Assessment	Electronic Health Record
282	Dementia: Functional Status Assessment	Registry
283	Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management	Registry
286	Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia	Registry
288	Dementia: Education and Support of Caregivers for Patients with Dementia	Registry
290	Parkinson's Disease: Psychiatric Symptoms Assessment for Patients with Parkinson's Disease	Registry
291	Parkinson's Disease: Cognitive Impairment or Dysfunction Assessment for Patients with Parkinson's Disease	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
309	Cervical Cancer Screening	Electronic Health Record
310	Chlamydia Screening for Women	Electronic Health Record
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
320	Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients	Claims, Registry
321	CAHPS for MIPS 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
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
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 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
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 Purposes	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
370	Depression Remission at Twelve Months	Electronic Health Record, Cms Web Interface, Registry
371	Depression Utilization of the PHQ-9 Tool	Electronic Health Record
372	Maternal Depression Screening	Electronic Health Record
374	Closing the Referral Loop: Receipt of Specialist Report	Electronic Health Record, Registry
375	Functional Status Assessment for Total Knee Replacement	Electronic Health Record
376	Functional Status Assessment for Total Hip Replacement	Electronic Health Record
377	Functional Status Assessments for Congestive Heart Failure	Electronic Health Record
378	Children Who Have Dental Decay or Cavities	Electronic Health Record
379	Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists	Electronic Health Record
382	Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment	Electronic Health Record
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-Susceptible 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 Systemic 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 Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) Where Patients Are Discharged Alive	Registry
418	Osteoporosis Management in Women Who Had a Fracture	Claims, Registry
419	Overuse of Imaging for the Evaluation of Primary Headache	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
424	Perioperative Temperature Management	Registry
425	Photodocumentation of Cecal Intubation	Claims, 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 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
448	Appropriate Workup 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) Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies	Registry
453	Percentage of Patients Who Died from Cancer Receiving Chemotherapy in the Last 14 Days of Life (lower score - better)	Registry
454	Percentage of Patients who Died from Cancer with More than One Emergency Department Visit in the Last 30 Days of Life (lower score - better)	Registry
455	Percentage of Patients Who Died from Cancer Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life (lower score - better)	Registry
456	Percentage of Patients Who Died From Cancer Not Admitted To Hospice (lower score - better)	Registry
457	Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score - better)	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
463	Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics)	Registry
464	Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use	Registry
465	Uterine Artery Embolization Technique: Documentation of Angigraphic Endpoints and Interrogation of Ovarian Arteries	Registry
467	Developmental Screening in the First Three Years of Life	Registry
468	Continuity of Pharmacotherapy for Opioid Use Disorder (OUD)	Registry
469	Average Change in Functional Status Following Lumbar Fusion Surgery	Registry
470	Average Change In Functional Status Following Total Knee Replacement Surgery	Registry
471	Average Change in Functional Status Following Lumbar Discectomy/Laminotomy Surgery	Registry
472	Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture	Electronic Health Record
473	Average Change in Leg Pain Following Lumbar Fusion Surgery	Registry
474	Zoster (Shingles) Vaccination	Registry
475	HIV Screening	Electronic Health Record
ACO321	CAHPS for ACOs Group Survey	Certified Survey Vendor
PI_PPHI_1	Security Risk Analysis
PI_ONCDIR_1	ONC Direct Review Attestation
PI_INFBLO_1	Prevention of Information Blocking Attestation
PI_ONCACB_1	ONC-ACB Surveillance Attestation
PI_EP_1	e-Prescribing
PI_LVPP_1	e-Prescribing Exclusion
PI_EP_2	Query of the Prescription Drug Monitoring Program (PDMP)
PI_EP_3	Verify Opioid Treatment Agreement
PI_HIE_1	Support Electronic Referral Loops By Sending Health Information
PI_LVOTC_1	Support Electronic Referral Loops By Sending Health Information Exclusion
PI_HIE_4	Support Electronic Referral Loops By Receiving and Incorporating Health Information
PI_LVITC_2	Support Electronic Referral Loops By Receiving and Incorporating Health Information Exclusion
PI_CUITC_1	Support Electronic Referral Loops By Receiving and Incorporating Health Information Exclusion
PI_PEA_1	Provide Patients Electronic Access to Their Health Information
PI_PHCDRR_2	Syndromic Surveillance Reporting
PI_PHCDRR_2_MULTI	Syndromic Surveillance Reporting for Multiple Registry Engagement
PI_PHCDRR_2_EX_1	Syndromic Surveillance Reporting Exclusion
PI_PHCDRR_2_EX_2	Syndromic Surveillance Reporting Exclusion
PI_PHCDRR_2_EX_3	Syndromic Surveillance Reporting Exclusion
PI_PHCDRR_1	Immunization Registry Reporting
PI_PHCDRR_1_MULTI	Immunization Registry Reporting for Multiple Registry Engagement
PI_PHCDRR_1_EX_1	Immunization Registry Reporting Exclusion
PI_PHCDRR_1_EX_2	Immunization Registry Reporting Exclusion
PI_PHCDRR_1_EX_3	Immunization Registry Reporting Exclusion
PI_PHCDRR_3	Electronic Case Reporting
PI_PHCDRR_3_MULTI	Electronic Case Reporting for Multiple Registry Engagement
PI_PHCDRR_3_EX_1	Electronic Case Reporting Exclusion
PI_PHCDRR_3_EX_2	Electronic Case Reporting Exclusion
PI_PHCDRR_3_EX_3	Electronic Case Reporting Exclusion
PI_PHCDRR_4	Public Health Registry Reporting
PI_PHCDRR_4_MULTI	Public Health Registry Reporting for Multiple Registry Engagement
PI_PHCDRR_4_EX_1	Public Health Registry Reporting Exclusion
PI_PHCDRR_4_EX_2	Public Health Registry Reporting Exclusion
PI_PHCDRR_4_EX_3	Public Health Registry Reporting Exclusion
PI_PHCDRR_5	Clinical Data Registry Reporting
PI_PHCDRR_5_MULTI	Clinical Data Registry Reporting for Multiple Registry Engagement
PI_PHCDRR_5_EX_1	Clinical Data Registry Reporting Exclusion
PI_PHCDRR_5_EX_2	Clinical Data Registry Reporting Exclusion
PI_PHCDRR_5_EX_3	Clinical Data Registry Reporting Exclusion
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_ACO_46	CAHPS for ACO SSM: Care Coordination	Certified Survey Vendor
CAHPS_9	CAHPS for MIPS SSM: Courteous and Helpful Office Staff	Certified Survey Vendor
CAHPS_ACO_45	CAHPS for ACO 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
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_PM_1	Participation in Systematic Anticoagulation Program
IA_PM_2	Anticoagulant Management Improvements
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_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_20	Glycemic Referring Services
IA_PM_21	Advance Care Planning
IA_CC_1	Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop
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_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_18	Relationship-Centered Communication
IA_BE_1	Use of certified EHR to capture patient reported outcomes
IA_BE_2	Use of QCDR to support clinical decision making
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_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_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_24	Financial Navigation Program
IA_PSPA_1	Participation in an AHRQ-listed patient safety organization.
IA_PSPA_2	Participation in MOC Part IV
IA_PSPA_3	Participate in IHI Training/Forum Event; National Academy of Medicine, AHRQ Team STEPPS® or Other Similar Activity
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
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_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_30	PCI Bleeding Campaign
IA_PSPA_31	Patient Medication Risk Education
IA_PSPA_32	Use of CDC Guideline for Clinical Decision Support to Prescribe Opioids for Chronic Pain via Clinical Decision Support
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_AHE_7	Comprehensive Eye Exams
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_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_BMH_10	Completion of Collaborative Care Management Training Program
IA_PCMH	Electronic submission of Patient Centered Medical Home accreditation
COST_EOPCI_1	Elective Outpatient Percutaneous Coronary Intervention (PCI)	Administrative Claims
COST_CCLI_1	Revascularization for Lower Extremity Chronic Critical Limb Ischemia	Administrative Claims
COST_SPH_1	Simple Pneumonia with Hospitalization	Administrative Claims
COST_SSC_1	Screening/Surveillance Colonoscopy	Administrative Claims
COST_KA_1	Knee Arthroplasty	Administrative Claims
COST_IOL_1	Routine Cataract Removal with Intraocular Lens (IOL) Implantation	Administrative Claims
COST_IHCI_1	Intracranial Hemorrhage or Cerebral Infarction	Administrative Claims
COST_STEMI_1	ST-Elevation Myocardial Infarction (STEMI) with Percutaneous Coronary Intervention (PCI)	Administrative Claims
MSPB_1	Medicare Spending Per Beneficiary (MSPB)	Administrative Claims
TPCC_1	Total Per Capita Costs (TPCC)	Administrative Claims
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
AAD2	Psoriasis: Screening for Psoriatic Arthritis	Registry
AAD5	Biopsy: Reporting Time - Clinician to Patient	Registry
ACMS1	Adherence to Mohs Micrographic Surgery Appropriate Use Criteria	Registry
AAPMR1	Assessment and Management of Muscle Spasticity--Inpatient	Registry
AAPMR2	Management of Muscle Spasticity--Outpatient	Registry
AAPMR3	Functional Assessment to Determine Rehabilitation Needs	Registry
AAPMR4	Family Training-Inpatient Rehabilitation/Skilled Nursing Facility-Discharged to Home	Registry
AAPMR5	Post-Acute Brain Injury: Depression Screening and Follow-Up Plan of Care	Registry
NPA24	Narcotic Pain Medicine Management Following Elective Spine Procedure	Registry
NPA25	Depression and Anxiety Assessment Prior to Spine-Related Therapies	Registry
NPA26	Functional Outcome Assessment for Spine Intervention	Registry
NPA27	Spine/Extremity Pain Assessment	Registry
NPA28	Patient Satisfaction With Spine Care	Registry
NPA29	Quality-of-Life Assessment for Spine Intervention	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
ABFM2	Patients Admitted to ICU who Have Care Preferences Documented	Registry
ABFM3	Patients Treated with an Opioid Who Are Given a Bowel Regimen	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
ABG16	Planned use of difficult airway equipment	Registry
ABG34	Mood Assessment Screening and treatment	Registry
ABG37	Preoperative Screening for Anesthetic Risk Factors	Registry
ABG38	Second provider present for induction/intubation of known or suspected difficult airway	Registry
ABG39	Preoperative Active Warming	Registry
ABG7	Immediate Adult Post-Operative Pain Management	Registry
AQI48	Patient-Reported Experience with 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
AQI61	Ambulatory Post-Discharge Patient Follow-Up	Registry
AQI62	Obstructive Sleep Apnea: Patient Education	Registry
AQI63	Neuromuscular Blockade: Documented Assessment of Neuromuscular Function Prior to Extubation	Registry
AQI64	Neuromuscular Blockade: Reversal Administered	Registry
AQI66	Obstructive Sleep Apnea: Mitigation Strategies	Registry
AQI67	Consultation for Frail Patients	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
ACEP25	Tobacco Use: Screening and Cessation Intervention for Patients with Asthma and COPD	Registry
ACEP30	Sepsis Management: Septic Shock: Lactate Clearance Rate of >= 10%	Registry
ACEP31	Appropriate Foley catheter use in the emergency department	Registry
ACEP48	Sepsis Management: Septic Shock: Lactate Level Measurement, Antibiotics Ordered, and Fluid Resuscitation	Registry
ACEP50	ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients	Registry
ACEP51	ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients	Registry
ACQR10	Syncope: complete evaluation	Registry
ACQR11	High Intensity Statin for patients with NSTEMI-ACS	Registry
ACQR12	ABCDEF Bundle - Early mobility for ICU patients	Registry
ACQR13	Sepsis: Hour One bundle	Registry
ACQR14	Use of HEART score for risk stratification in patients with suspected NSTEMI-ACS	Registry
ACQR15	Pneumonia: Use of CURB-65 for Risk Stratification in patient with CAP	Registry
ACQR16	COPD Exacerbation or CHF Exacerbation requiring Hospital Admission: Palliative Care Evaluation	Registry
ACQR3	COPD: Steroids for no more than 5 days in COPD Exacerbation	Registry
ACQR7	Sepsis Management: Septic Shock: Repeat Lactate Measurement Level Within 6 Hours	Registry
ACQR9	Use of ACE-I or ARB and beta blockade in CHF	Registry
MA1	Case Delay	Registry
AHSQC10	Ventral Hernia Repair: Pain and Functional Status Assessment	Registry
AHSQC6	Abdominal Wall Reconstruction Surgical Site Occurrence Requiring Procedural Intervention within the 30 Day Postoperative Period	Registry
IRIS1	Endothelial Keratoplasty - Post-operative improvement in best corrected visual acuity to 20/40 or better	Registry
IRIS13	Diabetic Macular Edema - Loss of Visual Acuity	Registry
IRIS18	Chronic Anterior Uveitis - Post-treatment visual acuity	Registry
IRIS2	Glaucoma - Intraocular Pressure (IOP) Reduction	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: Patients with a postoperative uncorrected visual acuity (UCVA) of 20/20 or better	Registry
IRIS24	Refractive Surgery: Patients with a postoperative correction within + or - 0.5 Diopter (D) of the intended correction	Registry
IRIS27	Complications After Cataract Surgery	Registry
IRIS35	Improvement of Macular Edema in Patients with Uveitis	Registry
IRIS36	Visual Acuity Improvement Following Cataract Surgery Combined with a Trabeculectomy or an Aqueous Shunt Procedure	Registry
IRIS37	Post-operative opioid management following oculoplastic surgery	Registry
IRIS38	Endothelial Keratoplasty - Dislocation Requiring Surgical Intervention	Registry
IRIS39	Intraocular Pressure Reduction Following Trabeculectomy or an Aqueous Shunt Procedure	Registry
IRIS40	Regaining Vision After Cataract Surgery	Registry
IRIS41	Improved visual acuity after epiretinal membrane treatment within 120 days	Registry
IRIS42	Return to the OR or endophthalmitis within 90 days after epiretinal membrane surgical treatment	Registry
IRIS43	Intraocular Pressure Reduction Following Laser Trabeculoplasty	Registry
IRIS44	Visual Field Progression in Glaucoma	Registry
IRIS45	Exudative Age-Related Macular Degeneration: Loss of Visual Acuity	Registry
IRIS46	Evidence of anatomic closure of macular hole within 90 days after surgery as documented by OCT	Registry
IRIS47	Return to the OR or endophthalmitis within 90 days after macular hole surgery	Registry
IRIS48	Adult Surgical Esotropia: Postoperative alignment	Registry
IRIS49	Surgical Pediatric Esotropia: Postoperative alignment	Registry
IRIS5	Surgery for Acquired Involutional Ptosis: Patients with an improvement of marginal reflex distance (MRD)	Registry
IRIS50	Amblyopia: Interocular visual acuity	Registry
IRIS51	Acute Anterior Uveitis: Post-treatment visual acuity	Registry
IRIS6	Acquired Involutional Entropion: Normalized lid position after surgical repair	Registry
AAN24	Vestibular Rehabilitation for Unilateral or Bilateral Vestibular Hypofunction	Registry
AAO12	Tympanostomy Tubes: Topical Ear Drop Monotherapy Acute Otorrhea	Registry
AAO13	Bell's Palsy: Inappropriate Use of Magnetic Resonance Imaging or Computed Tomography Scan (Inverse Measure)	Registry
AAO16	Age-related Hearing Loss: Audiometric Evaluation	Registry
AAO17	Age-related Hearing Loss: Advanced Diagnostic Imaging of Bilateral Presbycusis or Symmetric SNHL	Registry
AAO20	Tympanostomy Tubes: Hearing Test	Registry
AAO21	Otitis Media with Effusion: Hearing Test for Chronic OME > 3 months	Registry
AAO23	Allergic Rhinitis: Intranasal Corticosteroids or Oral Antihistamines	Registry
AAO24	Allergic Rhinitis: Avoidance of Leukotriene Inhibitors	Registry
AAO27	Tympanostomy Tubes: Resolution of Otitis Media with Effusion in Children	Registry
AAO28	Tympanostomy Tubes: Resolution of Otitis Media with Effusion in Adults	Registry
AAO29	Quality of Life for Patients with Neurotology Disorders	Registry
AAO30	Early Oral Cancer: Staging and Treatment	Registry
AAO31	Otitis Media with Effusion (OME): Avoidance of Inappropriate Use of Medications	Registry
AAO32	Standard BPPV Management	Registry
AAO33	Age-related Hearing Loss: Shared Decision Making	Registry
AAO34	Dysphonia: Postoperative Laryngeal Examination	Registry
AAO35	Benign Positional Paroxysmal Vertigo (BPPV): Dix-Hallpike and Canalith Repositioning	Registry
ASPS16	Airway Assessment for patients undergoing Rhinoplasty	Registry
ASPS17	Patient Satisfaction with Rhinoplasty Procedure	Registry
ASPS18	Shared-decision making for post-operative management of discomfort following Rhinoplasty	Registry
ASPS19	Pre-surgical discussion of motivations and outcomes for patients undergoing Rhinoplasty	Registry
ACMT1	Screening for risk of opioid misuse/overuse	Registry
ACMT2	Pregnancy test in women with a suspected toxicologic exposure	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
ACRAD1	CT Colonography True Positive Rate	Registry
ACRAD15	Report Turnaround Time: Radiography	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
ACRAD25	Report Turnaround Time: Mammography	Registry
ACRAD26	Appropriate venous access for hemodialysis	Registry
ACRAD29	Rate of percutaneous nephrostomy tube replacement within 30 days secondary to dislodgement	Registry
ACRAD30	Rate of Inadequate Percutaneous Image-Guided Biopsy	Registry
ACRAD34	Multi-strata weighted average for 3 CT Exam Types: Overall Percent of CT exams for which Dose Length Product is at or below the size-specific diagnostic reference level (for CT Abdomen-pelvis with contrast/single phase scan, CT Chest without contrast/single phase scan and CT Head/Brain without contrast/single phase scan)	Registry
ACRAD35	Screening Mammography Early Cancer Detection Rate	Registry
AQUA12	Benign Prostate Hyperplasia: IPSS improvement after diagnosis	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 within 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
AQUA21	Appropriate Management of Obstructive Azoospermia	Registry
AQUA22	Bone imaging and soft tissue imaging within 30 days (before or after) 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
AQUA29	Prostate Cancer: Patient Report of Urinary function after treatment	Registry
AQUA30	Prostate Cancer: Patient Report of Sexual function after treatment	Registry
AQUA31	Prostate Cancer: Documentation of PSA, Gleason score and clinical stage for risk stratification	Registry
AQUA32	Hypogonadism: Laboratory evaluation conducted within 6 months of starting testosterone replacement	Registry
AQUA33	Intracavernosal Injection Therapy In-Office Test	Registry
AQUA34	Genetic Testing and Patient Counseling of the Azoospermic Male	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
MUSIC4	Prostate Cancer: Active Surveillance/Watchful Waiting for Low Risk Prostate Cancer Patients	Registry
QOPI21	Oncology: Treatment Summary Communication - Radiation Oncology	Registry
QOPI22	External Beam Radiotherapy for Bone Metastases	Registry
AQI18	Coronary Artery Bypass Graft (CABG): Prolonged Intubation - Inverse Measure	Registry
AQI49	Adherence to Blood Conservation Guidelines for Cardiac Operations using Cardiopulmonary Bypass (CPB) - Composite	Registry
AQI65	Avoidance of Cerebral Hyperthermia for Procedures Involving Cardiopulmonary Bypass	Registry
QUANTUM31	Central Line Ultrasound Guidance	Registry
EPREOP29	Preoperative Assessment for Opioid Dependence Risk	Registry
EPREOP30	Ultrasound Guidance for Peripheral Nerve Block with Patient Experience	Registry
CCOME1	Patient-Reported Pain and/or Function Improvement after Total Knee Arthroplasty	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
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
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
ASPS20	Wound complications after primary panniculectomy in patients with BMI > or = to 30	Registry
ASPS5	Breast Reconstruction: Return to OR	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
CDR1	Adequate Off-loading of Diabetic Foot Ulcer at each visit	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 Outcome for Patients with Epilepsy	Registry
AAN14	Current MS Disability Scale Score	Registry
AAN19	Botulinum Toxin Serotype A (BoNT-A) for spasticity or dystonia	Registry
AAN20	Querying and follow-up for co-morbid conditions of tic disorder (TD) and Tourette syndrome (TS)	Registry
AAN22	Global Health	Registry
AAN23	Avoidance of Dopamine-Blocking Medications in Patients with Parkinson's Disease	Registry
AAN25	Pediatric Medication reconciliation	Registry
AAN26	Activity counseling for back pain	Registry
AAN27	Falls plan of care	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
MICS4	Pain, Function and General Health Postoperative Improvement	Registry
CCOME2	Patient-Reported Pain and/or Function Improvement after Total Hip Arthroplasty	Registry
CCOME3	Patient-Reported Pain and/or Function Improvement after Total Shoulder Arthroplasty	Registry
CCOME4	Patient-Reported Pain and/or Function Improvement after ACLR Surgery	Registry
CCOME5	Extent of Osteoarthritis Observed in Arthroscopic Partial Meniscectomy	Registry
CCOME6	Patient-Reported Pain and/or Function Improvement after APM Surgery	Registry
CLLC4	Foot Bone Infection Diagnosis Without MRI	Registry
CLLC5	Monitoring for albuminuria in patients with CKD	Registry
CLLC6	Appropriate dosages of H2 blockers in patients with CrCl < 50 ml/min	Registry
CLLC7	Renal Dysfunction: New Oral Anticoagulants (NOACs) Management	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
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
PPRNET8	Antiplatelet Medication for High Risk Patients	Registry
SCG6	Outcome of High Risk Pain Medications Prescribed in Last 6 Months	Registry
SCG7	Evaluation of High Risk Pain Medications for MME	Registry
CODE10	Improved Global Physical Health Outcome Assessment for Shoulder Arthroscopy	Registry
CODE12	Improved Functional Outcome Assessment for Hip Arthroscopy	Registry
CODE3	Improved Functional Outcome Assessment for Foot/Ankle Repair	Registry
CODE5	Improved Global Physical Health Outcome Assessment for Spine Surgery	Registry
CODE9	Improved Global Physical Health Outcome Assessment for Hand/Wrist/Elbow Repair	Registry
CESQIP1	Post operative hypocalcemia after thyroidectomy surgery	Registry
CESQIP3	Pre operative ultrasound exam of patients with thyroid cancer	Registry
CESQIP5	Related readmission for adrenal related problems	Registry
CUHSM3	CAHPS 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
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 Opiates 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
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
ECPR51	Discharge Prescription of Naloxone after Opioid Poisoning or Overdose	Registry
ECPR52	Appropriate Treatment of Psychosis and Agitation in the Emergency Department	Registry
ECPR53	Clinician Reporting of Loss of Consciousness to State Department of Public Health or Department of Motor Vehicles	Registry
ECPR6	Mean Time from Emergency Department (ED) Arrival to ED Departure for Discharged Higher Acuity ED Patients	Registry
EMIQ1	tPA and Endovascular Therapy Considered for Stroke Patients	Registry
FOTO1	Functional Status Change for Patients with Neck Impairments	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
GIQIC19	Appropriate indication for esophagogastroduodenoscopy (EGD)	Registry
GIQIC21	Appropriate follow-up interval of not less than 5 years for colonoscopies with findings of 1-2 tubular adenomas < 10 mm OR of 10 years for colonoscopies with only hyperplastic polyp findings in rectum or sigmoid	Registry
NHCR4	Repeat screening or surveillance colonoscopy recommended within one year due to inadequate/poor bowel preparation	Registry
HF4	Shoulder Arthroscopy: Measure of Change in a Validated Shoulder Patient Reported Outcome Following Shoulder Arthroscopy	Registry
HF7	Surgical Repair for Rotator Cuff Tear: Change in a Validated Shoulder Patient Reported Outcome Measure Following Surgical Rotator Cuff Repair	Registry
HF8	Knee Arthroscopy for Meniscal Repair: Change in a Validated Knee Measure Following Knee Arthroscopy for Meniscal Repair	Registry
IROMS11	Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in knee rehabilitation of patients with knee injury measured via their validated Knee Outcome Survey (KOS) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCID.	Registry
IROMS13	Failure to Progress (FTP): Proportion of patients not achieving a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with hip, leg or ankle injuries using the validated Lower Extremity Function Scale (LEFS) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCID.	Registry
IROMS15	Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with neck pain/injury measured via the validated Neck Disability Index (NDI).	Registry
IROMS19	Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with arm, shoulder, and hand injury measured via the validated Disability of Arm Shoulder and Hand (DASH) score, Quick Disability of Arm Shoulder and Hand (QDASH) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCID.	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 Readmit 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
HADV1	Use of high risk sleep medications in the elderly	Registry
HADV2	Atrial Fibrillation Prevention and Treatment - Lifestyle and Disease Factor Assessment	Registry
HADV3	Emergency Department effective use of a HEART (History, ECG, Age, Risk factors, Troponin) Score for treatment of patients presenting with nontraumatic chest pain.	Registry
HMIQ1	Discharge Summary Completed within 1 Day of Discharge Date	Registry
HMIQ2	Follow-Up Care Coordination Documented in Discharge Summary	Registry
ASNC19	Imaging Protocols for SPECT and PET MPI studies - Use of stress only protocol	Registry
ASNC23	SPECT-MPI study clinical utilization of Attenuation Correction image acquisition	Registry
ASNC28	SPECT-MPI 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
ASNC30	Transthoracic Echo (TTE) studies meeting appropriate use criteria	Registry
IGR1	Comprehensive TTE studies reporting a measured value of LVEF AND wall motion findings with LVEF < 50%	Registry
IGR10	Transthoracic Echo (TTE) performance per ASE guidelines	Registry
IGR2	Parameters in dobutamine testing for low flow, low gradient aortic stenosis	Registry
IGR3	Myocardial Perfusion Imaging (MPI) or Stress Echocardiography studies meeting appropriate use criteria	Registry
IGR4	Myocardial Perfusion Imaging (MPI) studies or Stress Echocardiography imaging studies not Equivocal	Registry
IGR5	Myocardial Perfusion Imaging (MPI) studies, Transthoracic Echo (TTE), or Stress Echocardiography imaging studies reporting Left Ventricular Ejection Fraction	Registry
IGR6	SPECT-MPI or Stress Echocardiography imaging protocol selection for morbidly obese patients	Registry
IGR7	SPECT-MPI or Stress Echocardiography imaging studies with adequate exercise testing performed	Registry
IGR8	SPECT-MPI or Stress Echocardiography study utilization of exercise as a stressor	Registry
IGR9	Stress echo performance for shortness of breath per ASE guidelines	Registry
IROMS12	Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in revalidation patients with knee injury pain.	Registry
IROMS14	Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with hip, leg or ankle (lower extremity except knee) injury.	Registry
IROMS16	Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with neck pain/injury.	Registry
IROMS17	Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation patients with low back pain measured via the validated Modified Low Back Pain Disability Questionnaire (MDQ) score.	Registry
IROMS18	Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in revalidation patients with low back pain.	Registry
IROMS20	Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with arm, shoulder, or hand injury.	Registry
K2MISSG1	Minimum Clinically Important Difference (MCID) of Patient-Reported Outcome Measurement Information System Computer Adapted Testing Physical Function Domain (PROMIS CAT PF) in Spine Surgery Patients	Registry
IQSS1	Hypogonadism: Serum T, CBC, PSA, IPSS within 6 months of Rx	Registry
IQSS2	Prostate Cancer: Newly diagnosed with documented T stage, PSA score, and Gleason score	Registry
IQSS3	Prostate Cancer: Treatment Options Counseling	Registry
IQSS4	BPH: Anticholinergics	Registry
MBHR1	Anxiety Utilization of the GAD-7 Tool	Registry
MBHR2	Anxiety Response at 6-months	Registry
MBHR3	Pain Interference Response utilizing PROMIS	Registry
MBHR4	Social Role Functioning Outcome utilizing PROMIS	Registry
MBHR5	Screening and monitoring for psychosocial problems among children and youth	Registry
MBHR6	Sleep Quality Screening and Sleep Response at 3-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
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
MEDNAX53	Use of Capnography for non-Operating Room anesthesia	Registry
MEDNAX54	Labor Epidural Failure when Converting from Labor Analgesia to Cesarean Section Anesthesia	Registry
MEDNAX55	Use of ASPECTS (Alberta Stroke Program Early CT Score) for non-contrast CT Head performed for suspected acute stroke.	Registry
MEX1	Heel Pain Treatment Outcomes for Adults	Registry
MEX14	Foot Ulcer Prevention	Registry
MEX2	Heel Pain Treatment Outcomes for Pediatric Patients	Registry
MEX3	Identification of Flat Foot in Pediatric Patients	Registry
MEX4	Bunion Outcome - Adult and Adolescent	Registry
MEX5	Hammer Toe Outcome	Registry
MUSIC12	Kidney Stones: ED visit within 30 days of ureteroscopy	Registry
MUSIC13	Kidney Stones: Antibiotics should not be provided at the time of SWL	Registry
MUSIC14	Kidney Stones: Alphablockers at discharge for patients undergoing kidney stone surgery, Ureteroscopy or Shockwave Lithotripsy	Registry
MUSIC15	Kidney Stones: SWL in patients with total renal stone burden > 2 cm or > 1 cm lower pole stones	Registry
MUSIC16	Kidney Stones: Opioid utilization after ureteroscopy	Registry
MUSIC3	Prostate Cancer: Avoidance of Overuse of CT Scan for Staging Low Risk Prostate Cancer Patients	Registry
MUSIC5	Prostate Cancer: Radical Prostatectomy Cases LOS	Registry
MIRAMED16	Perioperative Pain Plan	Registry
MIRAMED19	Onset atrial fibrillation or dysrhythmia requiring unanticipated therapy	Registry
MIRAMED20	Perioperative cognitive function test in elderly	Registry
MIRAMED21	Propofol Management of Obese Patients	Registry
MIRAMED22	New acute respiratory failure	Registry
ACMS2	Closing the Mohs Surgery Referral Loop: Transmission of Surgical Report	Registry
ACMS3	Antibiotic Prophylaxis for High Risk Cardiac / Orthopedic Cases prior to Mohs micrographic surgery - Prevention of Overuse	Registry
ACMS4	Surgical Site Infection Rate - Mohs Micrographic Surgery	Registry
MUSE1	CollaboRATE Shared Decision Making Score	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
NHBPC14	Cognitive Assessment and Plan of Care for Home-Based Primary Care and Palliative Care Patients	Registry
NHBPC15	Functional Assessment (Basic and Instrumental Activities of Daily Living [ADL]) for Home-Based Primary Care and Palliative Care Patients	Registry
NHBPC17	Screening for Depression and Follow-up Plan in Home-Based Primary Care and Palliative Care Patients	Registry
NHBPC2	Alcohol Problem Use Assessment & Brief Intervention 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
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
NPQR1	Notification to the ordering provider requesting myoglobin or CK-MB in the diagnosis of suspected acute myocardial infarction (AMI)	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 Specimen, 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
NHCR5	Repeat colonoscopy recommended due to piecemeal resection	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
OBERD28	Hip 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
SPINETRACK4	Percent of patients meeting SCB thresholds for back or neck pain	Registry
SPINETRACK6	Percent of patients meeting SCB thresholds for pain-related disability (ODI/NDI)	Registry
ONSQIR16	Recommendation for Exercise to Adult Cancer Survivors	Registry
ONSQIR18	Goal Setting and Attainment for Cancer Survivors	Registry
ONSQIR21	Patient Reported Health-Related Quality of Life (HRQOL) during Treatment for Advanced Cancer	Registry
ONSQIR22	PCR Test with MR2 or greater result (BCR-ABL1 transcript level <= 1% [IS]) for patients receiving TKI for at least 6 months for Chronic Myelogenous Leukemia	Registry
ONSQIR23	Assessment for and management of immune-related adverse events during cancer treatment with checkpoint inhibitors (ICPi)	Registry
OEIS2	Emergent transfer from an outpatient, ambulatory surgical center, or office setting	Registry
OEIS6	Appropriate non-invasive arterial testing for patients with intermittent claudication who are undergoing a LE peripheral vascular intervention	Registry
OEIS7	Structured Walking Program Prior to Intervention for Claudication	Registry
CAP10	Blood Laboratory Samples for Potassium Determination with Hemolysis Drawn in ED	Registry
CAP11	Accurate Human Epidermal Growth Factor Receptor 2 (HER2) Tumor Evaluation and Repeat Evaluation in Patients with Breast Carcinoma	Registry
CAP12	Accurate Human Epidermal Growth Factor Receptor 2 (HER2) Tumor Evaluation and Repeat Evaluation in Patients with Gastroesophageal Adenocarcinoma	Registry
CAP13	Anaplastic Lymphoma Kinase (ALK) Biomarker Testing to Inform Clinical Management and Treatment Decisions in Patients with Non-small Cell Lung Cancer	Registry
CAP14	Appropriate Formalin Fixation Time (6 - 72 hours) of Breast Cancer Specimens to Ensure Accurate Ancillary Testing Results	Registry
CAP15	BRAF Biomarker Testing to Inform Clinical Management and Treatment Decisions in Patients with Metastatic Colorectal Adenocarcinoma	Registry
CAP16	Epidermal Growth Factor Receptor (EGFR) Biomarker Testing to Inform Clinical Management and Treatment Decisions in Patients with Non-small Cell Lung Cancer	Registry
CAP17	FMS-like Tyrosine 3-Internal Tandem Duplication (FLT3-ITD) Biomarker Testing to Inform Clinical Management and Treatment Decisions in Patients with Acute Myeloid Leukemia	Registry
CAP18	Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing to Inform Clinical Management and Treatment Decisions in Patients with Primary or Metastatic Colorectal Carcinoma	Registry
CAP19	ROS 1 Biomarker Testing to Inform Clinical Management and Treatment Decisions in Patients with Non-small Cell Lung Cancer	Registry
CAP20	High Risk HPV Testing and p16 Scoring in Surgical Specimens for Patients with Oropharyngeal Squamous Cell Carcinoma (OPSCC)	Registry
CAP21	High Risk HPV Testing in Cytopathology Specimens for Patients with Oropharyngeal Squamous Cell Carcinoma (OPSCC)	Registry
CAP22	Turnaround Time (TAT) - Biopsies	Registry
CAP23	Cancer Protocol Elements and Turnaround Time for Carcinoma and Carcinosarcoma of the Endometrium	Registry
CAP24	Cancer Protocol Elements and Turnaround Time for Carcinoma of the Intrahepatic Bile Ducts	Registry
CAP25	Cancer Protocol Elements and Turnaround Time for Carcinoma of the Pancreas	Registry
CAP26	Cancer Protocol Elements and Turnaround Time for Hepatocellular Carcinoma	Registry
CAP27	Cancer Protocol Elements and Turnaround Time for Invasive Carcinoma of Renal Tubular Origin	Registry
CAP28	Helicobacter pylori Status and Turnaround Time	Registry
CAP8	Turnaround Time (TAT) - Lactate	Registry
CAP9	Turnaround Time (TAT) - Troponin	Registry
FORCE20	Review of Functional Status Assessment for Patients with Osteoarthritis	Registry
FORCE21	Review of Pain Status Assessment for Patients with Osteoarthritis	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
ACCPIN10	Hypertension: Blood Pressure Treatment and Control for Stage 2 Hypertensive Patients	Registry
ACCPIN7	Peripheral Artery Disease: Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk	Registry
ACCPIN8	Hypertension: Blood Pressure Control for Stage 1 or 2 Hypertensive Patients	Registry
ACCPIN9	Hypertension: Blood Pressure Treatment and Control for High Risk Patients	Registry
ARCO15	Diabetes: Nutritional, Weight Loss Counseling, Reduction of Sedentary Behavior	Registry
PIMSH1	Advance Care Planning in Stage 4 Disease	Registry
PIMSH4	Oncology: Patient-Reported Pain Improvement	Registry
PIMSH5	Oncology: Supportive Care Drug Utilization in Last 14 Days of Life	Registry
PIMSH8	Oncology: Mutation Testing for Lung Cancer (i.e. EGFR, alk, ROS) Completed Prior to Start of Therapy	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
ARCO3	Antipsychotic Use in Persons with Dementia	Registry
PP2	Follow-Up After Hospitalization for Schizophrenia (7- and 30-day)	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
PP7	Use of Multiple Concurrent Antipsychotics in Children and Adolescents (APC)	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
QOPI23	Concurrent Chemoradiation for Patients with a Diagnosis of Stage IIIB NSCLC	Registry
QOPI5	Chemotherapy administered to patients with metastatic solid tumor with performance status of 3, 4, or undocumented (Lower Score - Better)	Registry
NPA11	Unplanned Readmission Following Spine Procedure within the 30-Day Postoperative Period	Registry
NPA12	Selection of Prophylactic Antibiotic Prior to 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
NPA6	Spine-Related Procedure Site Infection	Registry
RCOIR1	CKD 3-5 Patients Seen at the Recommended Frequency Levels	Registry
RCOIR10	Upper Extremity Edema Improvement	Registry
RCOIR12	Tunneled Hemodialysis Catheter Success	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	End Stage Renal Disease (ESRD) Initiation of Home Dialysis or Self-Care	Registry
RCOIR7	Improved Access Site Bleeding	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
RPAQIR1	Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy	Registry
RPAQIR16	Peritoneal Dialysis Catheter Success Rate	Registry
RPAQIR17	Peritoneal Dialysis Catheter Exit Site Infection Rate	Registry
RPAQIR18	Advance Directives Completed	Registry
RPAQIR4	Arteriovenous Fistula Rate	Registry
RPAQIR5	Transplant Referral	Registry
RPAQIR9	Advance Care Planning (Pediatric Kidney Disease)	Registry
ACR7	Gout: Serum Urate Target	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
NJIISMD1	Critical Result: Pulmonary Embolism	Registry
NJIISMD11	Critical Result: New Deep Venous Thrombosis (DVT)	Registry
NJIISMD17	Result Requiring Follow Up Protocol	Registry
NJIISMD19	Critical Result: Cord Compression	Registry
NJIISMD2	Critical Result: Intracranial Hemorrhage	Registry
NJIISMD20	Critical Result: CTA of GI bleed	Registry
NJIISMD21	Critical Result: Positive nuclear 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
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 -Critical Result: Pneumoperitoneum	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: C-Spine fracture -Critical Result: Rib fracture -Urgent Result: Osteomyelitis -Urgent Result: Meniscal tear	Registry
SMD29	Incidental Finding Closed Loop Work Up Rate	Registry
SMD30	Aortic Aneurism Result Notification	Registry
SMD31	Ectopic Pregnancy Critical Results -Critical Result: Ruptured Ectopic Pregnancy -Critical Result: Ectopic Pregnancy	Registry
SMD32	Pathology Peer Review Duration (composite measure) Strata: -Breast cancer -Lung cancer -Melanoma -Colorectal cancer	Registry
SMD33	Radiology Peer Review Duration (composite measure) Strata: -Pneumonia -Pulmonary nodule -Pulmonary embolism -Stroke -Intracranial hemorrhage	Registry
SMD34	Image Guided Lung Biopsy Complication Rate	Registry
SMD35	Thyroid biopsy - percentage of non-diagnostic samples	Registry
ACS18	Patient Frailty Evaluation	Registry
ACS23	Unplanned Hospital Readmission within 30 Days of Principal Procedure	Registry
SCG05	Improvement in Quality of Life from Partial Foot, Prosthetics	Registry
SCG10	Treatment and Management Outcomes of Acute Wounds and/or Ulcers	Registry
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
SCG8	Pre-surgical screening for depression	Registry
SCG9	Avoidance of Inappropriate Emergency Department Use	Registry
SMX10	Prevalence and Severity of High Blood Pressure Among Children (SoDH) - Blood Pressure screening for children 1-13 years of age and 14 - 19 years of age	Registry
SMX11	Screening for Risk Factors for Adult Cardiovascular Disease in Children (SoDH) - Dyslipidemia screening for children ages 9 -11 and post-puberty ages 17-21	Registry
SPINETRACK5	Percent of patients meeting SCB thresholds for leg or arm pain	Registry
STS1	Prolonged Length of Stay Following Coronary Artery Bypass Grafting	Registry
STS11	Lobectomy - Air Leak Greater than 5 Days	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
ACS16	Preventative Care and Screening: Tobacco Screening and Cessation Intervention	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
ACS24	Surgical Phases of Care Patient-Reported Outcome Composite Measure	Registry
ACS25	Surgical Site Infection (SSI)	Registry
NIPM18	CHANGE IN PATIENT REPORTED QUALITY OF LIFE FOLLOWING EPIDURAL LYSIS OF ADHESIONS	Registry
NIPM19	CHANGE IN PATIENT REPORTED QUALITY OF LIFE AND FUNCTIONAL STATUS FOLLOWING MEDIAL BRANCH RADIOFREQUENCY ABLATION	Registry
NIPM20	CHANGE IN PATIENT REPORTED PAIN AND FUNCTIONAL STATUS FOLLOWING SPINAL CORD STIMULATOR IMPLANTATION	Registry
NIPM21	REDUCTION IN PATIENT REPORTED PAIN FOLLOWING MEDIAL BRANCH RADIOFREQUENCY ABLATION	Registry
NIPM22	CHANGE IN PATIENT REPORTED QUALITY OF LIFE FOLLOWING EPIDURAL CORTICOSTEROID INJECTION	Registry
NIPM23	CHANGE IN PATIENT REPORTED QUALITY OF LIFE FOLLOWING MAJOR JOINT CORTICOSTEROID INJECTION	Registry
CDR2	Diabetic Foot Ulcer (DFU) Healing or Closure	Registry
CDR3	Plan of Care Creation for Diabetic Foot Ulcer (DFU) and Venous Leg Ulcer (VLU) not Achieving 30% Closure at 4 Weeks after undergoing treatment with CTP	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
USWR16	Major Amputation in Wagner 3, 4, or 5 Diabetic Foot Ulcers (DFUs) Treated with HBOT	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
USWR25	Non-lower extremity Pressure Ulcer* (PU) Healing or Closure	Registry
USWR26	Patient Reported Outcome of late effects of radiation symptoms following treatment with Hyperbaric Oxygen Therapy (HBOT)	Registry
UREQA1	Ankylosing Spondylitis: Controlled Disease	Registry
UREQA2	Ankylosing Spondylitis: Appropriate Pharmacologic Therapy	Registry
UREQA3	Controlled Gout for Patients on Urate-Lowering Pharmacologic Therapy	Registry
UREQA4	Folic or Folinic Acid Therapy for Patients Treated with Methotrexate	Registry
UREQA6	Psoriatic Arthritis (PsA): Close Monitoring for Newly Diagnosed Patients	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 or patient medical record.	Registry