| # | Measure Title | Submission Methods | |
|---|---|---|---|
| 404 | Anesthesiology Smoking Abstinence | Registry | |
| 430 | Prevention of Post-Operative Nausea and Vomiting (PONV) - Combination Therapy | Registry | |
| 463 | Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics) | Registry | |
| 477 | Multimodal Pain Management | Registry | |
| # | Measure Title | Submission Methods | |
|---|---|---|---|
| 130 | Documentation of Current Medications in the Medical Record | Registry, Electronic Health Record | |
| 134 | Preventive Care and Screening: Screening for Depression and Follow-Up Plan | Claims, Electronic Health Record, Registry | |
| 134SSP | Preventive Care and Screening: Screening for Depression and Follow-Up Plan | Registry | |
| 155 | Falls: Plan of Care | Registry | |
| 181 | Elder Maltreatment Screen and Follow-Up Plan | Claims, Registry | |
| 182 | Functional Outcome Assessment | Registry | |
| 226 | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | Claims, Electronic Health Record, Registry | |
| 261 | Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness | Claims, 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 | |
| 431 | Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling | Registry | |
| # | Measure Title | Submission Methods | |
|---|---|---|---|
| 378 | Children Who Have Dental Decay or Cavities | Electronic Health Record | |
| 379 | Primary Caries Prevention Intervention as Offered by Dentists | Electronic Health Record | |
| # | Measure Title | Submission Methods | |
|---|---|---|---|
| 130 | Documentation of Current Medications in the Medical Record | Registry, Electronic Health Record | |
| 176 | Tuberculosis Screening Prior to First Course of Biologic and/or Immune Response Modifier Therapy | Registry | |
| 226 | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | Claims, Electronic Health Record, Registry | |
| 317 | Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | Claims, Electronic Health Record, Registry | |
| 374 | Closing the Referral Loop: Receipt of Specialist Report | Electronic Health Record, Registry | |
| 410 | Psoriasis: Clinical Response to Systemic Medications | Registry | |
| 440 | Skin Cancer: Biopsy Reporting Time - Pathologist to Clinician | Registry | |
| 485 | Psoriasis- Improvement in Patient-Reported Itch Severity | Registry | |
| 486 | Dermatitis – Improvement in Patient-Reported Itch Severity | Registry | |
| 503 | Gains in Patient Activation Measure (PAM®) Scores at 12 Months | Registry | |
| 509 | Melanoma: Tracking and Evaluation of Recurrence | Registry | |
| # | Measure Title | Submission Methods | |
|---|---|---|---|
| 392 | Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation | Registry | |
| 393 | Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision | Registry | |
| # | Measure Title | Submission Methods | |
|---|---|---|---|
| CAHPS_1 | CAHPS for MIPS SSM: Getting Timely Care, Appointments, and Information | Certified Survey Vendor | |
| CAHPS_2 | CAHPS for MIPS SSM: How Well Providers Communicate | Certified Survey Vendor | |
| CAHPS_3 | CAHPS for MIPS SSM: Patient’s Rating of Provider | Certified Survey Vendor | |
| CAHPS_4 | CAHPS for MIPS SSM: Access to Specialists | Certified Survey Vendor | |
| CAHPS_5 | CAHPS for MIPS SSM: Health Promotion and Education | Certified Survey Vendor | |
| CAHPS_6 | CAHPS for MIPS SSM: Shared Decision Making | Certified Survey Vendor | |
| CAHPS_7 | CAHPS for MIPS 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 | |
| # | Measure Title | Submission Methods | |
|---|---|---|---|
| 047 | Advance Care Plan | Claims, Registry | |
| 130 | Documentation of Current Medications in the Medical Record | Registry, Electronic Health Record | |
| 226 | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | Claims, Electronic Health Record, Registry | |
| 317 | Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | Claims, Electronic Health Record, 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 | |
| 374 | Closing the Referral Loop: Receipt of Specialist Report | Electronic Health Record, Registry | |
| # | Measure Title | Submission Methods | |
|---|---|---|---|
| 005 | Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD) | Electronic Health Record, Registry | |
| 008 | Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) | Electronic Health Record, Registry | |
| 047 | Advance Care Plan | Claims, Registry | |
| 130 | Documentation of Current Medications in the Medical Record | Registry, Electronic Health Record | |
| # | Measure Title | Submission Methods | |
|---|---|---|---|
| 145 | Radiology: Exposure Dose Indices Reported for Procedures Using Fluoroscopy | Claims, Registry | |
| 374 | Closing the Referral Loop: Receipt of Specialist Report | Electronic Health Record, Registry | |
| 413 | Door to Puncture Time for Endovascular Stroke Treatment | Registry | |
| 420 | Varicose Vein Treatment with Saphenous Ablation: Outcome Survey | Registry | |
| 421 | Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal | Registry | |
| 465 | Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian Arteries | Registry | |
| # | Measure Title | Submission Methods | |
|---|---|---|---|
| 130 | Documentation of Current Medications in the Medical Record | Registry, Electronic Health Record | |
| 187 | Stroke and Stroke Rehabilitation: Thrombolytic Therapy | Registry | |
| 226 | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | Claims, Electronic Health Record, Registry | |
| 344 | Rate of Carotid Endarterectomy (CEA) or Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2) | Registry | |
| 413 | Door to Puncture Time for Endovascular Stroke Treatment | Registry | |
| 459 | Back Pain After Lumbar Surgery | Registry | |
| 461 | Leg Pain After Lumbar Surgery | Registry | |
| 471 | Functional Status After Lumbar Surgery | Registry | |
| # | Measure Title | Submission Methods | |
|---|---|---|---|
| 001 | Diabetes: Glycemic Status Assessment Greater Than 9% | Claims, Electronic Health Record, Registry | |
| 001SSP | Diabetes: Glycemic Status Assessment Greater Than 9% | Registry | |
| 130 | Documentation of Current Medications in the Medical Record | Registry, Electronic Health Record | |
| 134 | Preventive Care and Screening: Screening for Depression and Follow-Up Plan | Claims, Electronic Health Record, Registry | |
| 134SSP | Preventive Care and Screening: Screening for Depression and Follow-Up Plan | Registry | |
| 181 | Elder Maltreatment Screen and Follow-Up Plan | Claims, Registry | |
| 226 | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | Claims, Electronic Health Record, Registry | |
| 239 | Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents | Electronic Health Record | |
| 431 | Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling | Registry | |
| # | Measure Title | Submission Methods | |
|---|---|---|---|
| 019 | Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care | Electronic Health Record | |
| 117 | Diabetes: Eye Exam | Registry, Electronic Health Record | |
| 130 | Documentation of Current Medications in the Medical Record | Registry, Electronic Health Record | |
| 226 | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | Claims, Electronic Health Record, Registry | |
| 238 | Use of High-Risk Medications in Older Adults | Electronic Health Record, Registry | |
| 374 | Closing the Referral Loop: Receipt of Specialist Report | Electronic Health Record, Registry | |
| # | Measure Title | Submission Methods | |
|---|---|---|---|
| 249 | Barrett's Esophagus | Claims, Registry | |
| 250 | Radical Prostatectomy Pathology Reporting | Claims, Registry | |
| 395 | Lung Cancer Reporting (Biopsy/Cytology Specimens) | Claims, Registry | |
| 396 | Lung Cancer Reporting (Resection Specimens) | Claims, Registry | |
| 397 | Melanoma Reporting | Claims, Registry | |
| 440 | Skin Cancer: Biopsy Reporting Time - Pathologist to Clinician | Registry | |
| 491 | Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status | Registry | |
| # | Measure Title | Submission Methods | |
|---|---|---|---|
| 047 | Advance Care Plan | Claims, Registry | |
| 130 | Documentation of Current Medications in the Medical Record | Registry, Electronic Health Record | |
| 155 | Falls: Plan of Care | Registry | |
| 182 | Functional Outcome Assessment | Registry | |
| 226 | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | Claims, Electronic Health Record, Registry | |
| 317 | Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | Claims, Electronic Health Record, Registry | |
| 374 | Closing the Referral Loop: Receipt of Specialist Report | Electronic Health Record, Registry | |
| 431 | Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling | Registry | |
| 468 | Continuity of Pharmacotherapy for Opioid Use Disorder (OUD) | Registry | |
| # | Measure Title | Submission Methods | |
|---|---|---|---|
| 130 | Documentation of Current Medications in the Medical Record | Registry, Electronic Health Record | |
| 226 | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | Claims, Electronic Health Record, Registry | |
| 317 | Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | Claims, Electronic Health Record, 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 | |
| # | Measure Title | Submission Methods | |
|---|---|---|---|
| 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 | |
| 155 | Falls: Plan of Care | Registry | |
| 219 | Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments | Registry | |
| 226 | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | Claims, 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 | |
| 358 | Patient-Centered Surgical Risk Assessment and Communication | Registry | |
| 503 | Gains in Patient Activation Measure (PAM®) Scores at 12 Months | Registry | |
| # | Measure Title | Submission Methods | |
|---|---|---|---|
| 102 | Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients | Electronic Health Record, Registry | |
| 143 | Oncology: Medical and Radiation - Pain Intensity Quantified | Electronic Health Record, Registry | |
| 144 | Oncology: Medical and Radiation - Plan of Care for Pain | Registry | |
| 226 | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | Claims, Electronic Health Record, Registry | |
| # | Measure Title | Submission Methods | |
|---|---|---|---|
| 130 | Documentation of Current Medications in the Medical Record | Registry, Electronic Health Record | |
| 134 | Preventive Care and Screening: Screening for Depression and Follow-Up Plan | Claims, Electronic Health Record, Registry | |
| 134SSP | Preventive Care and Screening: Screening for Depression and Follow-Up Plan | Registry | |
| 181 | Elder Maltreatment Screen and Follow-Up Plan | Claims, Registry | |
| 182 | Functional Outcome Assessment | Registry | |
| 226 | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | Claims, Electronic Health Record, Registry | |
| 282 | Dementia: Functional Status Assessment | 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 | |
| 291 | Assessment of Cognitive Impairment or Dysfunction for Patients with Parkinson's Disease | Registry | |
| 386 | Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences | Registry | |
| # | Measure Title | Submission Methods | |
|---|---|---|---|
| 047 | Advance Care Plan | Claims, Registry | |
| 130 | Documentation of Current Medications in the Medical Record | Registry, Electronic Health Record | |
| 164 | Coronary Artery Bypass Graft (CABG): Prolonged Intubation | Registry | |
| 167 | Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure | Registry | |
| 168 | Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration | Registry | |
| 226 | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | Claims, Electronic Health Record, Registry | |
| 356 | Unplanned Hospital Readmission within 30 Days of Principal Procedure | Registry | |
| 358 | Patient-Centered Surgical Risk Assessment and Communication | Registry | |
| 374 | Closing the Referral Loop: Receipt of Specialist Report | Electronic Health Record, Registry | |
| 445 | Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG) | Registry | |