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Eligible Hospital / Critical Access Hospital eCQMs

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Find older eCQM specifications in the eCQM Standards and Tools Version table.

2023 Reporting Period Eligible Hospital / Critical Access Hospital Resources
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eCQM Resources Short Description Published
Implementation checklist --
Assists implementers and measured entities with information on how to read eCQM specifications May 2022
List of eCQMs available for use  May 2022
eCQM technical specifications  May 2022
MAT-CGL specifications and technical release notes May 2022
Value sets used in eCQMs May 2022
eCQM Direct Reference Codes used in eCQMs May 2022
Value set metadata May 2022
Assists implementers and measured entities with how to use eCQMs and report issues May 2022
Year over year changes to eCQM logic and terminology May 2022
Year over year changes to eCQM logic and terminology May 2022
Tools and standards versions measure developers used to create eCQMs and versions of standards and tools used for their reporting May 2022
Standards and code system versions for the eCQM Annual Update Mar 2022
2023 Reporting Period Eligible Hospital / Critical Access Hospital eCQMs
Total number of EH/CAH eCQMs: 11
Measure Name Short Name CMS eCQM ID NQF # Meaningful Measure Area
Anticoagulation Therapy for Atrial Fibrillation/Flutter STK-3 CMS71v12 Not Applicable Preventive Care
Antithrombotic Therapy By End of Hospital Day 2 STK-5 CMS72v11 Not Applicable Preventive Care
Discharged on Antithrombotic Therapy STK-2 CMS104v11 Not Applicable Preventive Care
Discharged on Statin Medication STK-6 CMS105v11 Not Applicable Preventive Care
Exclusive Breast Milk Feeding PC-05 CMS9v11 0480e Care is Personalized and Aligned with Patient’s Goals
Hospital Harm - Severe Hyperglycemia HH-02 CMS871v2 3533e Preventable Healthcare Harm
Hospital Harm - Severe Hypoglycemia HH-01 CMS816v2 3503e Preventable Healthcare Harm
Intensive Care Unit Venous Thromboembolism Prophylaxis VTE-2 CMS190v11 Not Applicable Preventive Care
Median Admit Decision Time to ED Departure Time for Admitted Patients ED-2 CMS111v11 Not Applicable Admission and Readmissions to Hospitals
Safe Use of Opioids - Concurrent Prescribing N/A CMS506v5 3316e Prevention and Treatment of Opioid and Substance Use Disorders
Venous Thromboembolism Prophylaxis VTE-1 CMS108v11 Not Applicable Preventive Care

Each year, CMS updates the electronic clinical quality measures (eCQMs) for potential use in CMS quality reporting programs and publishes them on the eCQI Resource Center. CMS updates the specifications annually to align with current clinical guidelines and code systems so they remain relevant and actionable within the clinical care setting. CMS requires the use of the most current version of the eCQMs as specified and intended for the applicable reporting periods for all quality reporting programs.

The updated eCQMs are to be used by eligible hospitals and critical access hospitals to electronically report 2023 clinical quality measure data for CMS quality reporting programs. Measures will not be eligible for 2023 reporting unless and until they are proposed and finalized through notice-and-comment rulemaking for each applicable program.

  eCQM Implementation Checklist

eCQM Implementation Checklist

Use the eCQM Implementation Resources and follow the eCQM Implementation Checklist to update your electronic health record and processes for eCQM use and reporting.

Hybrid measures are quality measures that merge electronic health record data elements with claims data to calculate measure results. Currently, the Hybrid Hospital Wide Readmission (HWR) measure and the Hybrid Hospital Wide Mortality (HWM) measure are the hybrid measures adopted for use in a program.

The electronic specifications for the Hybrid HWR and Hybrid HWM measures are updated for the mandatory reporting period from July 1, 2023 through June 30, 2024 for the Hospital Inpatient Quality Reporting (IQR) Program. Hospitals that submit data for this measure reporting period will receive confidential hospital-specific reports that detail submission results from the reporting period, as well as the Hybrid HWR and Hybrid HWM measure results. Data for this reporting period will be publicly reported and will be used for Fiscal Year (FY) 2026 payment determination under the Inpatient Quality Reporting (IQR) program.

Each year, CMS makes updates to the Hybrid measures adopted for reporting in the Hospital Inpatient Quality Reporting (IQR) program. Hybrid measures require updates to the electronic specifications, posted below, and to claims-based specifications, available on QualityNet. CMS requires the use of updated electronic specifications for all its quality programs because they include updated codes, logic corrections, and clarifications. Reporting data for the Hybrid measures to the Hospital IQR program requires that a hospital or electronic health record vendor use the most current version of the electronic measure specifications (identified below) for the applicable reporting period.

2023 Reporting Period Eligible Hospital / Critical Access Hospitals
Measure Name Short Name CMS eCQM ID NQF # Meaningful Measure Area
Core Clinical Data Elements for the Hybrid Hospital-Wide (All-Condition, All-Procedure) Risk-Standardized Mortality Measure (HWM) Hybrid HWM CMS844v3 3502 Risk Adjusted Mortality
Core Clinical Data Elements for the Hybrid Hospital-Wide Readmission (HWR) Measure with Claims and Electronic Health Record Data Hybrid HWR CMS529v3 2879 Admissions and Readmissions to Hospitals
2023 Reporting Period Eligible Hospital / Critical Access Hospital Resources
For Use eCQM Resources Short Description Published
2023 Q3 - 2024 Q2 Implementation checklist --
2023 Q3 - 2024 Q2 Summary key dates and resources  May 2022
2023 Q3 - 2024 Q2 MAT-CGL specifications and technical release notes May 2022
2023 Q3 - 2024 Q2 Value sets used in eCQMs May 2022
2023 Q3 - 2024 Q2 eCQM Direct Reference Codes used in eCQMs May 2022
2023 Q3 - 2024 Q2 Value set metadata May 2022
2023 Q3 - 2024 Q2 Tools and standards versions measure developers used to create eCQMs and versions of standards and tools used for their reporting May 2022
2023 Q1-Q4 Standards and code system versions for the eCQM Annual Update Mar 2022
Last Updated: Dec 16, 2021