2015 Performance Period EP eCQMs

Clinical Quality Measures and their electronic specifications as defined in the July 2014 update for Eligible Professionals.

Measure Namesort descending CMS eCQM ID Domain NQF ID Measure Steward USHIK Version Links
ADE Prevention and Monitoring: Warfarin Time in Therapeutic Range CMS179v3 Patient Safety None Centers for Medicare & Medicaid Services Version Detail
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ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication CMS136v4 Effective Clinical Care 0108 National Committee for Quality Assurance Version Detail
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Adult Major Depressive Disorder (MDD): Suicide Risk Assessment CMS161v3 Effective Clinical Care 0104 American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI) Version Detail
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Anti-depressant Medication Management CMS128v3 Effective Clinical Care 0105 National Committee for Quality Assurance Version Detail
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Appropriate Testing for Children with Pharyngitis CMS146v3 Efficiency and Cost Reduction Use of Healthcare Resources 0002 National Committee for Quality Assurance Version Detail
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Appropriate Treatment for Children with Upper Respiratory Infection (URI) CMS154v3 Efficiency and Cost Reduction Use of Healthcare Resources 0069 National Committee for Quality Assurance Version Detail
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Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance use CMS169v3 Effective Clinical Care 0110 Center for Quality Assessment & Improvement in Mental Health (CQAIMH) Version Detail
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Breast Cancer Screening CMS125v3 Effective Clinical Care None National Committee for Quality Assurance Version Detail
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Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer CMS140v3 Effective Clinical Care 0387 American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI) Version Detail
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Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery CMS133v3 Effective Clinical Care 0565 American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI) Version Detail
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Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures CMS132v3 Patient Safety 0564 American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI) Version Detail
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Cervical Cancer Screening CMS124v3 Effective Clinical Care 0032 National Committee for Quality Assurance Version Detail
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Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment CMS177v3 Patient Safety 1365 American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI) Version Detail
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Childhood Immunization Status CMS117v3 Community, Population and Public Health 0038 National Committee for Quality Assurance Version Detail
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Children Who Have Dental Decay or Cavities CMS75v3 Effective Clinical Care None Centers for Medicare & Medicaid Services Version Detail
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Chlamydia Screening for Women CMS153v3 Community, Population and Public Health 0033 National Committee for Quality Assurance Version Detail
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Closing the Referral Loop: Receipt of Specialist Report CMS50v3 Communication and Care Coordination None Centers for Medicare & Medicaid Services Version Detail
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Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients CMS141v4 Effective Clinical Care 0385 American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI) Version Detail
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Colorectal Cancer Screening CMS130v3 Effective Clinical Care 0034 National Committee for Quality Assurance Version Detail
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Controlling High Blood Pressure CMS165v3 Effective Clinical Care 0018 National Committee for Quality Assurance Version Detail
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Coronary Artery Disease (CAD): Beta-Blocker Therapy—Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%) CMS145v3 Effective Clinical Care 0070 American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI) Version Detail
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Dementia: Cognitive Assessment CMS149v3 Effective Clinical Care None American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI) Version Detail
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Depression Remission at Twelve Months CMS159v3 Effective Clinical Care 0710 MN Community Measurement Version Detail
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Depression Utilization of the PHQ-9 Tool CMS160v3 Effective Clinical Care 0712 MN Community Measurement Version Detail
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Diabetes: Eye Exam CMS131v3 Effective Clinical Care 0055 National Committee for Quality Assurance Version Detail
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Diabetes: Foot Exam CMS123v3 Effective Clinical Care 0056 National Committee for Quality Assurance Version Detail
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Diabetes: Hemoglobin A1c Poor Control CMS122v3 Effective Clinical Care 0059 National Committee for Quality Assurance Version Detail
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Diabetes: Low Density Lipoprotein (LDL) Management CMS163v3 Effective Clinical Care 0064 National Committee for Quality Assurance Version Detail
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Diabetes: Urine Protein Screening CMS134v3 Effective Clinical Care 0062 National Committee for Quality Assurance Version Detail
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Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care CMS142v3 Effective Clinical Care 0089 American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI) Version Detail
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Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy CMS167v3 Effective Clinical Care 0088 American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI) Version Detail
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Documentation of Current Medications in the Medical Record CMS68v4 Patient Safety 0419 Centers for Medicare & Medicaid Services Version Detail
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Falls: Screening for Future Fall Risk CMS139v3 Patient Safety 0101 National Committee for Quality Assurance Version Detail
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Functional Status Assessment for Complex Chronic Conditions CMS90v4 Person and Caregiver-Centered Experience Outcomes None Centers for Medicare & Medicaid Services Version Detail
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Functional Status Assessment for Hip Replacement CMS56v3 Person and Caregiver-Centered Experience Outcomes None Centers for Medicare & Medicaid Services Version Detail
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Functional Status Assessment for Knee Replacement CMS66v3 Person and Caregiver-Centered Experience Outcomes None Centers for Medicare & Medicaid Services Version Detail
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Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) CMS135v3 Effective Clinical Care 0081 American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI) Version Detail
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Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) CMS144v3 Effective Clinical Care 0083 American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI) Version Detail
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Hemoglobin A1c Test for Pediatric Patients CMS148v3 Effective Clinical Care 0060 National Committee for Quality Assurance Version Detail
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HIV/AIDS: Medical Visit CMS62v3 Effective Clinical Care None National Committee for Quality Assurance Version Detail
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HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis CMS52v3 Effective Clinical Care 0405 National Committee for Quality Assurance Version Detail
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HIV/AIDS: RNA Control for Patients with HIV CMS77v3 Effective Clinical Care None Centers for Medicare & Medicaid Services Version Detail
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Hypertension: Improvement in Blood Pressure CMS65v4 Effective Clinical Care None Centers for Medicare & Medicaid Services Version Detail
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Initiation and Engagement of Alcohol and Other Drug Dependence Treatment CMS137v3 Effective Clinical Care 0004 National Committee for Quality Assurance Version Detail
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Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control CMS182v4 Effective Clinical Care 0075 National Committee for Quality Assurance Version Detail
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Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic CMS164v3 Effective Clinical Care 0068 National Committee for Quality Assurance Version Detail
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Maternal Depression Screening CMS82v2 Community, Population and Public Health 1401 National Committee for Quality Assurance Version Detail
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Oncology: Medical and Radiation – Pain Intensity Quantified CMS157v3 Person and Caregiver-Centered Experience Outcomes 0384 American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI) Version Detail
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Pneumonia Vaccination Status for Older Adults CMS127v3 Effective Clinical Care 0043 National Committee for Quality Assurance Version Detail
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Pregnant women that had HBsAg testing CMS158v3 Effective Clinical Care None OptumInsight Version Detail
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Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented CMS22v3 Community, Population and Public Health None Centers for Medicare & Medicaid Services Version Detail
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Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan CMS69v3 Community, Population and Public Health 0421 Centers for Medicare & Medicaid Services Version Detail
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Preventive Care and Screening: Cholesterol - Fasting Low Density Lipoprotein (LDL-C) Test Performed CMS61v4 Effective Clinical Care None Centers for Medicare & Medicaid Services Version Detail
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Preventive Care and Screening: Influenza Immunization CMS147v4 Community, Population and Public Health 0041 American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI) Version Detail
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Preventive Care and Screening: Risk-Stratified Cholesterol – Fasting Low Density Lipoprotein (LDL-C) CMS64v4 Effective Clinical Care None Centers for Medicare & Medicaid Services Version Detail
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Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan CMS2v4 Community, Population and Public Health 0418 Centers for Medicare & Medicaid Services Version Detail
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Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention CMS138v3 Community, Population and Public Health 0028 American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI) Version Detail
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Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists CMS74v4 Effective Clinical Care None Centers for Medicare & Medicaid Services Version Detail
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Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation CMS143v3 Effective Clinical Care 0086 American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI) Version Detail
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Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients CMS129v4 Efficiency and Cost Reduction Use of Healthcare Resources 0389 American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI) Version Detail
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Use of Appropriate Medications for Asthma CMS126v3 Effective Clinical Care 0036 National Committee for Quality Assurance Version Detail
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Use of High-Risk Medications in the Elderly CMS156v3 Patient Safety 0022 National Committee for Quality Assurance Version Detail
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Use of Imaging Studies for Low Back Pain CMS166v4 Efficiency and Cost Reduction Use of Healthcare Resources 0052 National Committee for Quality Assurance Version Detail
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Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents CMS155v3 Community, Population and Public Health 0024 National Committee for Quality Assurance Version Detail
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Recent Activity

Wednesday, May 18 2016

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    11:53am EDT
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    11:51am EDT
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    the time of the qualifying visit and the measure-specific denominator
     
    the time of the qualifying visit and the measure-specific denominator
     
    coding.
     
    coding.
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    BMI Measurement Guidance:
     
    BMI Measurement Guidance:
     
    measure both height and weight. Both height and weight must be measured
     
    measure both height and weight. Both height and weight must be measured
     
    within six months of the current encounter and may be obtained from
     
    within six months of the current encounter and may be obtained from
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    separate encounters. Self-reported values cannot be used.
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    separate encounters. Self-reported values cannot be used.
     
    * The BMI may be documented in the medical record of the provider or in
     
    * The BMI may be documented in the medical record of the provider or in
     
    outside medical records obtained by the provider.
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    11:51am EDT
    Changes to Measure Description
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    Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration.
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    Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration.
     
     
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    11:50am EDT
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    Percentage of patients aged 18 years and older with primary total knee arthroplasty (TKA) who completed baseline and follow-up (patient-reported) functional status assessments.
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    Percentage of patients aged 18 years and older with primary total knee arthroplasty (TKA) who completed baseline and follow-up (patient-reported) functional status assessments.
     
     
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    11:49am EDT
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    period with the exception of patients with 0 or 1 risk factors who may have
     
    period with the exception of patients with 0 or 1 risk factors who may have
     
    an fasting LDL-C performed up to four (4) years prior to the current
     
    an fasting LDL-C performed up to four (4) years prior to the current
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    measurement period. To meet the numerator criteria for this measure, the
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    measurement period. To meet the numerator criteria for this measure, the
     
    patient’s fasting LDL-C (low density lipoprotein) meets or exceeds the
     
    patient’s fasting LDL-C (low density lipoprotein) meets or exceeds the
     
    recommended LDL-C goal.
     
    recommended LDL-C goal.
     
     
     
     
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    11:49am EDT
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    11:48am EDT
    ...
    Changes to Denominator Statement
     
    *Denominator 2:* (Moderate Risk)
     
    *Denominator 2:* (Moderate Risk)
     
    All patients aged 20 through 79 years who have 2 or more Major CHD Risk
     
    All patients aged 20 through 79 years who have 2 or more Major CHD Risk
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    Factors OR 10-Year Framingham Risk 10-20%
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    Factors OR 10-Year Framingham Risk 10-20%
     
     
     
    *Denominator 3:* (Low Risk)
     
    *Denominator 3:* (Low Risk)
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    To be eligible for performance calculations, patients must have at least one
     
    To be eligible for performance calculations, patients must have at least one
     
    face-to-face visit with the eligible professional during the measurement
     
    face-to-face visit with the eligible professional during the measurement
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    period. To meet the numerator criteria for this measure, the patient will
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    period. To meet the numerator criteria for this measure, the patient will
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    11:48am EDT
    Changes to Initial Patient Population
     
    within the 12 month period that begins 180 days before the start of the
     
    within the 12 month period that begins 180 days before the start of the
     
    measurement period and ends 185 days after the start of the measurement
     
    measurement period and ends 185 days after the start of the measurement
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    period and who had an outpatient encounter not more than 180 days prior to
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    period and who had an outpatient encounter not more than 180 days prior to
     
    procedure, and at least 60 days and not more than 180 days after THA
     
    procedure, and at least 60 days and not more than 180 days after THA
     
    procedure.
     
    procedure.
     
     
     
     
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  • Your profile picture
    11:47am EDT
    Changes to Measure Type
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    11:47am EDT
    Too many differences to list. See Revisions for details.
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    11:46am EDT
    Changes to Denominator Exceptions
     
    Patient is in an urgent or emergent medical situation where time is of the
     
    Patient is in an urgent or emergent medical situation where time is of the
     
    essence and to delay treatment would jeopardize the patient’s health
     
    essence and to delay treatment would jeopardize the patient’s health
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    status. This may include but is not limited to severely elevated BP when
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    status. This may include but is not limited to severely elevated BP when
     
    immediate medical treatment is indicated.
     
    immediate medical treatment is indicated.
     
     
     
     
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    11:45am EDT
    Changes to Measure Observations
     
    Average percentage of time that patients in the measure population have INR
     
    Average percentage of time that patients in the measure population have INR
     
    results within the therapeutic range (i.e., TTR)
     
    results within the therapeutic range (i.e., TTR)
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    11:45am EDT
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    Changes to Guidance
     
     
     
    Use of a standardized tool or instrument to assess suicide risk will meet
     
    Use of a standardized tool or instrument to assess suicide risk will meet
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    numerator performance. Standardized tools can be mapped to the concept
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    numerator performance. Standardized tools can be mapped to the concept
     
    /Intervention, Performed: Suicide Risk Assessment/ included in the numerator
     
    /Intervention, Performed: Suicide Risk Assessment/ included in the numerator
     
    logic below.
     
    logic below.
     
     
     
     
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