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2025

year
2025

Core Clinical Data Elements for the Hybrid Hospital-Wide Readmission Measure with Claims and Electronic Health Record Data - HWR

eCQM -
(Last updated: May 06, 2025)
This logic is intended to extract electronic clinical data. This is not an electronic clinical quality measure and this logic will not produce measure results. Instead, it will produce a file containing the data that CMS will link with administrative claims to risk adjust the Hybrid HWR outcome…

Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF less than or equal to 40%)

eCQM -
(Last updated: Aug 27, 2025)
Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12-month period who also have a prior MI or a current or prior left ventricular ejection fraction (LVEF) <=40% who were prescribed beta-blocker therapy

Dementia: Cognitive Assessment

eCQM -
(Last updated: Aug 27, 2025)
Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period

Depression Remission at Twelve Months

eCQM -
(Last updated: Aug 27, 2025)
The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event

Diabetes: Eye Exam

eCQM -
(Last updated: Aug 27, 2025)
Percentage of patients 18-75 years of age with diabetes and an active diagnosis of retinopathy in any part of the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or diabetics with no diagnosis of retinopathy in any part of the…

Diabetes: Glycemic Status Assessment Greater Than 9%

eCQM -
(Last updated: Aug 27, 2025)
Percentage of patients 18-75 years of age with diabetes who had a glycemic status assessment (hemoglobin A1c [HbA1c] or glucose management indicator [GMI]) > 9.0% during the measurement period

Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care

eCQM -
(Last updated: Aug 27, 2025)
Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or…

Discharged on Antithrombotic Therapy

eCQM -
(Last updated: May 06, 2025)
Ischemic stroke patients prescribed or continuing to take antithrombotic therapy at hospital discharge

Documentation of Current Medications in the Medical Record

eCQM -
(Last updated: Aug 27, 2025)
Percentage of visits for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter

Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Clinician Level)

eCQM -
(Last updated: Aug 27, 2025)
This measure provides a standardized method for monitoring the performance of diagnostic CT to discourage unnecessarily high radiation doses, a risk factor for cancer, while preserving image quality. It is expressed as a percentage of patients with CT exams that are out-of-range based on having…
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