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2013 Physician Quality Reporting System (PQRS) Measures List 11/16/2012 Date: 11/16/2012 Version 7.1 Page 1 of 44 2013 PQRS Measures List The Physician Quality Reporting System (PQRS) measures were developed by various organizations for 2013. The following is a list of each measure’s NQF number, PQRS number, developer, and available reporting method. Contact information for specific measure developers is available on the last page of the 2013 PQRS Measures List. Questions regarding the construct of a measure or its intent should be referred to the measure developer/contact as outlined in Appendix II (on page 44). Please note that gaps in the PQRS measure numbering reflects measures retired from prior PQRS program years. Please reference the List of Retired PQRS Measure Specifications for specific information regarding measures’ year of retirement from PQRS. This table is contained within the 2013 PQRS Measure Specifications Manual for Claims and Registry Reporting of Individual Measures at the following link: http://www.cms.gov/Medicare/Quality-InitiativesPatient-Assessment-Instruments/PQRS/MeasuresCodes.html. This measure list is intended as a summary list to assist eligible professionals initially reviewing the measures and should not be used as a replacement for the measure specifications, which contain detailed reporting and coding instructions. A list of PQRS Measure Specifications by reporting method may be found in Appendix I (on page 43). NQF PQRS # # 0059 1 GPRO DM-2 0064 0061 0081 Date: 11/16/2012 Version 7.1 National Quality Strategy Domain Clinical Process/ Effectiveness 2 Clinical Process/ Effectiveness 3 Clinical Process/ Effectiveness 5 Clinical Process/ Effectiveness Measure Descriptiona Diabetes Mellitus: Hemoglobin A1c Poor Control: Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent hemoglobin A1c greater than 9.0% Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control: Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent LDL-C level in control (less than 100 mg/dL) Diabetes Mellitus: High Blood Pressure Control: Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent blood pressure in control (less than 140/90 mmHg) Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD): Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge Measure Developer NCQA NCQA NCQA AMAPCPI/ACCF/ AHA Reporting Options Claims, Registryb, EHR, GPRO/ACOc, DM Measures Group (C/R) Claims, Registry, EHR, DM Measures Group (C/R), Cardiovascular Prevention Measures Group (C/R) Claims, Registry, EHR, DM Measures Group (C/R) Registry, EHR, HF Measures Group (R) Page 2 of 44 2013 PQRS Measures List NQF PQRS # # National Quality Strategy Domain 6 Clinical Process/ Effectiveness 0070 7 Clinical Process/ Effectiveness 0083 8 GPRO HF-6 Clinical Process/ Effectiveness 0105 9 Clinical Process/ Effectiveness 0086 12 Clinical Process/ Effectiveness 0087 14 Clinical Process/ Effectiveness 0067 Date: 11/16/2012 Version 7.1 Measure Descriptiona Coronary Artery Disease (CAD): Antiplatelet Therapy: Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who were prescribed aspirin or clopidogrel Coronary Artery Disease (CAD): Beta-Blocker Therapy - Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%): Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have prior MI OR a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD): Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge Major Depressive Disorder (MDD): Antidepressant Medication During Acute Phase for Patients with MDD: Percentage of patients aged 18 years and older diagnosed with new episode of MDD and documented as treated with antidepressant medication during the entire 84-day (12-week) acute treatment phase Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation: Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma who have an optic nerve head evaluation during one or more office visits within 12 months Age-Related Macular Degeneration (AMD): Dilated Macular Examination: Percentage of patients aged 50 years and older with a diagnosis of AMD who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or hemorrhage AND the level of macular degeneration severity during one or more office visits within 12 months Measure Developer Reporting Options AMAPCPI/ACCF/ AHA Claims, Registry, EHR, CAD Measures Group (R) AMAPCPI/ACCF/ AHA AMAPCPI/ACCF/ AHA Registry, EHR Registry, EHR, GPRO/ACO, HF Measures Group (R) NCQA Claims, Registry, EHR AMAPCPI/NCQA Claims, Registry, EHR AMAPCPI/NCQA Claims, Registry Page 3 of 44 2013 PQRS Measures List NQF PQRS # # National Quality Strategy Domain 0088 18 Clinical Process/ Effectiveness 0089 19 Clinical Process/ Effectiveness 0270 20 Patient Safety 0268 21 Patient Safety 0271 22 Patient Safety Date: 11/16/2012 Version 7.1 Measure Descriptiona Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy: Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy and the presence or absence of macular edema during one or more office visits within 12 months Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care: 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 fundus exam at least once within 12 months Perioperative Care: Timing of Prophylactic Parenteral Antibiotic – Ordering Physician: Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic parenteral antibiotics, who have an order for prophylactic parenteral antibiotic to be given within one hour (if fluoroquinolone or vancomycin, two hours), prior to the surgical incision (or start of procedure when no incision is required) Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin: Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic, who had an order for cefazolin OR cefuroxime for antimicrobial prophylaxis Perioperative Care: Discontinuation of Prophylactic Parenteral Antibiotics (Non-Cardiac Procedures): Percentage of non-cardiac surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic parenteral antibiotics AND who received a prophylactic parenteral antibiotic, who have an order for discontinuation of prophylactic parenteral antibiotics within 24 hours of surgical end time Measure Developer Reporting Options AMAPCPI/NCQA Claims, Registry, EHR AMAPCPI/NCQA Claims, Registry, EHR AMAPCPI/NCQA Claims, Registry, Periop Measures Group (C/R) AMAPCPI/NCQA Claims, Registry, Periop Measures Group (C/R) AMAPCPI/NCQA Claims, Registry, Periop Measures Group (C/R) Page 4 of 44 2013 PQRS Measures List NQF PQRS # # National Quality Strategy Domain 0239 23 Patient Safety 0045 24 Care Coordination 0092 28 Clinical Process/ Effectiveness 0269 30 Patient Safety 0240 31 Clinical Process/ Effectiveness 0325 32 Clinical Process/ Effectiveness Date: 11/16/2012 Version 7.1 Measure Descriptiona Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients): Percentage of surgical patients aged 18 years and older undergoing procedures for which VTE prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time Osteoporosis: Communication with the Physician Managing On-going Care Post-Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older: Percentage of patients aged 50 years and older treated for a hip, spine or distal radial fracture with documentation of communication with the physician managing the patient’s on-going care that a fracture occurred and that the patient was or should be tested or treated for osteoporosis Aspirin at Arrival for Acute Myocardial Infarction (AMI): Percentage of patients, regardless of age, with an emergency department discharge diagnosis of AMI who had documentation of receiving aspirin within 24 hours before emergency department arrival or during emergency department stay Perioperative Care: Timely Administration of Prophylactic Parenteral Antibiotics: Percentage of surgical patients aged 18 years and older who receive an anesthetic when undergoing procedures with the indications for prophylactic parenteral antibiotics for whom administration of the prophylactic parenteral antibiotic ordered has been initiated within one hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required) Stroke and Stroke Rehabilitation: Deep Vein Thrombosis (DVT) Prophylaxis for Ischemic Stroke or Intracranial Hemorrhage: Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial hemorrhage who were administered DVT prophylaxis by end of hospital day two Stroke and Stroke Rehabilitation: Discharged on Antithrombotic Therapy: Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or transient ischemic attack (TIA) who were prescribed antithrombotic therapy at discharge Measure Developer Reporting Options AMAPCPI/NCQA Claims, Registry, Periop Measures Group (C/R) AMAPCPI/NCQA Claims, Registry AMAPCPI/NCQA Claims, Registry AMAPCPI/NCQA Claims, Registry AMAPCPI/NCQA Claims, Registry AMAPCPI/NCQA Claims, Registry Page 5 of 44 2013 PQRS Measures List NQF PQRS # # National Quality Strategy Domain 0241 33 Clinical Process/ Effectiveness 0243 35 Clinical Process/ Effectiveness 0244 36 Clinical Process/ Effectiveness 0046 39 Clinical Process/ Effectiveness 0048 40 Clinical Process/ Effectiveness 0049 41 0134 43 Date: 11/16/2012 Version 7.1 Clinical Process/ Effectiveness Clinical Process/ Effectiveness Measure Descriptiona Stroke and Stroke Rehabilitation: Anticoagulant Therapy Prescribed for Atrial Fibrillation (AF) at Discharge: Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or transient ischemic attack (TIA) with documented permanent, persistent, or paroxysmal atrial fibrillation who were prescribed an anticoagulant at discharge Stroke and Stroke Rehabilitation: Screening for Dysphagia: Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial hemorrhage who receive any food, fluids or medication by mouth (PO) for whom a dysphagia screening was performed prior to PO intake in accordance with a dysphagia screening tool approved by the institution in which the patient is receiving care Stroke and Stroke Rehabilitation: Rehabilitation Services Ordered: Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial hemorrhage for whom occupational, physical, or speech rehabilitation services were ordered at or prior to inpatient discharge OR documentation that no rehabilitation services are indicated at or prior to inpatient discharge Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older: Percentage of female patients aged 65 years and older who have a central dualenergy X-ray absorptiometry (DXA) measurement ordered or performed at least once since age 60 or pharmacologic therapy prescribed within 12 months Osteoporosis: Management Following Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older: Percentage of patients aged 50 years and older with fracture of the hip, spine, or distal radius who had a central dual-energy X-ray absorptiometry (DXA) measurement ordered or performed or pharmacologic therapy prescribed Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years and Older: Percentage of patients aged 50 years and older with a diagnosis of osteoporosis who were prescribed pharmacologic therapy within 12 months Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery: Percentage of patients aged 18 years and older undergoing isolated CABG surgery who received an IMA graft Measure Developer Reporting Options AMAPCPI/NCQA Registry AMAPCPI/NCQA Claims, Registry AMAPCPI/NCQA Claims, Registry AMAPCPI/NCQA Claims, Registry, EHR, Prev Care Measures Group (C/R) AMAPCPI/NCQA Claims, Registry AMAPCPI/NCQA Claims, Registry STS Claims, Registry, CABG Measures Group (R) Page 6 of 44 2013 PQRS Measures List NQF PQRS # # National Quality Strategy Domain 0236 44 Clinical Process/ Effectiveness 0637 45 Patient Safety 0097 46 GPRO CARE-1 Patient Safety 0326 47 Care Coordination 48 Clinical Process/ Effectiveness 0098 Date: 11/16/2012 Version 7.1 Measure Descriptiona Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery: Percentage of isolated Coronary Artery Bypass Graft (CABG) surgeries for patients aged 18 years and older who received a beta-blocker within 24 hours prior to surgical incision Perioperative Care: Discontinuation of Prophylactic Parenteral Antibiotics (Cardiac Procedures): Percentage of cardiac surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic parenteral antibiotics AND who received a prophylactic parenteral antibiotic, who have an order for discontinuation of prophylactic parenteral antibiotics within 48 hours of surgical end time Medication Reconciliation: Percentage of patients aged 65 years and older discharged from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) and seen within 30 days following discharge in the office by the physician providing on-going care who had a reconciliation of the discharge medications with the current medication list in the outpatient medical record documented Advance Care Plan: Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older: Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months Measure Developer Reporting Options CMS/QIP Claims, Registry, CABG Measures Group (R) AMAPCPI/NCQA Claims, Registry AMAPCPI/NCQA Claims, Registry, GPRO/ACO AMAPCPI/NCQA Claims, Registry, EHR AMAPCPI/NCQA Claims, Registry, EHR, Prev Care Measures Group (C/R) Page 7 of 44 2013 PQRS Measures List NQF PQRS # # National Quality Strategy Domain 49 Clinical Process/ Effectiveness 0100 50 Patient and Family Engagement 0091 51 Clinical Process/ Effectiveness 0102 52 Clinical Process/ Effectiveness 0047 53 Clinical Process/ Effectiveness 0090 54 Clinical Process/ Effectiveness 0099 0093 55 0232 56 Date: 11/16/2012 Version 7.1 Clinical Process/ Effectiveness Clinical Process/ Effectiveness Measure Descriptiona Urinary Incontinence: Characterization of Urinary Incontinence in Women Aged 65 Years and Older: Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence whose urinary incontinence was characterized at least once within 12 months Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older: Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation: Percentage of patients aged 18 years and older with a diagnosis of COPD who had spirometry evaluation results documented Chronic Obstructive Pulmonary Disease (COPD): Bronchodilator Therapy: Percentage of patients aged 18 years and older with a diagnosis of COPD and who have an FEV1/FVC less than 60% and have symptoms who were prescribed an inhaled bronchodilator Asthma: Pharmacologic Therapy for Persistent Asthma - Ambulatory Care Setting: Percentage of patients aged 5 through 50 years with a diagnosis of persistent asthma and at least one medical encounter for asthma during the measurement year who were prescribed long-term control medication Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for NonTraumatic Chest Pain: Percentage of patients aged 40 years and older with an emergency department discharge diagnosis of non-traumatic chest pain who had a 12-lead ECG performed Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for Syncope: Percentage of patients aged 60 years and older with an emergency department discharge diagnosis of syncope who had a 12-lead ECG performed Emergency Medicine: Community-Acquired Pneumonia (CAP): Vital Signs: Percentage of patients aged 18 years and older with a diagnosis of communityacquired bacterial pneumonia with vital signs documented and reviewed Measure Developer Reporting Options AMAPCPI/NCQA Claims, Registry AMAPCPI/NCQA Claims, Registry AMAPCPI Claims, Registry, COPD Measures Group (C/R) AMAPCPI Claims, Registry, COPD Measures Group (C/R) AMAPCPI/NCQA Claims, Registry, EHR, Asthma Measures Group (C/R) AMAPCPI/NCQA Claims, Registry AMAPCPI/NCQA Claims, Registry AMAPCPI/NCQA Claims, Registry Page 8 of 44 2013 PQRS Measures List NQF PQRS # # National Quality Strategy Domain 59 Clinical Process/ Effectiveness 0001 64 Clinical Process/ Effectiveness 0069 65 Efficient Use of Healthcare Resources 0002 66 Efficient Use of Healthcare Resources 0377 67 Clinical Process/ Effectiveness 0378 68 Clinical Process/ Effectiveness 0380 69 Clinical Process/ Effectiveness 0096 Date: 11/16/2012 Version 7.1 Measure Descriptiona Emergency Medicine: Community-Acquired Pneumonia (CAP): Empiric Antibiotic: Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia with an appropriate empiric antibiotic prescribed Asthma: Assessment of Asthma Control – Ambulatory Care Setting: Percentage of patients aged 5 through 50 years with a diagnosis of asthma who were evaluated at least once for asthma control (comprising asthma impairment and asthma risk) Appropriate Treatment for Children with Upper Respiratory Infection (URI): Percentage of children aged 3 months through 18 years with a diagnosis of URI who were not prescribed or dispensed an antibiotic prescription on or within 3 days of the initial date of service Appropriate Testing for Children with Pharyngitis: Percentage of children aged 2 through 18 years with a diagnosis of pharyngitis, who were prescribed an antibiotic and who received a group A streptococcus (strep) test for the episode. A higher rate represents better performance (i.e. appropriate testing). Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow: Percentage of patients aged 18 years and older with a diagnosis of MDS or an acute leukemia who had baseline cytogenetic testing performed on bone marrow Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy: Percentage of patients aged 18 years and older with a diagnosis of MDS who are receiving erythropoietin therapy with documentation of iron stores within 60 days prior to initiating erythropoietin therapy Hematology: Multiple Myeloma: Treatment with Bisphosphonates: Percentage of patients aged 18 years and older with a diagnosis of multiple myeloma, not in remission, who were prescribed or received intravenous bisphosphonate therapy within the 12-month reporting period Measure Developer Reporting Options AMAPCPI/NCQA Claims, Registry AMAPCPI/NCQA Claims, Registry, EHR, Asthma Measures Group (C/R) NCQA Claims, Registry NCQA Claims, Registry, EHR AMAPCPI/ASH Claims, Registry AMAPCPI/ASH Claims, Registry AMAPCPI/ASH Claims, Registry Page 9 of 44 2013 PQRS Measures List NQF PQRS # # National Quality Strategy Domain 0379 70 Clinical Process/ Effectiveness 0387 71 Clinical Process/ Effectiveness 0385 72 Clinical Process/ Effectiveness 0464 76 Patient Safety 0323 81 Care Coordination 0321 82 Care Coordination Date: 11/16/2012 Version 7.1 Measure Descriptiona Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry: Percentage of patients aged 18 years and older seen within a 12 month reporting period with a diagnosis of chronic lymphocytic leukemia (CLL) made at any time during or prior to the reporting period who had baseline flow cytometry studies performed and documented in the chart Breast Cancer: Hormonal Therapy for Stage IC - IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer: Percentage of female patients aged 18 years and older with Stage IC through IIIC, ER or PR positive breast cancer who were prescribed tamoxifen or aromatase inhibitor (AI) during the 12-month reporting period Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients: Percentage of patients aged 18 through 80 years with AJCC Stage III colon cancer who are referred for adjuvant chemotherapy, prescribed adjuvant chemotherapy, or have previously received adjuvant chemotherapy within the 12-month reporting period Prevention of Catheter-Related Bloodstream Infections (CRBSI): Central Venous Catheter (CVC) Insertion Protocol: Percentage of patients, regardless of age, who undergo CVC insertion for whom CVC was inserted with all elements of maximal sterile barrier technique [cap AND mask AND sterile gown AND sterile gloves AND a large sterile sheet AND hand hygiene AND 2% chlorhexidine for cutaneous antisepsis (or acceptable alternative antiseptics per current guideline)] followed Adult Kidney Disease: Hemodialysis Adequacy: Solute: Percentage of calendar months within a 12-month period during which patients aged 18 years and older with DGLDJQRVLVRI(65'UHFHLYLQJKHPRGLDO\VLVWKUHHWLPHVDZHHNIRU GD\VZKR KDYHDVS.W9 Adult Kidney Disease: Peritoneal Dialysis Adequacy: Solute: Percentage of patients aged 18 years and older with a diagnosis of ESRD receiving peritoneal GLDO\VLVZKRKDYHDWRWDO.W91.7 per week measured once every 4 months Measure Developer Reporting Options AMAPCPI/ASH Claims, Registry AMAPCPI/ ASCO/NCCN Claims, Registry, EHR, Oncology Measures Group (R) AMAPCPI/ ASCO/NCCN Claims, Registry, EHR, Oncology Measures Group (R) AMAPCPI Claims, Registry AMAPCPI Registry AMAPCPI Registry Page 10 of 44 2013 PQRS Measures List NQF PQRS # # National Quality Strategy Domain 83 Clinical Process/ Effectiveness 0395 84 Clinical Process/ Effectiveness 0396 85 Clinical Process/ Effectiveness 0397 86 Clinical Process/ Effectiveness 0398 87 Clinical Process/ Effectiveness 0401 89 Clinical Process/ Effectiveness 0394 90 Clinical Process/ Effectiveness 0653 91 Clinical Process/ Effectiveness 0393 Date: 11/16/2012 Version 7.1 Measure Descriptiona Hepatitis C: Testing for Chronic Hepatitis C – Confirmation of Hepatitis C Viremia: Percentage of patients aged 18 years and older with a diagnosis of hepatitis C seen for an initial evaluation who had HCV RNA testing ordered or previously performed Hepatitis C: Ribonucleic Acid (RNA) Testing Before Initiating Treatment: Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment for whom quantitative HCV RNA testing was performed within 6 months prior to initiation of antiviral treatment Hepatitis C: HCV Genotype Testing Prior to Treatment: Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment for whom HCV genotype testing was performed prior to initiation of antiviral treatment Hepatitis C: Antiviral Treatment Prescribed: Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who were prescribed at a minimum peginterferon and ribavirin therapy within the 12-month reporting period Hepatitis C: HCV Ribonucleic Acid (RNA) Testing at Week 12 of Treatment: Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment for whom quantitative HCV RNA testing was performed at no greater than 12 weeks from the initiation of antiviral treatment Hepatitis C: Counseling Regarding Risk of Alcohol Consumption: Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who were counseled about the risks of alcohol use at least once within 12-months Hepatitis C: Counseling Regarding Use of Contraception Prior to Antiviral Therapy: Percentage of female patients aged 18 through 44 years and all men aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving antiviral treatment who were counseled regarding contraception prior to the initiation of treatment Acute Otitis Externa (AOE): Topical Therapy: Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed topical preparations Measure Developer Reporting Options AMAPCPI Registry AMAPCPI Claims, Registry, Hep C Measures Group (C/R) AMAPCPI Claims, Registry, Hep C Measures Group (C/R) AMAPCPI Claims, Registry, Hep C Measures Group (C/R) AMAPCPI Claims, Registry, Hep C Measures Group (C/R) AMAPCPI Claims, Registry, Hep C Measures Group (C/R) AMAPCPI Claims, Registry, Hep C Measures Group (C/R) AMAPCPI Claims, Registry Page 11 of 44 2013 PQRS Measures List NQF PQRS # # National Quality Strategy Domain 0654 93 Care Coordination 0391 99 Clinical Process/ Effectiveness 0392 100 Clinical Process/ Effectiveness 0389 102 Efficient Use of Healthcare Resources 0390 104 Clinical Process/ Effectiveness 0103 106 Clinical Process/ Effectiveness 0104 107 Clinical Process/ Effectiveness Date: 11/16/2012 Version 7.1 Measure Descriptiona Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use: Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade: Percentage of breast cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes), and the histologic grade Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade: Percentage of colon and rectum cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes) and the histologic grade Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients: Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer Prostate Cancer: Adjuvant Hormonal Therapy for High Risk Prostate Cancer Patients: Percentage of patients, regardless of age, with a diagnosis of prostate cancer at high risk of recurrence receiving external beam radiotherapy to the prostate who were prescribed adjuvant hormonal therapy (GnRH agonist or antagonist) Adult Major Depressive Disorder (MDD): Comprehensive Depression Evaluation: Diagnosis and Severity: Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with evidence that they met the DSM-IV-TR criteria for MDD AND for whom there is an assessment of depression severity during the visit in which a new diagnosis or recurrent episode was identified Adult Major Depressive Disorder (MDD): Suicide Risk Assessment: Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified Measure Developer Reporting Options AMAPCPI Claims, Registry AMAPCPI/CAP Claims, Registry AMAPCPI/CAP Claims, Registry AMAPCPI Claims, Registry, EHR AMAPCPI Claims, Registry AMAPCPI Claims, Registry AMAPCPI Claims, Registry Page 12 of 44 2013 PQRS Measures List NQF PQRS # # National Quality Strategy Domain 0054 108 Clinical Process/ Effectiveness 0050 109 Patient and Family Engagement 0041 110 GPRO PREV-7 Population/ Public Health 0043 111 GPRO PREV-8 Clinical Process/ Effectiveness 0031 112 GPRO PREV-5 Clinical Process/ Effectiveness 0034 113 GPRO PREV-6 Clinical Process/ Effectiveness Date: 11/16/2012 Version 7.1 Measure Descriptiona Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug (DMARD) Therapy: Percentage of patients aged 18 years and older who were diagnosed with RA and were prescribed, dispensed, or administered at least one ambulatory prescription for a DMARD Osteoarthritis (OA): Function and Pain Assessment: Percentage of patient visits for patients aged 21 years and older with a diagnosis of OA with assessment for function and pain Preventive Care and Screening: Influenza Immunization: Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization Preventive Care and Screening: Pneumococcal Vaccination for Patients 65 Years and Older: Percentage of patients aged 65 years and older who have ever received a pneumococcal vaccine Measure Developer Reporting Options NCQA Claims, Registry, RA Measures Group (C/R) AMAPCPI Claims, Registry AMAPCPI NCQA Preventive Care and Screening: Breast Cancer Screening: Percentage of women aged 40 through 69 years who had a mammogram to screen for breast cancer within 24 months NCQA Preventive Care and Screening: Colorectal Cancer Screening: Percentage of patients aged 50 through 75 years who received the appropriate colorectal cancer screening NCQA Claims, Registry, EHR, GPRO/ACO, COPD Measures Group (C/R), Prev Care Measures Group (C/R), CKD Measures Group (C/R), Oncology Measures Group (R) Claims, Registry, EHR, GPRO/ACO, COPD Measures Group (C/R), Prev Care Measures Group (C/R) Claims, Registry, EHR, GPRO/ACO, Prev Care Measures Group (C/R) Claims, Registry, EHR, GPRO/ACO, Prev Care Measures Group (C/R) Page 13 of 44 2013 PQRS Measures List NQF # PQRS # National Quality Strategy Domain 0058 116 Efficient Use of Healthcare Resources 0055 117 Clinical Process/ Effectiveness 0066 118 GPRO CAD-7 Clinical Process/ Effectiveness 0062 119 Clinical Process/ Effectiveness AQA adopted 121 Clinical Process/ Effectiveness AQA adopted 122 Clinical Process/ Effectiveness Date: 11/16/2012 Version 7.1 Measure Descriptiona Antibiotic Treatment for Adults with Acute Bronchitis: Avoidance of Inappropriate Use: Percentage of adults aged 18 through 64 years with a diagnosis of acute bronchitis who were not prescribed or dispensed an antibiotic prescription on or within 3 days of the initial date of service Diabetes Mellitus: Dilated Eye Exam: Percentage of patients aged 18 through 75 years with a diagnosis of diabetes mellitus who had a dilated eye exam Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%): Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy Diabetes Mellitus: Medical Attention for Nephropathy: Percentage of patients aged 18 through 75 years with diabetes mellitus who received urine protein screening or medical attention for nephropathy during at least one office visit within 12 months Adult Kidney Disease: Laboratory Testing (Lipid Profile): Percentage of patients aged 18 years and older with a diagnosis of CKD (stage 3, 4, or 5, not receiving Renal Replacement Therapy [RRT]) who had a fasting lipid profile performed at least once within a 12-month period Adult Kidney Disease: Blood Pressure Management: Percentage of patient visits for those patients aged 18 years and older with a diagnosis of CKD (stage 3, 4, or 5, not receiving Renal Replacement Therapy [RRT]) and documented proteinuria with a blood pressXUH PP+J25PP+JZLWKD documented plan of care Measure Developer Reporting Options NCQA Claims, Registry NCQA Claims, Registry, EHR, DM Measures Group (C/R) AMAPCPI/ACCF/ AHA Registry, GPRO/ACO NCQA Claims, Registry, EHR, DM Measures Group (C/R) AMAPCPI Claims, Registry, CKD Measures Group (C/R) AMAPCPI Claims, Registry, CKD Measures Group (C/R) Page 14 of 44 2013 PQRS Measures List NQF # PQRS # National Quality Strategy Domain AQA adopted 123 Clinical Process/ Effectiveness 0486 125 Care Coordination/ Patient Safety 0417 126 Clinical Process/ Effectiveness 0416 127 Clinical Process/ Effectiveness 0421 128 GPRO PREV-9 Population/ Public Health 0419 130 Patient Safety Date: 11/16/2012 Version 7.1 Measure Descriptiona Adult Kidney Disease: Patients On Erythropoiesis-Stimulating Agent (ESA) Hemoglobin Level > 12.0 g/dL: Percentage of calendar months within a 12-month period during which a hemoglobin level is measured for patients aged 18 years and older with a diagnosis of advanced Chronic Kidney Disease (CKD) (stage 4 or 5, not receiving RRT [Renal Replacement Therapy]) or End Stage Renal Disease (ESRD) (who are on hemodialysis or peritoneal dialysis) who are also receiving ESA therapy AND have a Hemoglobin level > 12.0 g/dL Refer to the Electronic Prescribing (eRx) Incentive Program Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation: Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 months Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear: Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up: Percentage of patients aged 18 years and older with a calculated BMI in the past six months or during the current visit documented in the medical record AND if the most recent BMI is outside of normal parameters, a follow-up plan is documented within the past six months or during the current visit Normal Parameters: $JH\HDUVDQGROGHU%0,DQG $JH– 64 \HDUV%0,DQG Documentation of Current Medications in the Medical Record: Percentage of specified visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications to the best of his/her knowledge and ability. This list must include ALL prescriptions, over-thecounters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration Measure Developer Reporting Options AMAPCPI Claims, Registry, CKD Measures Group (C/R) CMS/QIP Claims, Registry, EHR, GPRO/ACO APMA Claims, Registry APMA Claims, Registry CMS/QIP Claims, Registry, EHR, GPRO/ACO, Prev Care Measures Group (C/R) CMS/QIP Claims, Registry, Oncology Measure Group (R) Page 15 of 44 2013 PQRS Measures List NQF # PQRS # National Quality Strategy Domain 0420 131 Population/ Public Health 0418 134 GPRO PREV12 Population/ Public Health 0650 137 Clinical Process/ Effectiveness 0561 138 Care Coordination 0566 140 Clinical Process/ Effectiveness 0563 141 Care Coordination Date: 11/16/2012 Version 7.1 Measure Descriptiona Pain Assessment and Follow-Up: Percentage of visits for patients aged 18 years and older with documentation of a pain assessment through discussion with the patient including the use of a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present Preventive Care and Screening: Screening for Clinical Depression and FollowUp Plan: Percentage of patients aged 12 years and older screened for clinical depression on the date of encounter using an age appropriate standardized depression screening tool AND, if positive, a follow-up plan is documented on the date of the positive screen Melanoma: Continuity of Care – Recall System: Percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered, at least once within a 12 month period, into a recall system that includes: • A target date for the next complete physical skin exam, AND • A process to follow up with patients who either did not make an appointment within the specified timeframe or who missed a scheduled appointment Melanoma: Coordination of Care: Percentage of patient visits, regardless of age, with a new occurrence of melanoma who have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement: Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration or their caregiver(s) who were counseled within 12 months on the benefits and/or risks of the Age-Related Eye Disease Study (AREDS) formulation for preventing progression of AMD Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care: Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 15% from the pre- intervention level) OR if the most recent IOP was not reduced by at least 15% from the pre- intervention level, a plan of care was documented within 12 months Measure Developer Reporting Options CMS/QIP Claims, Registry CMS/QIP Claims, Registry, GPRO/ACO AMAPCPI/NCQA Registry AMAPCPI/NCQA Registry AMAPCPI/NCQA Claims, Registry AMAPCPI/NCQA Claims, Registry Page 16 of 44 2013 PQRS Measures List NQF # PQRS # National Quality Strategy Domain 0051 142 Clinical Process/ Effectiveness 0384 143 Patient and Family Engagement 0383 144 Patient and Family Engagement 0510 145 Patient Safety 0508 146 Efficient Use of Healthcare Resources 0511 147 Care Coordination 0322 148 0319 149 Date: 11/16/2012 Version 7.1 Efficient Use of Healthcare Resources Clinical Process/ Effectiveness Measure Descriptiona Osteoarthritis (OA): Assessment for Use of Anti-Inflammatory or Analgesic Over-the-Counter (OTC) Medications: Percentage of patient visits for patients aged 21 years and older with a diagnosis of OA with an assessment for use of antiinflammatory or analgesic OTC medications Oncology: Medical and Radiation – Pain Intensity Quantified: Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified Oncology: Medical and Radiation – Plan of Care for Pain: Percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain Radiology: Exposure Time Reported for Procedures Using Fluoroscopy: Percentage of final reports for procedures using fluoroscopy that include documentation of radiation exposure or exposure time Radiology: Inappropriate Use of “Probably Benign” Assessment Category in Mammography Screening: Percentage of final reports for screening mammograms that are classified as “probably benign” Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy: Percentage of final reports for all patients, regardless of age, undergoing bone scintigraphy that include physician documentation of correlation with existing relevant imaging studies (e.g., x-ray, MRI, CT, etc.) that were performed Back Pain: Initial Visit: The percentage of patients aged 18 through 79 years with a diagnosis of back pain or undergoing back surgery who had back pain and function assessed during the initial visit to the clinician for the episode of back pain Back Pain: Physical Exam: Percentage of patients aged 18 through 79 years with a diagnosis of back pain or undergoing back surgery who received a physical examination at the initial visit to the clinician for the episode of back pain Measure Developer Reporting Options AMAPCPI Claims, Registry AMAPCPI Registry, Oncology Measures Group (R) AMAPCPI Registry, Oncology Measures Group (R) AMAPCPI/NCQA Claims, Registry AMAPCPI/NCQA Claims, Registry AMAPCPI Claims, Registry NCQA Back Pain Measures Group (C/R) NCQA Back Pain Measures Group (C/R) Page 17 of 44 2013 PQRS Measures List NQF # PQRS # National Quality Strategy Domain 150 Clinical Process/ Effectiveness 0313 151 Clinical Process/ Effectiveness 0101 154 Patient Safety 0101 155 Care Coordination 0382 156 Patient Safety 0455 157 Patient Safety 0404 159 Clinical Process/ Effectiveness 0405 160 Clinical Process/ Effectiveness 0314 Date: 11/16/2012 Version 7.1 Measure Descriptiona Back Pain: Advice for Normal Activities: The percentage of patients aged 18 through 79 years with a diagnosis of back pain or undergoing back surgery who received advice for normal activities at the initial visit to the clinician for the episode of back pain Back Pain: Advice Against Bed Rest: The percentage of patients aged 18 through 79 years with a diagnosis of back pain or undergoing back surgery who received advice against bed rest lasting four days or longer at the initial visit to the clinician for the episode of back pain Falls: Risk Assessment: Percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls completed within 12 months Falls: Plan of Care: Percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months Oncology: Radiation Dose Limits to Normal Tissues: Percentage of patients, regardless of age, with a diagnosis of pancreatic or lung cancer receiving 3D conformal radiation therapy with documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues Thoracic Surgery: Recording of Clinical Stage Prior to Lung Cancer or Esophageal Cancer Resection: Percentage of surgical patients aged 18 years and older undergoing resection for lung or esophageal cancer who had clinical staging provided prior to surgery HIV/AIDS: CD4+ Cell Count or CD4+ Percentage: Percentage of patients aged 6 months and older with a diagnosis of HIV/AIDS for whom a CD4+ cell count or CD4+ cell percentage was performed at least once every 6 months HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis: Percentage of patients aged 6 years and older with a diagnosis of HIV/AIDS and CD4+ cell count < 200 cells/mm3 who were prescribed PCP prophylaxis within 3 months of low CD4+ cell count Measure Developer Reporting Options NCQA Back Pain Measures Group (C/R) NCQA Back Pain Measures Group (C/R) AMAPCPI/NCQA AMAPCPI/NCQA Claims, Registry Claims, Registry AMAPCPI Claims, Registry STS Claims, Registry AMAPCPI/NCQA Registry, HIV/AIDS Measures Group (R) AMAPCPI/NCQA Registry, HIV/AIDS Measures Group (R) Page 18 of 44 2013 PQRS Measures List NQF # PQRS # National Quality Strategy Domain 0406 161 Clinical Process/ Effectiveness 0407 162 Clinical Process/ Effectiveness 0056 163 0129 164 0130 165 Clinical Process/ Effectiveness 0131 166 Clinical Process/ Effectiveness 167 Clinical Process/ Effectiveness 0114 Date: 11/16/2012 Version 7.1 Clinical Process/ Effectiveness Clinical Process/ Effectiveness Measure Descriptiona HIV/AIDS: Adolescent and Adult Patients with HIV/AIDS Who Are Prescribed Potent Antiretroviral Therapy: Percentage of patients with a diagnosis of HIV/AIDS aged 13 years and older: who have a history of a nadir CD4+ cell count below 350/mm3 or who have a history of an AIDS- defining condition, regardless of CD4+ cell count; or who are pregnant, regardless of CD4+ cell count or age, who were prescribed potent antiretroviral therapy HIV/AIDS: HIV RNA Control After Six Months of Potent Antiretroviral Therapy: Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS who are receiving potent antiretroviral therapy, who have a viral load below limits of quantification after at least 6 months of potent antiretroviral therapy or patients whose viral load is not below limits of quantification after at least 6 months of potent antiretroviral therapy and have documentation of a plan of care Diabetes Mellitus: Foot Exam: The percentage of patients aged 18 through 75 years with diabetes who had a foot examination Coronary Artery Bypass Graft (CABG): Prolonged Intubation: Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require intubation > 24 hours Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate: Percentage of patients aged 18 years and older undergoing isolated CABG surgery who, within 30 days postoperatively, develop deep sternal wound infection involving muscle, bone, and/or mediastinum requiring operative intervention Coronary Artery Bypass Graft (CABG): Stroke: Percentage of patients aged 18 years and older undergoing isolated CABG surgery who have a postoperative stroke (i.e., any confirmed neurological deficit of abrupt onset caused by a disturbance in blood supply to the brain) that did not resolve within 24 hours Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure: Percentage of patients aged 18 years and older undergoing isolated CABG surgery (without pre-existing renal failure) who develop postoperative renal failure or require dialysis Measure Developer Reporting Options AMAPCPI/NCQA Registry, HIV/AIDS Measures Group (R) AMAPCPI/NCQA Registry, HIV/AIDS Measures Group (R) NCQA Claims, Registry, EHR, DM Measures Group (C/R) STS Registry, CABG Measures Group (R) STS Registry, CABG Measures Group (R) STS Registry, CABG Measures Group (R) STS Registry, CABG Measures Group (R) Page 19 of 44 2013 PQRS Measures List NQF # PQRS # National Quality Strategy Domain Clinical Process/ Effectiveness 0115 168 0116 169 0117 170 0118 171 0259 172 Clinical Process/ Effectiveness 173 Population/ Public Health AQA adopted Clinical Process/ Effectiveness Clinical Process/ Effectiveness Clinical Process/ Effectiveness AQA adopted 176 Clinical Process/ Effectiveness AQA adopted 177 Clinical Process/ Effectiveness Date: 11/16/2012 Version 7.1 Measure Descriptiona Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration: Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require a return to the operating room (OR) during the current hospitalization for mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction, or other cardiac reason Coronary Artery Bypass Graft (CABG): Antiplatelet Medications at Discharge: Percentage of patients aged 18 years and older undergoing isolated CABG surgery who were discharged on antiplatelet medication Coronary Artery Bypass Graft (CABG): Beta-Blockers Administered at Discharge: Percentage of patients aged 18 years and older undergoing isolated CABG surgery who were discharged on beta-blockers Coronary Artery Bypass Graft (CABG): Anti-Lipid Treatment at Discharge: Percentage of patients aged 18 years and older undergoing isolated CABG surgery who were discharged on a statin or other lipid-lowering regimen Hemodialysis Vascular Access Decision-Making by Surgeon to Maximize Placement of Autogenous Arterial Venous (AV) Fistula: Percentage of patients aged 18 years and older with a diagnosis of advanced Chronic Kidney Disease (CKD) (stage 4 or 5) or End Stage Renal Disease (ESRD) requiring hemodialysis vascular access documented by surgeon to have received autogenous AV fistula Preventive Care and Screening: Unhealthy Alcohol Use – Screening: Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method within 24 months Rheumatoid Arthritis (RA): Tuberculosis Screening: Percentage of patients aged 18 years and older with a diagnosis of RA who have documentation of a tuberculosis (TB) screening performed and results interpreted within 6 months prior to receiving a first course of therapy using a biologic disease-modifying antirheumatic drug (DMARD) Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity: Percentage of patients aged 18 years and older with a diagnosis of RA who have an assessment and classification of disease activity within 12 months Measure Developer Reporting Options STS Registry, CABG Measures Group (R) STS Registry, CABG Measures Group (R) STS Registry, CABG Measures Group (R) STS Registry, CABG Measures Group (R) SVS Claims, Registry AMAPCPI Claims, Registry, EHR, Prev Care Measures Group (C/R) AMAPCPI/NCQA Claims, Registry, RA Measures Group (C/R) AMAPCPI/NCQA Claims, Registry, RA Measures Group (C/R) Page 20 of 44 2013 PQRS Measures List NQF # PQRS # National Quality Strategy Domain AQA adopted 178 Clinical Process/ Effectiveness AQA adopted 179 Clinical Process/ Effectiveness AQA adopted 180 Care Coordination AQA adopted 181 Patient Safety AQA adopted 182 Care Coordination 0399 183 Population/ Public Health 0400 184 Population/ Public Health Date: 11/16/2012 Version 7.1 Measure Descriptiona Rheumatoid Arthritis (RA): Functional Status Assessment: Percentage of patients aged 18 years and older with a diagnosis of RA for whom a functional status assessment was performed at least once within 12 months Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis: Percentage of patients aged 18 years and older with a diagnosis of RA who have an assessment and classification of disease prognosis at least once within 12 months Rheumatoid Arthritis (RA): Glucocorticoid Management: Percentage of patients aged 18 years and older with a diagnosis of RA who have been assessed for JOXFRFRUWLFRLGXVHDQGIRUWKRVHRQSURORQJHGGRVHVRISUHGQLVRQHPJGDLO\ (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months Elder Maltreatment Screen and Follow-Up Plan: Percentage of patients aged 65 years and older with a documented elder maltreatment screen on the date of encounter AND a documented follow-up plan on the date of positive screen Functional Outcome Assessment: Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies Hepatitis C: Hepatitis A Vaccination in Patients with HCV: Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who received at least one injection of hepatitis A vaccine, or who have documented immunity to hepatitis A Hepatitis C: Hepatitis B Vaccination in Patients with HCV: Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who received at least one injection of hepatitis B vaccine, or who have documented immunity to hepatitis B Measure Developer Reporting Options AMAPCPI/NCQA Claims, Registry, RA Measures Group (C/R) AMAPCPI/NCQA Claims, Registry, RA Measures Group (C/R) AMAPCPI/NCQA Claims, Registry, RA Measures Group (C/R) CMS/QIP Claims, Registry CMS/QIP Claims, Registry AMAPCPI Claims, Registry, Hep C Measures Group (C/R) AMAPCPI Claims, Registry, Hep C Measures Group (C/R) Page 21 of 44 2013 PQRS Measures List NQF # PQRS # National Quality Strategy Domain 0659 185 Care Coordination 0437 187 Clinical Process/ Effectiveness N/A 188. Care Coordination 0565 191 Clinical Process/ Effectiveness 0564 192 Patient Safety Date: 11/16/2012 Version 7.1 Measure Descriptiona Endoscopy & Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use: Percentage of patients aged 18 years and older receiving a surveillance colonoscopy with a history of a prior colonic polyp(s) in previous colonoscopy findings, who had an interval of 3 or more years since their last colonoscopy Stroke and Stroke Rehabilitation: Thrombolytic Therapy: Percentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who arrive at the hospital within two hours of time last known well and for whom IV t-PA was initiated within three hours of time last known well Referral for Otologic Evaluation for Patients with Congenital or Traumatic Deformity of the Ear: Percentage of patients aged birth and older referred to a physician (preferably a physician with training in disorders of the ear) for an otologic evaluation subsequent to an audiologic evaluation after presenting with a congenital or traumatic deformity of the ear (internal or external) Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery: Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following the cataract surgery Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures: Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and had any of a specified list of surgical procedures in the 30 days following cataract surgery which would indicate the occurrence of any of the following major complications: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence Measure Developer Reporting Options AMAPCPI/NCQA Claims, Registry AHA/ASA/ TJC Registry AQC Claims, Registry AMAPCPI/NCQA Registry, Cataract Measures Group (R) AMAPCPI/NCQA Registry, Cataract Measures Group (R) Page 22 of 44 2013 PQRS Measures List NQF # PQRS # National Quality Strategy Domain 0454 193 Patient Safety 0386 194 Clinical Process/ Effectiveness 0507 195 Clinical Process/ Effectiveness 0074 197 GPRO CAD-2 Clinical Process/ Effectiveness Date: 11/16/2012 Version 7.1 Measure Descriptiona Perioperative Temperature Management: Percentage of patients, regardless of age, undergoing surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer, except patients undergoing cardiopulmonary bypass, for whom either active warming was used intraoperatively for the purpose of maintaining normothermia, OR at least one body temperature equal to or greater than 36 degrees Centigrade (or 96.8 degrees Fahrenheit) was recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time Oncology: Cancer Stage Documented: Percentage of patients, regardless of age, with a diagnosis of cancer who are seen in the ambulatory setting who have a baseline AJCC cancer stage or documentation that the cancer is metastatic in the medical record at least once within 12 months Radiology: Stenosis Measurement in Carotid Imaging Reports: Percentage of final reports for carotid imaging studies (neck magnetic resonance angiography [MRA], neck computed tomography angiography [CTA], neck duplex ultrasound, carotid angiogram) performed that include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement Coronary Artery Disease (CAD): Lipid Control: Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who have a LDL-C result < 100 mg/dL OR patients who have a LDL-C result PJG/DQGKave a documented plan of care to achieve LDL-C <100 mg/dL, including at a minimum the prescription of a statin Measure Developer AMAPCPI Reporting Options Claims, Registry AMAA PCPI/ASCO Claims, Registry, Oncology Measure Group (R) AMAPCPI/NCQA Claims, Registry AMAPCPI/ACCF/ AHA Registry, EHR, GPRO/ACO, CAD Measures Group (R) Page 23 of 44 2013 PQRS Measures List NQF # PQRS # 0079 198 0084 200 National Quality Strategy Domain Clinical Process/ Effectiveness Clinical Process/ Effectiveness Clinical Process/ Effectiveness 0073 201 0068 204 GPRO IVD-2 Clinical Process/ Effectiveness 0409 205 Clinical Process/ Effectiveness 0410 208 Clinical Process/ Effectiveness 0445 209 Clinical Process/ Effectiveness 0449 210 Clinical Process/ Effectiveness Date: 11/16/2012 Version 7.1 Measure Descriptiona Heart Failure: Left Ventricular Ejection Fraction (LVEF) Assessment: Percentage of patients aged 18 years and older with a diagnosis of heart failure for whom the quantitative or qualitative results of a recent or prior [any time in the past] LVEF assessment is documented within a 12 month period Heart Failure: Warfarin Therapy for Patients with Atrial Fibrillation: Percentage of all patients aged 18 and older with a diagnosis of heart failure and paroxysmal or chronic atrial fibrillation who were prescribed warfarin therapy Ischemic Vascular Disease (IVD): Blood Pressure Management: Percentage of patients aged 18 to 75 years with Ischemic Vascular Disease (IVD) who had most recent blood pressure in control (less than 140/90 mmHg) Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic: Percentage of patients aged 18 years and older with Ischemic Vascular Disease (IVD) with documented use of aspirin or another antithrombotic HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia and Gonorrhea: Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia and gonorrhea screenings were performed at least once since the diagnosis of HIV infection HIV/AIDS: Sexually Transmitted Disease Screening for Syphilis: Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS who were screened for syphilis at least once within 12 months Functional Communication Measure - Spoken Language Comprehension: Percentage of patients aged 16 years and older with a diagnosis of late effects of cerebrovascular disease (CVD) that make progress on the Spoken Language Comprehension Functional Communication Measure Functional Communication Measure - Attention: Percentage of patients aged 16 years and older with a diagnosis of late effects of cerebrovascular disease (CVD) that make progress on the Attention Functional Communication Measure Measure Developer Reporting Options AMAPCPI/ACCF/ AHA AMAPCPI/ACCF/A HA Registry, HF Measures Group (R) NCQA NCQA EHR Claims, Registry, EHR, IVD Measures Group (C/R) Claims, Registry, EHR, GPRO/ACO, IVD Measures Group (C/R), Cardiovascular Prevention Measures Group (C/R) AMAPCPI/NCQA Registry, HIV/AIDS Measures Group (R) AMAPCPI/NCQA Registry, HIV/AIDS Measures Group (R) ASHA Registry ASHA Registry Page 24 of 44 2013 PQRS Measures List NQF # PQRS # National Quality Strategy Domain 0448 211 Clinical Process/ Effectiveness 0447 212 Clinical Process/ Effectiveness 0446 213 Clinical Process/ Effectiveness 0444 214 Clinical Process/ Effectiveness 0442 215 0443 216 0422 217 Care Coordination 0423 218 Care Coordination Date: 11/16/2012 Version 7.1 Clinical Process/ Effectiveness Clinical Process/ Effectiveness Measure Descriptiona Functional Communication Measure - Memory: Percentage of patients aged 16 years and older with a diagnosis of late effects of cerebrovascular disease (CVD) that make progress on the Memory Functional Communication Measure Functional Communication Measure - Motor Speech: Percentage of patients aged 16 years and older with a diagnosis of late effects of cerebrovascular disease (CVD) that make progress on the Motor Speech Functional Communication Measure Functional Communication Measure - Reading: Percentage of patients aged 16 years and older with a diagnosis of late effects of cerebrovascular disease (CVD) that make progress on the Reading Functional Communication Measure Functional Communication Measure - Spoken Language Expression: Percentage of patients aged 16 years and older with a diagnosis of late effects of cerebrovascular disease (CVD) that make progress on the Spoken Language Expression Functional Communication Measure Functional Communication Measure - Writing: Percentage of patients aged 16 years and older with a diagnosis of late effects of cerebrovascular disease (CVD) that make progress on the Writing Functional Communication Measure Functional Communication Measure - Swallowing: Percentage of patients aged 16 years and older with a diagnosis of late effects of cerebrovascular disease (CVD) that make progress on the Swallowing Functional Communication Measure Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Knee Impairments: Percentage of patients aged 18 or older that receive treatment for a functional deficit secondary to a diagnosis that affects the knee in which the change in their Risk-Adjusted Functional Status is measured Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Hip Impairments: Percentage of patients aged 18 or older that receive treatment for a functional deficit secondary to a diagnosis that affects the hip in which the change in their Risk-Adjusted Functional Status is measured Measure Developer Reporting Options ASHA Registry ASHA Registry ASHA Registry ASHA Registry ASHA Registry ASHA Registry FOTO Registry FOTO Registry Page 25 of 44 2013 PQRS Measures List NQF # PQRS # National Quality Strategy Domain 0424 219 Care Coordination 0425 220 Care Coordination 0426 221 Care Coordination 0427 222 Care Coordination 0428 223 Care Coordination 0562 224 Efficient Use of Healthcare Resources Date: 11/16/2012 Version 7.1 Measure Descriptiona Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Lower Leg, Foot or Ankle Impairments: Percentage of patients aged 18 or older that receive treatment for a functional deficit secondary to a diagnosis that affects the lower leg, foot or ankle in which the change in their Risk-Adjusted Functional Status is measured Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Lumbar Spine Impairments: Percentage of patients aged 18 or older that receive treatment for a functional deficit secondary to a diagnosis that affects the lumbar spine in which the change in their Risk- Adjusted Functional Status is measured Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Shoulder Impairments: Percentage of patients aged 18 or older that receive treatment for a functional deficit secondary to a diagnosis that affects the shoulder in which the change in their Risk-Adjusted Functional Status is measured Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Elbow, Wrist or Hand Impairments: Percentage of patients aged 18 or older that receive treatment for a functional deficit secondary to a diagnosis that affects the elbow, wrist or hand in which the change in their Risk-Adjusted Functional Status is measured Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Neck, Cranium, Mandible, Thoracic Spine, Ribs, or Other General Orthopedic Impairments: Percentage of patients aged 18 or older that receive treatment for a functional deficit secondary to a diagnosis that affects the neck, cranium, mandible, thoracic spine, ribs, or other general orthopedic impairment in which the change in their Risk-Adjusted Functional Status is measured Melanoma: Overutilization of Imaging Studies in Melanoma: Percentage of patients, regardless of age, with a current diagnosis of stage 0 through IIC melanoma or a history of melanoma of any stage, without signs or symptoms suggesting systemic spread, seen for an office visit during the one-year measurement period, for whom no diagnostic imaging studies were ordered Measure Developer Reporting Options FOTO Registry FOTO Registry FOTO Registry FOTO Registry FOTO Registry AMAPCPI/NCQA Registry Page 26 of 44 2013 PQRS Measures List NQF # PQRS # 0509 225 National Quality Strategy Domain Care Coordination 226 GPRO PREV10 Population/ Public Health N/A 228 Clinical Process/ Effectiveness N/A 231 Clinical Process/ Effectiveness 0028 Date: 11/16/2012 Version 7.1 Measure Descriptiona Radiology: Reminder System for Mammograms: Percentage of patients aged 40 years and older undergoing a screening mammogram whose information is entered into a reminder system with a target due date for the next mammogram Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user Heart Failure (HF): Left Ventricular Function (LVF) Testing: Percentage of patients 18 years and older with Left Ventricular Function (LVF) testing performed within the previous 12 months for patients who are hospitalized with a principal diagnosis of Heart Failure (HF) during the reporting period Asthma: Tobacco Use: Screening - Ambulatory Care Setting: Percentage of patients (or their primary caregiver) aged 5 through 50 years with a diagnosis of asthma who were queried about tobacco use and exposure to second hand smoke within their home environment at least once during the one-year measurement period Measure Developer Reporting Options AMAPCPI/NCQA Claims, Registry AMAPCPI Claims, Registry, EHR, GPRO/ACO, CAD Measures Group (R), COPD Measures Group (C/R), HF Measures Group (R), IBD Measures Group (R), IVD Measures Group (C/R), Prev Care Measures Group (C/R), Cardiovascular Prevention Measures Group (C/R), Oncology Measure Group (R) CMS/QIP Registry AMAPCPI/NCQA Claims, Registry, Asthma Measures Group (C/R) Page 27 of 44 2013 PQRS Measures List NQF # PQRS # National Quality Strategy Domain N/A 232 Clinical Process/ Effectiveness 0457 233 Clinical Process/ Effectiveness 0458 234 Patient Safety 0018 236 GPRO HTN-2 Clinical Process/ Effectiveness 0013 237 Clinical Process/ Effectiveness 0022 238 Patient Safety 0024 239 Population/ Public Health Date: 11/16/2012 Version 7.1 Measure Descriptiona Asthma: Tobacco Use: Intervention - Ambulatory Care Setting: Percentage of patients (or their primary caregiver) aged 5 through 50 years with a diagnosis of asthma who were identified as tobacco users (patients who currently use tobacco AND patients who do not currently use tobacco, but are exposed to second hand smoke in their home environment) who received tobacco cessation intervention at least once during the one-year measurement period Thoracic Surgery: Recording of Performance Status Prior to Lung or Esophageal Cancer Resection: Percentage of patients aged 18 years and older undergoing resection for lung or esophageal cancer who had performance status documented and reviewed within 2 weeks prior to surgery Thoracic Surgery: Pulmonary Function Tests Before Major Anatomic Lung Resection (Pneumonectomy, Lobectomy, or Formal Segmentectomy): Percentage of thoracic surgical patients aged 18 years and older undergoing at least one pulmonary function test within 12 months prior to a major lung resection (pneumonectomy, lobectomy, or formal segmentectomy) Hypertension (HTN): Controlling High Blood Pressure: Percentage of patients aged 18 through 85 years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled (< 140/90 mmHg) Hypertension (HTN): Blood Pressure Measurement: Percentage of patient visits for patients aged 18 years and older with a diagnosis of hypertension with blood pressure (BP) recorded Drugs to be Avoided in the Elderly: Percentage of patients ages 65 years and older who received at least one drug to be avoided in the elderly and/or two different drugs to be avoided in the elderly in the measurement period Weight Assessment and Counseling for Children and Adolescents: Percentage of children 2 through 17 years of age who had an outpatient visit with a PCP or OB/GYN and who had evidence of BMI percentile documentation, counseling for nutrition and counseling for physical activity during the measurement period Measure Developer Reporting Options AMAPCPI/NCQA Claims, Registry, Asthma Measures Group (C/R) STS Registry STS Registry NCQA Claims, Registry, EHR, GPRO/ACO, Cardiovascular Prevention Measures Group (C/R) AMAPCPI EHR NCQA EHR NCQA EHR Page 28 of 44 2013 PQRS Measures List NQF # PQRS # 0038 240 National Quality Strategy Domain Population/ Public Health 241 GPRO IVD-1 Clinical Process/ Effectiveness N/A 242 Clinical Process/ Effectiveness 0643 243 Clinical Process/ Effectiveness N/A 244 Clinical Process/ Effectiveness 0075 Date: 11/16/2012 Version 7.1 Measure Descriptiona Childhood Immunization Status: The percentage of children two years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV); one measles, mumps, rubella (MMR); three H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); two hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday Ischemic Vascular Disease (IVD): Complete Lipid Panel and Low Density Lipoprotein (LDL-C) Control: Percentage of patients aged 18 years and older with Ischemic Vascular Disease (IVD) who received at least one lipid profile within 12 months and whose most recent LDL-C level was in control (less than 100 mg/dL) Coronary Artery Disease (CAD): Symptom Management: Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period with an evaluation of level of activity and an assessment of whether anginal symptoms are present or absent with appropriate management of anginal symptoms within a 12 month period Cardiac Rehabilitation Patient Referral from an Outpatient Setting: Percentage of patients evaluated in an outpatient setting who within the previous 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the qualifying event/diagnosis who were referred to a CR program Hypertension: Blood Pressure Management: Percentage of patients aged 18 years and older with a diagnosis of hypertension seen within a 12 month period with DEORRGSUHVVXUH PP+J25SDWLHQWVZLWKDEORRGSUHVVXUH mmHg and prescribed two or more anti-hypertensive medications during the most recent office visit Measure Developer Reporting Options NCQA EHR NCQA Claims, Registry, EHR, GPRO/ACO, IVD Measures Group (C/R), Cardiovascular Prevention Measures Group (C/R) AMAPCPI/ACCF/ AHA ACCFAHA AMAPCPI/ACCF/ AHA Registry, CAD Measures Group (R) Registry Registry Page 29 of 44 2013 PQRS Measures List NQF # PQRS # National Quality Strategy Domain AQA adopted 245 Clinical Process/ Effectiveness AQA adopted 246 Clinical Process/ Effectiveness AQA adopted 247 Clinical Process/ Effectiveness AQA adopted 248 Clinical Process/ Effectiveness N/A 249 N/A 250 N/A 251 Date: 11/16/2012 Version 7.1 Clinical Process/ Effectiveness Clinical Process/ Effectiveness Clinical Process/ Effectiveness Measure Descriptiona Chronic Wound Care: Use of Wound Surface Culture Technique in Patients with Chronic Skin Ulcers (Overuse Measure): Percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic skin ulcer without the use of a wound surface culture technique Chronic Wound Care: Use of Wet to Dry Dressings in Patients with Chronic Skin Ulcers (Overuse Measure): Percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic skin ulcer without a prescription or recommendation to use wet to dry dressings Substance Use Disorders: Counseling Regarding Psychosocial and Pharmacologic Treatment Options for Alcohol Dependence: Percentage of patients aged 18 years and older with a diagnosis of current alcohol dependence who were counseled regarding psychosocial AND pharmacologic treatment options for alcohol dependence within the 12-month reporting period Substance Use Disorders: Screening for Depression Among Patients with Substance Abuse or Dependence: Percentage of patients aged 18 years and older with a diagnosis of current substance abuse or dependence who were screened for depression within the 12-month reporting period Barrett's Esophagus: Percentage of esophageal biopsy reports that document the presence of Barrett’s mucosa that also include a statement about dysplasia Radical Prostatectomy Pathology Reporting: Percentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin status Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) for Breast Cancer Patients: This is a measure based on whether quantitative evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) by immunohistochemistry (IHC) uses the system recommended in the ASCO/CAP Guidelines for Human Epidermal Growth Factor Receptor 2 Testing in breast cancer Measure Developer Reporting Options AMAPCPI/NCQA Claims, Registry AMAPCPI/NCQA Claims, Registry AMAPCPI/NCQA Claims, Registry AMAPCPI/NCQA Claims, Registry CAP Claims, Registry CAP Claims, Registry CAP Claims, Registry Page 30 of 44 2013 PQRS Measures List NQF # PQRS # National Quality Strategy Domain 0503 252 Clinical Process/ Effectiveness 0651 254 Clinical Process/ Effectiveness 0652 255 Clinical Process/ Effectiveness N/A 256 Care Coordination N/A 257 Clinical Process/ Effectiveness N/A 258 Care Coordination N/A 259 Care Coordination Date: 11/16/2012 Version 7.1 Measure Descriptiona Anticoagulation for Acute Pulmonary Embolus Patients: Anticoagulation ordered for patients who have been discharged from the emergency department (ED) with a diagnosis of acute pulmonary embolus Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain: Percentage of pregnant female patients aged 14 to 50 who present to the emergency department (ED) with a chief complaint of abdominal pain or vaginal bleeding who receive a trans-abdominal or trans-vaginal ultrasound to determine pregnancy location Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure: Percentage of Rh-negative pregnant women aged 14-50 years at risk of fetal blood exposure who receive Rh-Immunoglobulin (Rhogam) in the emergency department (ED) Surveillance after Endovascular Abdominal Aortic Aneurysm Repair (EVAR): Percentage of patients 18 years of age or older undergoing endovascular abdominal aortic aneurysm repair (EVAR) who have at least one follow-up imaging study after 3 months and within 15 months of EVAR placement that documents aneurysm sac diameter and endoleak status Statin Therapy at Discharge after Lower Extremity Bypass (LEB): Percentage of patients aged 18 years and older undergoing infra-inguinal lower extremity bypass who are prescribed a statin medication at discharge Rate of Open Repair of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by PostOperative Day #7): Percent of patients undergoing open repair of small or moderate sized non-ruptured abdominal aortic aneurysms who do not experience a major complication (discharge to home no later than post-operative day #7) Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate NonRuptured Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #2): Percent of patients undergoing endovascular repair of small or moderate non-ruptured abdominal aortic aneurysms (AAA) that do not experience a major complication (discharged to home no later than post-operative day #2) Measure Developer Reporting Options ACEP Claims, Registry ACEP Claims, Registry ACEP Claims, Registry SVS Registry SVS Registry SVS Registry SVS Registry Page 31 of 44 2013 PQRS Measures List NQF # PQRS # National Quality Strategy Domain N/A 260 Care Coordination N/A 261. Care Coordination N/A 262 Patient Safety N/A 263 N/A 264 0645 265 Care Coordination 266 Clinical Process/ Effectiveness N/A Date: 11/16/2012 Version 7.1 Clinical Process/ Effectiveness Clinical Process/ Effectiveness Measure Descriptiona Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2): Percent of asymptomatic patients undergoing CEA who are discharged to home no later than post-operative day #2 Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness: Percentage of patients aged birth and older referred to a physician (preferably a physician specially trained in disorders of the ear) for an otologic evaluation subsequent to an audiologic evaluation after presenting with acute or chronic dizziness Image Confirmation of Successful Excision of Image–Localized Breast Lesion: Image confirmation of lesion(s) targeted for image guided excisional biopsy or image guided partial mastectomy in patients with nonpalpable, image-detected breast lesion(s). Lesions may include: microcalcifications, mammographic or sonographic mass or architectural distortion, focal suspicious abnormalities on magnetic resonance imaging (MRI) or other breast imaging amenable to localization such as positron emission tomography (PET) mammography, or a biopsy marker demarcating site of confirmed pathology as established by previous core biopsy. Preoperative Diagnosis of Breast Cancer: The percent of patients undergoing breast cancer operations who obtained the diagnosis of breast cancer preoperatively by a minimally invasive biopsy method Sentinel Lymph Node Biopsy for Invasive Breast Cancer: The percentage of clinically node negative (clinical stage T1N0M0 or T2N0M0) breast cancer patients who undergo a sentinel lymph node (SLN) procedure Biopsy Follow-Up: Percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient by the performing physician Epilepsy: Seizure Type(s) and Current Seizure Frequency(ies): Percentage of patient visits with a diagnosis of epilepsy who had the type(s) of seizure(s) and current seizure frequency(ies) for each seizure type documented in the medical record Measure Developer Reporting Options SVS Registry AQC Claims, Registry ASBS Claims, Registry ASBS Claims, Registry ASBS Registry AAD Registry AAN Claims, Registry Page 32 of 44 2013 PQRS Measures List NQF # PQRS # National Quality Strategy Domain 267 Clinical Process/ Effectiveness N/A 268 Clinical Process/ Effectiveness N/A 269 Clinical Process/ Effectiveness N/A 270 Clinical Process/ Effectiveness N/A 271 Clinical Process/ Effectiveness N/A 272 Clinical Process/ Effectiveness N/A 273 Clinical Process/ Effectiveness N/A Date: 11/16/2012 Version 7.1 Measure Descriptiona Epilepsy: Documentation of Etiology of Epilepsy or Epilepsy Syndrome: All visits for patients with a diagnosis of epilepsy who had their etiology of epilepsy or with epilepsy syndrome(s) reviewed and documented if known, or documented as unknown or cryptogenic Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy: All female patients of childbearing potential (12-44 years old) diagnosed with epilepsy who were counseled about epilepsy and how its treatment may affect contraception and pregnancy at least once a year Inflammatory Bowel Disease (IBD): Type, Anatomic Location and Activity All Documented: Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease who have documented the disease type, anatomic location and activity, at least once during the reporting period Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Sparing Therapy: Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease who have been managed by corticosteroids greater than or equal to 10 mg/day for 60 or greater consecutive days that have been prescribed corticosteroid sparing therapy in the last reporting year Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury – Bone Loss Assessment: Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease who have received dose of corticosteroids greater than or equal to 10 mg/day for 60 or greater consecutive days and were assessed for risk of bone loss once per the reporting year Inflammatory Bowel Disease (IBD): Preventive Care: Influenza Immunization: Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease for whom influenza immunization was recommended, administered or previously received during the reporting year Inflammatory Bowel Disease (IBD): Preventive Care: Pneumococcal Immunization: Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease that had pneumococcal vaccination administered or previously received Measure Developer Reporting Options AAN Claims, Registry AAN Claims, Registry AGA IBD Measures Group (R) AGA IBD Measures Group (R) AGA IBD Measures Group (R) AGA IBD Measures Group (R) AGA IBD Measures Group (R) Page 33 of 44 2013 PQRS Measures List NQF # PQRS # National Quality Strategy Domain N/A 274 Clinical Process/ Effectiveness N/A 275 Clinical Process/ Effectiveness N/A 276 Clinical Process/ Effectiveness N/A 277 Clinical Process/ Effectiveness N/A 278 Clinical Process/ Effectiveness N/A 279 Clinical Process/ Effectiveness N/A 280 Care Coordination Date: 11/16/2012 Version 7.1 Measure Descriptiona Inflammatory Bowel Disease (IBD): Testing for Latent Tuberculosis (TB) Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy: Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease for whom a tuberculosis (TB) screening was performed and results interpreted within 6 months prior to receiving a first course of anti-TNF (tumor necrosis factor) therapy Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy: Percentage of patients aged 18 years and older with a diagnosis of inflammatory bowel disease who had Hepatitis B Virus (HBV) status assessed and results interpreted within one year prior to receiving a first course of anti-TNF (tumor necrosis factor) therapy Sleep Apnea: Assessment of Sleep Symptoms: Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea that includes documentation of an assessment of symptoms, including presence or absence of snoring and daytime sleepiness Sleep Apnea: Severity Assessment at Initial Diagnosis: Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) measured at the time of initial diagnosis Sleep Apnea: Positive Airway Pressure Therapy Prescribed: Percentage of patients aged 18 years and older with a diagnosis of moderate or severe obstructive sleep apnea who were prescribed positive airway pressure therapy Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy: Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea who were prescribed positive airway pressure therapy who had documentation that adherence to positive airway pressure therapy was objectively measured Dementia: Staging of Dementia: Percentage of patients, regardless of age, with a diagnosis of dementia whose severity of dementia was classified as mild, moderate or severe at least once within a 12 month period Measure Developer Reporting Options AGA IBD Measures Group (R) AGA IBD Measures Group (R) AMAPCPI/NCQA Sleep Apnea Measures Group (R) AMAPCPI/NCQA Sleep Apnea Measures Group (R) AMAPCPI/NCQA Sleep Apnea Measures Group (R) AMAPCPI/NCQA Sleep Apnea Measures Group (R) AMAPCPI Dementia Measures Group (C/R) Page 34 of 44 2013 PQRS Measures List NQF # PQRS # National Quality Strategy Domain Clinical Process/ Effectiveness Clinical Process/ Effectiveness N/A 281 N/A 282 N/A 283 Clinical Process/ Effectiveness N/A 284 Clinical Process/ Effectiveness N/A 285 Clinical Process/ Effectiveness N/A 286 Patient Safety N/A 287 Clinical Process/ Effectiveness 288 Clinical Process/ Effectiveness N/A Date: 11/16/2012 Version 7.1 Measure Descriptiona Dementia: Cognitive Assessment: 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 Dementia: Functional Status Assessment: Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of patient’s functional status is performed and the results reviewed at least once within a 12 month period Dementia: Neuropsychiatric Symptom Assessment: Percentage of patients, regardless of age, with a diagnosis of dementia and for whom an assessment of patient’s neuropsychiatric symptoms is performed and results reviewed at least once in a 12 month period Dementia: Management of Neuropsychiatric Symptoms: Percentage of patients, regardless of age, with a diagnosis of dementia who have one or more neuropsychiatric symptoms who received or were recommended to receive an intervention for neuropsychiatric symptoms within a 12 month period Dementia: Screening for Depressive Symptoms: Percentage of patients, regardless of age, with a diagnosis of dementia who were screened for depressive symptoms within a 12 month period Dementia: Counseling Regarding Safety Concerns: Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled or referred for counseling regarding safety concerns within a 12 month period Dementia: Counseling Regarding Risks of Driving: Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled regarding the risks of driving and the alternatives to driving at least once within a 12 month period Dementia: Caregiver Education and Support: Percentage of patients, regardless of age, with a diagnosis of dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND referred to additional sources for support within a 12 month period Measure Developer Reporting Options AMAPCPI Dementia Measures Group (C/R) AMAPCPI Dementia Measures Group (C/R) AMAPCPI Dementia Measures Group (C/R) AMAPCPI Dementia Measures Group (C/R) AMAPCPI Dementia Measures Group (C/R) AMAPCPI Dementia Measures Group (C/R) AMAPCPI Dementia Measures Group (C/R) AMAPCPI Dementia Measures Group (C/R) Page 35 of 44 2013 PQRS Measures List NQF # PQRS # National Quality Strategy Domain N/A 289 Clinical Process/ Effectiveness N/A 290 Clinical Process/ Effectiveness N/A 291 N/A 292 N/A 293 Clinical Process/ Effectiveness N/A 294 Clinical Process/ Effectiveness 295 Clinical Process/ Effectiveness N/A Date: 11/16/2012 Version 7.1 Clinical Process/ Effectiveness Clinical Process/ Effectiveness Measure Descriptiona Parkinson’s Disease: Annual Parkinson’s Disease Diagnosis Review: All patients with a diagnosis of Parkinson’s disease who had an annual assessment including a review of current medications (e.g., medications that can produce Parkinson-like signs or symptoms) and a review for the presence of atypical features (e.g., falls at presentation and early in the disease course, poor response to levodopa, symmetry at onset, rapid progression [to Hoehn and Yahr stage 3 in 3 years], lack of tremor or dysautonomia) at least annually Parkinson’s Disease: Psychiatric Disorders or Disturbances Assessment: All patients with a diagnosis of Parkinson’s disease who were assessed for psychiatric disorders or disturbances (e.g., psychosis, depression, anxiety disorder, apathy, or impulse control disorder) at least annually Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment: All patients with a diagnosis of Parkinson’s disease who were assessed for cognitive impairment or dysfunction at least annually Parkinson’s Disease: Querying about Sleep Disturbances: All patients with a diagnosis of Parkinson’s disease (or caregivers, as appropriate) who were queried about sleep disturbances at least annually. Parkinson’s Disease: Rehabilitative Therapy Options: All patients with a diagnosis of Parkinson’s disease (or caregiver(s), as appropriate) who had rehabilitative therapy options (e.g., physical, occupational, or speech therapy) discussed at least annually Parkinson’s Disease: Parkinson’s Disease Medical and Surgical Treatment Options Reviewed: All patients with a diagnosis of Parkinson’s disease (or caregiver(s), as appropriate who had the Parkinson’s disease treatment options (e.g., non-pharmacological treatment, pharmacological treatment, or surgical treatment) reviewed at least once annually Hypertension: Appropriate Use of Aspirin or Other Antithrombotic Therapy: Percentage of patients aged 30 through 90 years old with a diagnosis of hypertension and are eligible for aspirin or other antithrombotic therapy who were prescribed aspirin or other antithrombotic therapy Measure Developer Reporting Options AAN Parkinson’s Disease Measures Group (R) AAN Parkinson’s Disease Measures Group (R) AAN Parkinson’s Disease Measures Group (R) AAN Parkinson’s Disease Measures Group (R) AAN Parkinson’s Disease Measures Group (R) AAN Parkinson’s Disease Measures Group (R) ABIM Hypertension Measures Group (R) Page 36 of 44 2013 PQRS Measures List NQF # PQRS # National Quality Strategy Domain Clinical Process/ Effectiveness Clinical Process/ Effectiveness Clinical Process/ Effectiveness Clinical Process/ Effectiveness Clinical Process/ Effectiveness Clinical Process/ Effectiveness N/A 296 N/A 297 N/A 298 N/A 299 N/A 300 N/A 301 N/A 302 Clinical Process/ Effectiveness N/A 303 Clinical Process/ Effectiveness Date: 11/16/2012 Version 7.1 Measure Descriptiona Hypertension: Complete Lipid Profile: Percentage of patients aged 18 through 90 years old with a diagnosis of hypertension who received a complete lipid profile within 60 months Hypertension: Urine Protein Test: Percentage of patients aged 18 through 90 years old with a diagnosis of hypertension who either have chronic kidney disease diagnosis documented or had a urine protein test done within 36 months Hypertension: Annual Serum Creatinine Test: Percentage of patients aged 18 through 90 years old with a diagnosis of hypertension who had a serum creatinine test done within 12 months Hypertension: Diabetes Mellitus Screening Test: Percentage of patients aged 18 through 90 years old with a diagnosis of hypertension who had a diabetes screening test within 36 months Hypertension: Blood Pressure Control: Percentage of patients aged 18 through 90 years old with a diagnosis of hypertension who had most recent blood pressure level under control (at goal) Hypertension: Low Density Lipoprotein (LDL-C) Control: Percentage of patients aged 18 through 90 years old with a diagnosis of hypertension who had most recent LDL cholesterol level under control (at goal) Hypertension: Dietary and Physical Activity Modifications Appropriately Prescribed: Percentage of patients aged 18 through 90 years old with a diagnosis of hypertension who received dietary and physical activity counseling at least once within 12 months Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery: Percentage of patients aged 18 years and older in sample who had cataract surgery and had improvement in visual function achieved within 90 days following the cataract surgery, based on completing a pre-operative and postoperative visual function survey Measure Developer Reporting Options ABIM Hypertension Measures Group (R) ABIM Hypertension Measures Group (R) ABIM Hypertension Measures Group (R) ABIM Hypertension Measures Group (R) ABIM Hypertension Measures Group (R) ABIM Hypertension Measures Group (R) ABIM Hypertension Measures Group (R) AAO Registry, Cataract Measures Group (R) Page 37 of 44 2013 PQRS Measures List NQF # PQRS # National Quality Strategy Domain N/A 304 Patient and Family Engagement Safety 0004 305 Clinical Process/ Effectiveness 0012 306 Population/ Public Health 0014 307 Patient Safety 0027 308 Population/ Public Health 0032 309 Clinical Process/ Effectiveness 0033 310 Population/ Public Health Date: 11/16/2012 Version 7.1 Measure Descriptiona Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery: Percentage of patients aged 18 years and older in sample who had cataract surgery and were satisfied with their care within 90 days following the cataract surgery, based on completion of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: (a) Initiation, (b) Engagement: Percentage of adolescent and adult patients with a new episode of alcohol or other drug (AOD) dependence who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis and who initiated treatment AND who had two or more additional services with an AOD diagnosis within 30 days of the initial visit Prenatal Care: Screening for Human Immunodeficiency Virus (HIV): Percentage of patients, regardless of age, who gave birth during a 12-month period who were screened for HIV infection during the first or second prenatal visit Prenatal Care: Anti-D Immune Globulin: Percentage of D (Rh) negative, unsensitized patients, regardless of age, who gave birth during a 12-month period who received anti-D immune globulin at 26-30 weeks gestation Smoking and Tobacco Use Cessation, Medical Assistance: a. Advising Smokers and Tobacco Users to Quit, b. Discussing Smoking and Tobacco Use Cessation Medications, c. Discussing Smoking and Tobacco Use Cessation Strategies: Percentage of patients aged 18 years and older who were current smokers or tobacco users, who were seen by a practitioner during the measurement year and who received advice to quit smoking or tobacco use or whose practitioner recommended or discussed smoking or tobacco use cessation medications, methods or strategies Cervical Cancer Screening: Percentage of women aged 21 through 63 years who received one or more Pap tests to screen for cervical cancer Chlamydia Screening for Women: Percentage of women aged 15 through 24 years who were identified as sexually active and who had at least one test for chlamydia during the measurement year Measure Developer Reporting Options AAO Registry, Cataract Measures Group (R) NCQA EHR AMAPCPI EHR AMAPCPI EHR NCQA EHR NCQA EHR NCQA EHR Page 38 of 44 2013 PQRS Measures List NQF # PQRS # National Quality Strategy Domain Clinical Process/ Effectiveness Efficient Use of Healthcare Resources Clinical Process/ Effectiveness 0036 311 0052 312 0575 313 N/A 316 N/A 317 GPRO PREV11 Population/ Public Health 0101 318 GPRO CARE-2 Patient Safety Date: 11/16/2012 Version 7.1 Clinical Process/ Effectiveness Measure Descriptiona Use of Appropriate Medications for Asthma: Percentage of patients aged 5 through 50 years of age who were identified as having persistent asthma and were appropriately prescribed medication during the measurement year Low Back Pain: Use of Imaging Studies: Percentage of patients with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of diagnosis Diabetes Mellitus: Hemoglobin A1c Control (< 8%): The percentage of patients 18 through 75 years of age with a diagnosis of diabetes (type 1 or type 2) who had HbA1c < 8% Preventive Care and Screening: Cholesterol – Fasting Low Density Lipoprotein (LDL) Test Performed AND Risk-Stratified Fasting LDL: Percentage of patients aged 20 through 79 years whose risk factors* have been assessed and a fasting LDL test has been performed *There are three criteria for this measure based on the patient’s risk category. 1. Highest Level of Risk: Coronary Heart Disease (CHD) or CHD Risk Equivalent 2. Moderate Level of Risk: Multiple (2+) Risk Factors 3. Lowest Level of Risk: 0 or 1 Risk Factor Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented: Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure (BP) AND a recommended follow-up plan is documented based on the current blood pressure reading as indicated Falls: Screening for Future Fall Risk: Percentage of patients aged 65 years and older who were screened for future fall risk at least once within the reporting period Measure Developer Reporting Options NCQA EHR NCQA EHR NCQA EHR CMS/QIP EHR CMS/QIP Claims, Registry, EHR, GPRO/ACO, Cardiovascular Prevention Measures Group (C/R) AMAPCPI/NCQA GPRO/ACO Page 39 of 44 2013 PQRS Measures List NQF # PQRS # National Quality Strategy Domain 0729 319 GPRO DM-13 thru DM-17 Clinical Process/ Effectiveness 0658 320 Care Coordination 0493 321 Care Coordination Date: 11/16/2012 Version 7.1 Measure Descriptiona Diabetes Composite: Optimal Diabetes Care: Patients ages 18 through 75 with a diagnosis of diabetes, who meet all the numerator targets of this composite measure: x A1c < 8.0%, LDL < 100 mg/dL, x blood pressure < 140/90 mmHg, x tobacco non-user and for patients with a diagnosis of ischemic vascular disease daily aspirin use unless contraindicated Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients: Percentage of patients aged 50 years and older receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report Participation by a Hospital, Physician or Other Clinician in a Systematic Clinical Database Registry that Includes Consensus Endorsed Quality: Participation in a systematic qualified clinical database registry involves: a. Physician or other clinician submits standardized data elements to registry. b. Data elements are applicable to consensus endorsed quality measures. c. Registry measures shall include at least two (2) representative NQF consensus endorsed measures for registry's clinical topic(s) and report on all patients eligible for the selected measures. d. Registry provides calculated measures results, benchmarking, and quality improvement information to individual physicians and clinicians. e. Registry must receive data from more than 5 separate practices and may not be located (warehoused) at an individual group’s practice. Participation in a national or state-wide registry is encouraged for this measure. f. Registry may provide feedback directly to the provider’s local registry if one exists. Measure Developer Reporting Options MNCM GPRO/ACO AMA-PCPI Claims, Registry OFMQ Claims, Registry Page 40 of 44 2013 PQRS Measures List NQF # PQRS # National Quality Strategy Domain 0670 322 Efficient Use of Healthcare Resources 0671 323 Efficient Use of Healthcare Resources 0672 324 Efficient Use of Healthcare Resources N/A 325 Clinical Process/ Effectiveness Date: 11/16/2012 Version 7.1 Measure Descriptiona Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients: Percentage of stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), or cardiac magnetic resonance (CMR) performed in low risk surgery patients 18 years or older for preoperative evaluation during the 12-month reporting period Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI): Percentage of all stress singlephoton emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in patients aged 18 years and older routinely after percutaneous coronary intervention (PCI), with reference to timing of test after PCI and symptom status Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients: Percentage of all stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), cardiac computed tomography angiography (CCTA), and cardiovascular magnetic resonance (CMR) performed in asymptomatic, low coronary heart disease (CHD) risk patients 18 years and older for initial detection and risk assessment Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions: Percentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], ESRD or congestive heart failure) being treated by another clinician with communication to the other clinician treating the comorbid condition Measure Developer Reporting Options ACC Registry ACC Registry ACC Registry AMAPCPI Registry Page 41 of 44 2013 PQRS Measures List NQF # PQRS # National Quality Strategy Domain 1525 326 Patient Safety N/A 327 Clinical Process/ Effectiveness 1667 328 Clinical Process/ Effectiveness a) b) c) Measure Descriptiona Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy: Patients aged 18 and older with a diagnosis of nonvalvular AF or atrial flutter whose assessment of specified thromboembolic risk factors indicate one or more high-risk factors or more than one moderate risk factor, as determined by CHADS2 risk stratification, who were prescribed warfarin OR another oral anticoagulant drug that is FDA approved for the prevention of thromboembolism Pediatric Kidney Disease: Adequacy of Volume Management: Percentage of calendar months within a 12-month period during which patients aged 17 years and younger with a diagnosis of End Stage Renal Disease (ESRD) undergoing maintenance hemodialysis in an outpatient dialysis facility have an assessment of the adequacy of volume management from a nephrologist Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level < 10g/dL: Percentage of calendar months within a 12-month period during which patients aged 17 years and younger with a diagnosis of End Stage Renal Disease (ESRD) receiving hemodialysis or peritoneal dialysis have a hemoglobin level < 10 g/dL Measure Developer AMAPCPI/ACCF/A HA Reporting Options Claims, Registry AMAPCPI Claims, Registry AMAPCPI Claims, Registry Measure titles and descriptions for some measures may vary by measure reporting options/methods for a particular program year. This is due to the timing of measure specification preparation for the various reporting options/methods. The titles and descriptions referenced in this document refer to the claims/registry measure specifications. Please refer to the measure specifications that apply to the other reporting options/methods for the measure details (e.g., measure titles and descriptions) that apply to those specific options/methods. A list of Registries and qualified EHR vendors and products for the 2013 program year will be available on the Alternative Reporting Mechanisms section available from the navigation bar on the left side of the CMS PQRS website. Please visit this site periodically for updates and contact your EHR vendor or registry to determine if they are planning to become qualified for upcoming program years. 1. PQRS Registry website: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Registry-Reporting.html 2. PQRS EHR: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Electronic-Health-Record-Reporting.html The Group Practice Reporting Option (GPRO) is only available to those group practices participating in the PQRS group practice reporting option (GPRO) reporting via the Web Interface. For information on how to self-nominate/register to participate in the GPRO, refer to the downloads on the Group Practice Reporting Option section available from the navigation bar on the left side of the CMS PQRS website. Please visit this site periodically for updates. 1. PQRS GPRO website: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Group_Practice_Reporting_Option.html Date: 11/16/2012 Version 7.1 Page 42 of 44 2013 PQRS Measures List Appendix I - Measure Specifications Reporting Measure Specification Name Option/Method Claims 2013 PQRS Measure Specifications Manual for Claims and Registry Reporting of Individual Measures and Release Notes CMS PQRS website location http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/MeasuresCodes.html 2013 PQRS Measure Specifications Manual for Claims and Registry Reporting of Individual Measures and Release Notes ZIP file Registry 2013 PQRS Measure Specifications Manual for Claims and Registry Reporting of Individual Measures and Release Notes http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/MeasuresCodes.html 2013 PQRS Measure Specifications Manual for Claims and Registry Reporting of Individual Measures and Release Notes ZIP file EHR Electronic Health Record 2013 EHR Measure Specifications and Release Notes http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/Electronic-Health-Record-Reporting.html EHR Documents for Eligible Professionals ZIP file Measures Groups 2013 PQRS Measures Groups Specifications Manual and Release Notes http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/MeasuresCodes.html 2013 PQRS Measures Groups Specifications Manual and Release Notes ZIP file GPRO Group Practice Reporting Option NOTE: Refer to these measure specifications for more information on which reporting mechanism (claims or registry) may be used to submit each Measures Group. 2013 PQRS GPRO Narrative Measure Specifications http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessmentand Release Notes Instruments/PQRS/Group_Practice_Reporting_Option.html 2013 PQRS GPRO Narrative Measure Specifications and Release Notes ZIP file Date: 11/16/2012 Version 7.1 Page 43 of 44 2013 PQRS Measures List Appendix II - Measure Developer/Contact Information Acronym Full Name AAD American Academy of Dermatology AAN American Academy of Neurology AAO American Academy of Ophthalmology ABIM American Board of Internal Medicine ACC American College of Cardiology ACEP American College of Emergency Physicians AGA American Gastroenterological Association AHA American Heart Association AMA-PCPI American Medical Association (AMA)-convened Physician Consortium for Performance Improvement® (PCPI™) APMA American Podiatric Medical Association ASBS American Society of Breast Surgeons ASH American Society of Hematology ASCO American Society of Clinical Oncology ASHA American Speech-Language-Hearing Association ASA American Stroke Association AQC Audiology Quality Consortium CAP College of American Pathologists CMS Centers for Medicare & Medicaid Services MNCM Minnesota Community Measurement OFMQ Oklahoma Foundation for Medical Quality QIP Quality Insights of Pennsylvania FOTO Focus on Therapeutic Outcomes NCCN National Comprehensive Cancer Network NCQA National Committee for Quality Assurance STS The Society of Thoracic Surgeons SVS Society for Vascular Surgery Date: 11/16/2012 Version 7.1 Contact e-mail questions and comments to sweinberg@aad.org e-mail questions and comments to ggjorvad@aan.com e-mail questions and comments to flum@aao.org or kkurth@aaodc.org e-mail questions and comments to measures@abim.org e-mail questions and comments to mshahria@acc.org e-mail questions and comments to sjones@acep.org e-mail questions and comments to drobin@gastro.org e-mail questions and comments to guidelinesinfo@heart.org e-mail questions and comments to the PCPI at cpe@ama-assn.org e-mail questions and comments to jrchristina@apma.org e-mail questions and comments to sgrutman@breastsurgeons.org e-mail questions and comments to ash@hematology.org http://www.asco.org and click on “Contact Us” e-mail questions and comments to rmullen@asha.org http://www.heart.org/HEARTORG/General/Contact-Us_UCM_308813_Article.jsp e-mail questions and comments to lsatterfield@asha.org or pfarrell@asha.org e-mail questions and comments to http://www.cap.org e-mail questions and comments to qnetsupport@sdps.org e-mail questions and comments to info@mncm.org email questions and comments to https://cms-ip.custhelp.com/ http://www.usqualitymeasures.org/For-Your-Information/contact.aspx e-mail questions and comments to fotoregistry@fotoinc.com http://www.nccn.org/about/contact.asp http://www.ncqa.org and click on “Contact Us” e-mail questions and comments to jhan@sts.org e-mail questions and comments at http://www.vascularweb.org Page 44 of 44
| File Type | application/pdf |
| File Title | 2013 Physician Quality Reporting System Measures List |
| Subject | 2013 Physician Quality Reporting System Measures List |
| Author | PMBR/CMS |
| File Modified | 2013-09-16 |
| File Created | 2013-09-16 |