2024 Measures

Measure Description

Percentage of emergency department visits during which patients aged 18 years and older had a CT pulmonary angiogram (CTPA) ordered by an emergency care provider, regardless of discharge disposition, with either moderate or high pre-test clinical probability for pulmonary embolism OR positive result or elevated D-dimer level.

Denominator

All emergency department visits during which patients aged 18 years and older had a CT pulmonary angiogram (CTPA) ordered by an emergency care provider, regardless of discharge disposition.

Numerator

Emergency department visits for patients with either:

• Moderate or high pre-test clinical probability for pulmonary embolism OR
• Elevated D-dimer level

Denominator Exclusions

Pregnancy

Denominator Exceptions

• Medical reason for ordering a CTPA without moderate or high pre-test clinical probability for pulmonary embolism AND no positive result or elevated D-dimer level (e.g., CT ordered for aortic dissection)
• Patients who had CT pulmonary angiogram (CTPA) ordered during an emergency department visit for trauma or dangerous mechanism of injury

Measure Description

Percentage of patients aged 18 years and older with a diagnosis of asthma or COPD seen in the ED who were screened for tobacco use during any ED encounter AND who received tobacco cessation intervention if identified as a tobacco user.

Denominator

All patients aged 18 years and older with a diagnosis of asthma or COPD seen in the ED and were discharged.

Numerator

Patients who were screened for tobacco use during any ED encounter AND who received tobacco cessation intervention if identified as a tobacco user.

Denominator Exclusions

None

Denominator Exceptions

Documented medical reason(s) for not screening for tobacco use OR for not providing tobacco cessation intervention for patients identified as tobacco users (e.g., limited life expectancy, other medical reasons).

Measure Description

Percentage of emergency department visits for patients aged 18 years and older with septic shock who had an elevated serum lactate result (>2mmol/L) and a subsequent serum lactate level measurement performed following the elevated serum lactate result with a lactate clearance rate of ≥10% during the emergency department visit.

Denominator

All emergency department visits resulting in hospital admission for patients aged 18 years and older with septic shock who had an elevated serum lactate result (>2mmol/L) and a subsequent serum lactate level measurement performed following the elevated serum lactate result.

Numerator

Emergency department visits for patients with a lactate clearance rate of ≥ 10% during the emergency department visit.

Denominator Exclusions

• Transferred to the emergency department from another acute care facility or other in-patient hospital setting
• Left before treatment was complete
• Died during the emergency department visit
• Cardiac arrest within the emergency department visit
• Patient or surrogate decision maker declined care
• Advanced care directives present in patient medical record for comfort care
• Status epilepticus
• Receiving epinephrine
• Liver dysfunction or cirrhosis with decompensation
• Liver failure
• End-stage liver disease
• Secondary diagnosis of: Gastrointestinal bleeding, Stroke, Acute myocardial infarction or Acute trauma
• COVID-19 diagnosis

Denominator Exceptions

None

Measure Description

Percentage of emergency department (ED) visits for admitted patients aged 18 years and older where an indwelling Foley catheter is ordered and the patient had at least one indication for an indwelling Foley catheter.

Denominator

All emergency department visits for admitted patients aged 18 years and older where an indwelling Foley catheter is ordered

Numerator

"Emergency department visits where the patient had at least one of the following indications for an indwelling Foley catheter:

• Acute urinary retention or bladder outlet obstruction
• Need for accurate measurement of urinary output with no reasonable alternative
• Pre-operative use for selected surgical procedures
• Open sacral or perineal wounds in incontinent patients
• Patient requires prolonged immobilization
• Comfort for end of life care
• Other institution-specific indication

Denominator Exclusions

Patients who had an existing indwelling Foley catheter at ED arrival.

Denominator Exceptions

None

Measure Description

Percentage of emergency department visits resulting in hospital admission for patients aged 18 years and older with septic shock who had an order for all the following during the emergency department visit: a serum lactate level, antibiotics, and >1L of crystalloids.

Denominator

All emergency department visits resulting in hospital admission for patients aged 18 years and older with septic shock.

Numerator

Emergency department visits for patients who had an order for all of the following during the emergency department visit: a serum lactate level, antibiotics, and >1L of crystalloids.

Denominator Exclusions

• Transferred to the emergency department from another acute care facility or other in-patient hospital setting
• Left before treatment was complete
• Died during the emergency department visit
• Cardiac arrest within the emergency department visit
• Patient or surrogate decision maker declined care
• Advanced care directives present in patient medical record for comfort care
• Severe Heart Failure (LVEF<20%)
• Left Ventricular Assist Device (LVAD)
• Acute Pulmonary Edema
• Toxicological emergencies
• Burn
• Seizures
• Anuria
• End stage renal disease
• Secondary diagnosis of: Gastrointestinal bleeding, Stroke, Acute myocardial infarction or Acute trauma
• COVID-19 diagnosis

Denominator Exceptions

Patient is admitted within 1hr of ED Arrival

Measure Description

Time (in minutes) from ED arrival to ED departure for all Adult Patients.

Denominator

All Emergency Department encounters for patients aged 18 years and older with documented discharge disposition.

Numerator

Time (in minutes) from ED arrival to ED departure for discharged Adult patients.

Denominator Exclusions

• Transfers
• Psychiatric and mental health patients
• Patients who expired in the emergency department
• Patients transferred to observation
• Admissions

Denominator Exceptions

None

Measure Description

Time (in minutes) from ED arrival to ED departure for all Pediatric Patients.

Denominator

All Emergency Department encounters for patients aged 17 years and younger with documented discharge disposition.

Numerator

Time (in minutes) from ED arrival to ED departure for discharged Pediatric patients.

Denominator Exclusions

• Transfers
• Psychiatric and mental health patients
• Patients who expired in the emergency department
• Patients transferred to observation
• Admissions

Denominator Exceptions

None

Measure Description

Percentage of emergency department visits during which patients aged 18 years and older had a CT or MRI of the Lumbar Spine ordered by an emergency care provider, regardless of discharge disposition, presenting with acute, non-complex low back pain..

Denominator

All emergency department visits for patients aged 18 years and older who presented with acute, non-complex low back pack for whom a lumbar spine CT or MRI was ordered by an emergency care provider.

Numerator

Emergency department visits for patients who have an indication for a lumbar spine CT or MRI.

Denominator Exclusions

None

Denominator Exceptions

None

Measure Description

Percentage of emergency department (ED) visits for patients aged 18-50 years presenting with flank pain with a history of kidney stones during which no imaging is ordered, OR appropriate imaging (i.e., plain film radiography or ultrasound) is ordered.

Denominator

All emergency department visits for patients aged 18 - 50 years presenting with flank pain with any history of kidney stones.

Numerator

Emergency department visits during which no imaging is ordered OR appropriate imaging (i.e., plain film radiography or ultrasound) is ordered.

Denominator Exclusions

• Infection (fever, elevated white blood cell count, laboratory confirmation of urinary tract infection)
• Cancer
• Known acute or chronic renal disease (e.g., transplant, creatinine >1.5 mg/dL, renal insufficiency, polycystic kidney disease, acute kidney failure)
• Patient on anticoagulants
• Stone episode duration ≥ 72 hours
• Pregnancy
• Trauma
• Persistent pain that cannot be controlled during the ED visit
• Urologic procedure performed in the past 48 hours
• BMI>35

Denominator Exceptions

None

Measure Description

Percentage of patients aged 18 years and older for which follow-up care coordination was documented in Hospital Discharge Summary.

Denominator

Any patient ≥18 years of age and patient encounter during the performance period (CPT or HPCS): 99238, 99239, 99234, 99235, 99236, 99218, 99219, 99220.

Numerator

Patients discharged with communication to follow-up provider documented in discharge summary.

Definition of follow-up care coordination attempt:

• Specific date and time of scheduled follow-up with provider.
• Communication documented to follow-up provider performed.
• If hospital guideline, policy or similar rule provides guaranteed follow-up visit and time at a specific clinic, documentation of such follow-up coordination in discharge summary.

Numerator Options:

• Performance Met: Patients discharged with communication to follow-up provider documented in discharge summary.
• Performance Not Met: Patients discharged without communication to follow-up provider documented in discharge summary.

Denominator Exclusions

Disposition of transferred, eloped or AMA patients.

Denominator Exceptions

None

Measure Description

Percentage of adult patients who came to the Emergency Department with low-risk chest pain and were discharged.

Denominator

All adult patients 35-64 years of age with an ED diagnosis of chest pain.

Numerator

All adult patients 35-64 years of age with an ED diagnosis of chest pain who were discharged.

Denominator Exclusions

• Diagnosis warranting admission: MI, pneumonia, PE, aortic dissection, PTX, dysrhythmia, esophageal rupture, cholecystitis, pancreatitis
• Other Diagnosis: Active cancer, ESRD, ESLD, SLE, AIDS, cardiomyopathy, coagulopathy, LBBB

Denominator Exceptions

None

Measure Description

Percentage of emergency department (ED) visits for patients aged 18-50 years with a diagnosis of low-risk syncope who were discharged.

Denominator

All ED encounters for patients aged 18 to 50 years of age with the diagnosis of syncope.

Numerator

All ED encounters for patients aged 18 to 50 years of age with diagnosis of syncope who were discharged.

Denominator Exclusions

• Heart Disease (coronary artery disease, Myocardial Infarction, CHF, cardiomyopathy, etc.)
• Heart Rhythm Disorders (Arrhythmias, Sinus Node Dysfunction, Uncontrolled Atrial Fibrillation, etc.)
• Aortic Dissection, Pulmonary Embolism, Subarachnoid Hemorrhage Coagulation Disorder

Denominator Exceptions

Death & LAMA

Measure Description

Percentage of ED visits for pediatric patients with Asthma, Bronchiolitis or Croup for whom a Chest X-ray was ordered/performed.

Denominator

AAll patients <18 years of age coming to the Emergency Department with a diagnosis of Asthma, Bronchiolitis or Croup.

Numerator

AAll patients <18 years of age with a diagnosis of Asthma, Bronchiolitis or Croup and for whom a chest x-ray was ordered/performed.

Denominator Exclusions

• History of Cystic Fibrosis
• Airway Malformations
• Immunodeficiency Syndromes
• Pneumonia

Denominator Exceptions

None

Measure Description

All acute encounters for patients aged 18 years and older with, diagnosis of dental pain, who were not prescribed Opioids or Opiates.

Denominator

All acute encounters for patients aged 18 years and older evaluated by the Eligible Professional with a diagnosis of dental pain.

Numerator

All acute encounters for patients who were not prescribed Opioids or Opiates.

Denominator Exclusions

• Patients with active cancer
• Palliative care
• End-of-life care

Denominator Exceptions

Opiate prescribed for acute dental trauma (e.g., tooth or facial fracture, etc.)

Measure Description

The percentage of adults 65 years of age and older who were prescribed an Acute High-Risk Medication at discharge.

Denominator

All patients 65 years of age and older with an ED visit and were discharged.

Numerator

All patients included in the Denominator, who were prescribed one/more of the acute high-risk medications.

Denominator Exclusions

• Seizure disorder
• Rapid eye movement sleep disorder
• Ethanol withdrawal
• Benzodiazepine withdrawal
• Severe generalized anxiety disorder
• End-of-life care
• Allergic Reactions
• Dermatitis
• Vertigo
• Labyrinthitis
• ED Visit for prescription refill

Denominator Exceptions

None

Measure Description

Percentage of patients 18 years and older who present to the Emergency Department with low-risk Deep Vein Thrombosis (DVT) and are discharged home.

Denominator

All patients aged 18 years and older with an Emergency Department diagnosis of DVT.

Numerator

Patients who were discharged.

Denominator Exclusions

Diagnosis-related:

• Syncope
• Pulmonary embolism
• Proximal DVT

Patient-related: Already on anticoagulation at time of DVT diagnosis based on listed home medications.

Denominator Exceptions

LAMA, LWT, LWBS, Death

Measure Description

Percentage of adult patients aged 55 years and older presenting to the Emergency Department with abdominal pain or back pain and hypotension for whom a POC Ultrasound or CT scan was performed.

Denominator

All patients aged 55 years and older presenting to the Emergency Department with abdominal pain or back pain and hypotension.

Numerator

Patients for whom a POC Ultrasound performed or CT scan was ordered/performed.

Denominator Exclusions

None

Denominator Exceptions

• Patient Refusal
• US/CT done in last one year
• Previously screened for AAA
• Transferred to operating room
• LAMA, LWT, LWBS, Death

Measure Description

Percentage of patients aged 18 and older in the Emergency Department who are being tested for other sexually transmitted infections (STI) (Gonorrhea, Chlamydia, Syphilis or Trichomonas) are also tested for HIV.

Denominator

All patients aged 18 years and older who were tested for a STI (Gonorrhea, Chlamydia, Syphilis or Trichomonas).

Numerator

Patients who were tested for HIV.

Denominator Exclusions

Patients with HIV disease.

Denominator Exceptions

LAMA, LWT, LWBS, Death, Patient refusal to be tested

Measure Description

Percentage of Adult Syncope Patients Who Did Not Receive a Head CT Scan Ordered by the Provider.

Denominator

Any patient ≥18 years of age evaluated by the Eligible Professional in the Emergency Department or Urgent Care Clinic PLUS Diagnosis of Syncope. (Not including transferred, eloped or AMA patients).

Numerator

Syncope Patients Who Did Not Have a Head CT Ordered by the Provider.

Denominator Exclusions

None

Denominator Exceptions

Patients who did have a head CT ordered for medical reason documented by the eligible professional(i.e., seizure; alcohol/drug intoxication; vomiting; altered mental status; abnormal neurologic exam; concern for intracranial injury/hemorrhage, stroke, or mass lesion).

Measure Description

Percentage of Patients with Low Back Pain and/or Migraines Who Were Not Prescribed an Opiate.

Denominator

Any patient ≥18 years of age evaluated by the Eligible Professional PLUS Diagnosis of low back pain OR Diagnosis of migraine PLUS Disposition of Discharged.

Numerator

Patients who were not prescribed an opiate.

Denominator Exclusions

Patients with active cancer, palliative care, end-of-life care./p>

Denominator Exceptions

Opiate prescribed for medical reason documented by the Eligible Professional (e.g., headache pain refractory to other medications, severe headache, suspected or diagnosed herniated disk, fracture, sciatica, radiculopathy).

Measure Description

Percentage of Opioid Poisoning or Overdose Patients Presenting to An Acute Care Facility Who Were Prescribed Naloxone at Discharge.

Denominator

Any patient evaluated by the Eligible Professional in the acute care setting PLUS diagnoses of opioid poisoning from heroin, methadone, morphine, opium, codeine, hydrocodone, or another opioid substance PLUS Disposition of Discharged (Not including transferred, eloped or AMA patients).

Numerator

Patients Who Were Prescribed Naloxone AND Educated About Utilization at Discharge.

Denominator Exclusions

None

Denominator Exceptions

Naloxone was not prescribed at discharge due to medical reasons such as allergy.

Measure Description

Percentage of Adult Patients Who Had a Risk Assessment for C. difficile Infection and, If High-Risk, Had a Plan of Care for C. difficile Completed on the Day Of or Day After Hospital Admission.

Denominator

AAny patient greater or equal to 18 years of age evaluated by the Eligible Professional in the hospital setting (Not including transferred, eloped, AMA patients).

Numerator

Patients that had a risk assessment for C. difficile infection and, if high-risk, a plan of care documented on the day of or day after hospital admission.

Denominator Exclusions

None

Denominator Exceptions

Patients who did not have a C. difficile infection risk assessment, AND if high risk, a plan of care for C. difficile for medical reasons documented by the Eligible Professional (e.g., C. difficile infection already documented prior to hospital admission, patients unable to provide history, patients on comfort measures).

Measure Description

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 or ARNI therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge

Denominator

• SUBMISSION CRITERIA 1: All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF < 40%, OR
• SUBMISSION CRITERIA 2: All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF < 40%

Numerator

• SUBMISSION CRITERIA 1:Patients who were prescribed ACE inhibitor or ARB or ARNI therapy within a 12-month period when seen in the outpatient setting, OR
• SUBMISSION CRITERIA 2: Patients who were prescribed ACE inhibitor or ARB therapy at hospital discharge

Denominator Exclusions

None

Denominator Exceptions

• Documentation of medical reason(s) for not prescribing ACE inhibitor or ARB therapy (eg, hypotensive patients who are at immediate risk of cardiogenic shock, hospitalized patients who have experienced marked azotemia, allergy, intolerance, other medical reasons)
• Documentation of patient reason(s) for not prescribing ACE inhibitor or ARB therapy (eg, patient declined, other patient reasons)
• Documentation of system reason(s) for not prescribing ACE inhibitor or ARB therapy (eg, other system reasons)

Measure Description

Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12-month period who were prescribed aspirin or clopidogrel

Denominator

All patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12-month period

Numerator

Patients who were prescribed aspirin or clopidogrel

Denominator Exclusions

None

Denominator Exceptions

• Documentation of medical reason(s) for not prescribing aspirin or clopidogrel (e.g., allergy, intolerance, receiving other thienopyridine therapy, receiving warfarin therapy, bleeding coagulation disorders, other medical reasons)
• Documentation of patient reason(s) for not prescribing aspirin or clopidogrel (e.g., patient declined, other patient reasons)
• Documentation of system reason(s) for not prescribing aspirin or clopidogrel (e.g., lack of drug availability, other reasons attributable to the health care system)

Measure Description

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

Denominator

• SUBMISSION CRITERIA 1: All patients with a diagnosis of HF seen in the outpatient setting with a current or prior LVEF < 40%, OR
• SUBMISSION CRITERIA 2: All patients with a diagnosis of HF and discharged from hospital with a current or prior LVEF < 40%

Numerator

• SUBMISSION CRITERIA 1: Patients who were prescribed beta-blocker therapy within a 12 month period when seen in the outpatient setting, OR
• SUBMISSION CRITERIA 2: Patients who were prescribed beta-blocker therapy at each hospital discharge

Denominator Exclusions

None

Denominator Exceptions

Beta-Blocker Therapy for LVEF < 40% not prescribed for reasons documented by the clinician (e.g., low blood pressure, fluid overload, asthma, patients recently treated with an intravenous positive inotropic agent, allergy, intolerance, other medical reasons, patient declined, other patient reasons, or other reasons attributable to the healthcare system)

Measure Description

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

Denominator

All patients aged 65 years and older

Numerator

Patients 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 patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan

Denominator Exclusions

Hospice services received by patient any time during the measurement period

Denominator Exceptions

None

Measure Description

Percentage of patients ≥ 3 months of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode

Denominator

Patients ≥ 3 months of age who had an outpatient or emergency department (ED) visit with a diagnosis of upper respiratory infection (URI) during the measurement period

Numerator

Children without a prescription for antibiotic medication on or 3 days after the outpatient or ED visit for an upper respiratory infection

Denominator Exclusions

• URI episodes where the patient had a competing comorbid condition during the 12 months prior to or on the episode date (e.g., tuberculosis, neutropenia, cystic fibrosis, chronic bronchitis, pulmonary edema, respiratory failure, rheumatoid lung disease)
• URI episodes when the patient had a new or refill prescription of antibiotics in the 30 days prior to or on the episode date
• URI episodes when the patient had competing diagnoses on or three days after the episode date (e.g., intestinal infection, pertussis, bacterial infection, Lyme disease, otitis media, acute sinusitis, acute pharyngitis, acute tonsillitis, chronic sinusitis, infection of the pharynx/larynx/tonsils/adenoids, prostatitis, cellulitis, mastoiditis, or bone infections, acute lymphadenitis, impetigo, skin staph infections, pneumonia/gonococcal infections, venereal disease (syphilis, chlamydia, inflammatory diseases [female reproductive organs]), infections of the kidney, cystitis or UTI, and acne)
• Patients who use hospice services any time during the measurement period

Denominator Exceptions

None

Measure Description

The percentage of episodes for patients ≥ 3 years old with a diagnosis of pharyngitis that resulted in an antibiotic dispensing event and a group A streptococcus (strep) test

Denominator

Patients ≥ 3 years old who had an outpatient or emergency department (ED) visit with a diagnosis of pharyngitis during the measurement period and an antibiotic prescribed or dispensed

Numerator

Children with a group A streptococcus test in the 7-day period from 3 days prior through 3 days after the diagnosis of pharyngitis

Denominator Exclusions

• Episodes where the patient is taking antibiotics (Table 1) in the 30 days prior to the episode date
• Episodes where the patient had a competing comorbid condition during the 12 months prior to or on the episode date (e.g., tuberculosis, neutropenia, cystic fibrosis, chronic bronchitis, pulmonary edema, respiratory failure, rheumatoid lung disease)
• Episodes where the patient had a competing diagnosis within three days after the episode date (e.g., intestinal infection, pertussis, bacterial infection, Lyme disease, otitis media, acute sinusitis, chronic sinusitis, infection of the adenoids, prostatitis, cellulitis, mastoiditis, or bone infections, acute lymphadenitis, impetigo, skin staph infections, pneumonia/gonococcal infections, venereal disease (syphilis, chlamydia, inflammatory diseases [female reproductive organs]), infections of the kidney, cystitis or UTI)
• Patients who use hospice services any time during the measurement period

Denominator Exceptions

None

Measure Description

The percentage of episodes for patients ≥ 3 months of age with a diagnosis of acute bronchitis/bronchiolitis that did not result in an antibiotic dispensing event.

Denominator

All patients aged patients ≥ 3 months with an outpatient, observation or emergency department (ED) visit with a diagnosis of acute bronchitis/bronchiolitis during the measurement period

Numerator

Patients who were not prescribed or dispensed antibiotics on or within 3 days of the initial date of service

Denominator Exclusions

• Observation or ED visits that result in an inpatient admission
• Documentation of medical reason(s) for prescribing or dispensing antibiotic (e.g., intestinal infection, pertussis, bacterial infection, Lyme disease, otitis media, acute sinusitis, acute pharyngitis, acute tonsillitis, chronic sinusitis, infection of the pharynx/larynx/tonsils/adenoids, prostatitis, cellulitis/ mastoiditis/bone infections, acute lymphadenitis, impetigo, skin staph infections, pneumonia, gonococcal infections/venereal disease (syphilis, chlamydia, inflammatory diseases [female reproductive organs]), infections of the kidney, cystitis/UTI, acne, HIV disease/asymptomatic HIV, cystic fibrosis, disorders of the immune system, malignancy neoplasms, chronic bronchitis, emphysema, bronchiectasis, extrinsic allergic alveolitis, chronic airway obstruction, chronic obstructive asthma, pneumoconiosis and other lung disease due to external agents, other diseases of the respiratory system, and tuberculosis.
• Patients who use hospice services any time during the measurement period.

Denominator Exceptions

Documentation of medical reason(s) for prescribing systemic antimicrobial therapy.

Measure Description

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

Denominator

• SUBMISSION CRITERIA 1: All patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have a current or prior LVEF < 40%, OR
• SUBMISSION CRITERIA 2: All patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes

Numerator

Patients who were prescribed ACE inhibitor or ARB therapy

Denominator Exclusions

None

Denominator Exceptions

• SUBMISSION CRITERIA 1: Clinician documented that patient was not an eligible candidate for angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy (e.g., allergy, intolerance, pregnancy, renal failure due to ACE inhibitor, diseases of the aortic or mitral valve, other medical reasons) or (e.g., patient declined, other patient reasons) or (e.g., lack of drug availability, other reasons attributable to the health care system), OR
• SUBMISSION CRITERIA 2: Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy not prescribed for reasons documented by the clinician (e.g., allergy, intolerance, pregnancy, renal failure due to ACE inhibitor, diseases of the aortic or mitral valve, other medical reasons) or (e.g., patient declined, other patient reasons) or (e.g., lack of drug availability, other reasons attributable to the health care system)

Measure Description

Percentage of visits for patients aged 18 years and older for which the MIPS eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration

Denominator

All visits occurring during the 12 month measurement period for patients aged 18 years and older

Numerator

MIPS eligible clinician attests to documenting, updating or reviewing a patient’s current medications using all immediate resources available on the date of encounter. This list must include ALL known prescriptions, over-the counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosages, frequency and route of administration

Denominator Exclusions

None

Denominator Exceptions

Eligible clinician attests to documenting in the medical record the patient is not eligible for a current list of medications being obtained, updated, or reviewed by the eligible clinician

Measure Description

Percentage of patients aged 12 years and older screened for depression on the date of the encounter or up to 14 days prior to the date of the encounter using an age-appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of or up to two days after the date of the qualifying encounter.

Denominator

All patients aged 12 years and older at the beginning of the performance period with at least one qualifying encounter during the performance period.

Numerator

Patients screened for depression on the date of the encounter or up to 14 days prior to the date of the encounter using an age-appropriate standardized tool AND if positive, a follow-up plan is documented on the date of or up to two days after the date of the qualifying encounter.

Denominator Exclusions

Documentation stating the patient has had a diagnosis of bipolar disorder.

Denominator Exceptions

Patient refuses to participate in or complete the depression screening OR Documentation of medical reason for not screening patient for depression (e.g., cognitive, functional, or motivational limitations that may impact accuracy of results; patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status)

Measure Description

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 alteplase was initiated within three hours of time last known well

Denominator

All patients aged 18 years and older with a diagnosis of acute ischemic stroke whose time of arrival is within two hours (≤ 120 minutes) of time last known well

Numerator

Patients for whom IV thrombolytic therapy was initiated at the hospital within three hours (≤ 180 minutes) of time last known well

Denominator Exclusions

None

Denominator Exceptions

IV alteplase not initiated within three hours (≤ 180 minutes) of time last known well for reasons documented by clinician (e.g. patient enrolled in clinical trial for stroke, patient admitted for elective carotid intervention).

Measure Description

Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within the measurement period AND who received tobacco cessation intervention on the date of the encounter or within the previous 12 months if identified as a tobacco user.

Denominator

All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period.

Numerator

Patients who were screened for tobacco use at least once within the measurement period AND who received tobacco cessation intervention if identified as a tobacco user on the date of the encounter or within the previous 12 months

Denominator Exclusions

None

Denominator Exceptions

Documentation of medical reason(s) for not screening for tobacco use (e.g., limited life expectancy, other medical reason) OR Documentation of medical reason(s) for not providing tobacco cessation intervention on the date of the encounter or within the previous 12 months if identified as a tobacco user (e.g., limited life expectancy, other medical reason)

Measure Description

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.

Denominator

All pregnant female patients aged 14 to 50 who present to the ED with a chief complaint of abdominal pain or vaginal bleeding along with diagnosis of other current condition in the mother classifiable elsewhere but complicating Pregnancy, Childbirth, or the Puerperium.

Numerator

Patients who receive a trans-abdominal or trans-vaginal ultrasound with documentation of pregnancy location in medical record.

Denominator Exclusions

None

Denominator Exceptions

Trans-abdominal or trans-vaginal ultrasound not performed for reasons documented by clinician (e.g., patient has visited the ED multiple times within 72 hours, patient has a documented Intrauterine Pregnancy [IUP]).

Measure Description

Percentage of patients aged 18 years and older seen during the submitting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated

Denominator

All patients aged 18 years and older at the beginning of the measurement period with at least one eligible encounter during the measurement period.

Numerator

Patients who were screened for high blood pressure AND have a recommended follow-up plan documented, as indicated if the blood pressure is pre-hypertensive or hypertensive

Denominator Exclusions

Patient not eligible due to active diagnosis of hypertension

Denominator Exceptions

• Patient refuses to participate (either BP measurement or follow-up)
• Patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient's health status. This may include but is not limited to severely elevated BP when immediate medical treatment is indicated.
• Documented reason for not screening or recommending a follow-up for high blood pressure

Measure Description

Percentage of patients aged 18 years and older with nonvalvular atrial fibrillation (AF) or atrial flutter who were prescribed warfarin OR another FDA-approved oral anticoagulant drug for the prevention of thromboembolism during the measurement period

Denominator

All patients aged 18 years and older with a diagnosis of nonvalvular AF or atrial flutter who do not have a documented CHA2DS2-VASc risk score of 0 or 1

Numerator

Patients with nonvalvular AF or atrial flutter for whom warfarin or another FDA-approved oral anticoagulant was prescribed

Denominator Exclusions

• Patient with transient or reversible cause of AF (e.g., pneumonia, hyperthyroidism, pregnancy, cardiac surgery)
• Patients who are receiving comfort care only OR Documentation of CHA2DS2-VASc risk score of 0 or 1

Denominator Exceptions

• Documentation of medical reason(s) for not prescribing warfarin OR another FDA-approved anticoagulant (e.g., atrial appendage device in place)
• Documentation of patient reason(s) for not prescribing warfarin OR another FDA-approved oral anticoagulant that is FDA-approved for the prevention of thromboembolism (e.g., patient choice of having atrial appendage device placed)
• Documentation of system reason(s) for not prescribing warfarin OR another FDA-approved anticoagulation due to patient being currently enrolled in a clinical trial related to AF/atrial flutter treatment

Measure Description

Percentage of patients, aged 18 years and older, with a diagnosis of acute viral sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms

Denominator

All patients aged 18 years and older with a diagnosis of acute sinusitis

Numerator

Patients prescribed any antibiotic within 10 days after onset of symptoms

Denominator Exclusions

None

Denominator Exceptions

Antibiotic regimen prescribed within 10 days after onset of symptoms for documented medical reason

Measure Description

Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosis.

Denominator

All patients aged 18 years and older with a diagnosis of acute bacterial sinusitis who are prescribed an antibiotic.

Numerator

Patients who were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosis.

Denominator Exclusions

None

Denominator Exceptions

Amoxicillin, with or without clavulanate, not prescribed as first line antibiotic at the time of diagnosis for documented reason

Measure Description

Percentage of emergency department visits for patients aged 18 years and older who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT

Denominator

All emergency department visits for patients aged 18 years and older who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider.

Numerator

Emergency department visits for patients who have an indication for a head CT

Denominator Exclusions

Patient has documentation of ventricular shunt, brain tumor, multisystem trauma, or is currently taking an antiplatelet medication including: abciximab, anagrelide, cangrelor, cilostazol, clopidogrel, dipyridamole, eptifibatide, prasugrel, ticlopidine, ticagrelor, tirofiban, or vorapaxar

Denominator Exceptions

None

Measure Description

Percentage of emergency department visits for patients aged 2 through 17 years who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the Pediatric Emergency Care Applied Research Network (PECARN) prediction rules for traumatic brain injury

Denominator

All emergency department visits for patients aged 2 through 17 years who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider

Numerator

Emergency department visits for patients who are classified as low risk according to the PECARN prediction rules for traumatic brain injury

Denominator Exclusions

Patient has documentation of ventricular shunt, brain tumor, or coagulopathy

Denominator Exceptions

None

Measure Description

Percentage of patients for whom imaging of the head (CT or MRI) is obtained for the evaluation of primary headache when clinical indications are not present

Denominator

All patients seen for evaluation of primary headache

Numerator

Patients for whom imaging of the head (Computed Tomography (CT) or Magnetic Resonance Imaging (MRI)) is obtained for the evaluation of primary headache when clinical indications are not present

Denominator Exclusions

None

Denominator Exceptions

• Documentation of patients with primary headache diagnosis and imaging other than CT or MRI obtained
• Documentation of System reason(s) for obtaining imaging of the head (CT or MRI) (i.e., needed as part of a clinical trial; other clinician ordered the study)

Measure Description

Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 12 months AND who received brief counseling if identified as an unhealthy alcohol user.

Denominator

• 1. All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period.
• 2. All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period who were screened for unhealthy alcohol use and identified as an unhealthy alcohol user.
• 3. All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period.

Numerator

• 1. Patients who were screened for unhealthy alcohol use using a systematic screening method at least once within thelast 12 months.
• 2. Patients who received brief counseling.
• 3. Patients who were screened for unhealthy alcohol use using a systematic screening method at least once within 12 months AND who received brief counseling if identified as an unhealthy alcohol user.

Denominator Exclusions

1. Patients with dementia any time during the patient’s history through the end of the measurement period OR Patients who use hospice services any time during the measurement period.

Denominator Exceptions

None