2021 Measures

With the CEDR Qualified Clinical Data Registry (QCDR) option in 2021, clinicians may choose to report the following QCDR Measures & MIPS Measures to receive credit for MIPS quality reporting. Quality Improvement (QI) measures are not eligible to be reported for MIPS Quality Reporting through CEDR.

QCDR Measures Supported

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ID
Description
Domain
Type
High Priority
ACEP19
Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older
Efficiency & Cost Reduction
Process

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

  • Ventricular shunt
  • Brain Tumor
  • Multisystem trauma
  • Currently taking antiplatelet medications

Denominator Exceptions

None

ACEP21
Coagulation Studies in Patients Presenting with Chest Pain with No Coagulopathy or Bleeding
Efficiency & Cost Reduction
Process

Measure Description

Percentage of emergency department visits for patients aged 18 years and older with an emergency department discharge diagnosis of chest pain during which coagulation studies were ordered by an emergency care provider.

Denominator

All emergency department visits for patients aged 18 years and older with an emergency department discharge diagnosis of chest pain.

Numerator

Emergency department visits during which coagulation studies (PT, PTT, or INR tests) were ordered by an emergency care provider.

Denominator Exclusions

  • End stage liver disease
  • Coagulopathy
  • Thrombocytopenia
  • Currently taking or newly prescribed the following anticoagulant medications: apixaban, argatroban, betrixaban, bivalirudin, dabigatran, dalteparin, desirudin, edoxaban, enoxaparin, fondaparinux, heparin, rivaroxaban, warfarin
  • Pulmonary or gastrointestinal hemorrhage
  • Atrial Fibrillation
  • Inability to obtain medical history
  • Trauma
  • Pulmonary embolism or deep vein thrombosis

Denominator Exceptions

COVID-19

ACEP22
Appropriate Emergency Department Utilization of CT for Pulmonary Embolism
Efficiency & Cost Reduction
Process

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
ACEP25
Tobacco Use: Screening and Cessation Intervention for Patients with Asthma and COPD
Community/Population Health
Process

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.

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).

ACEP30
Sepsis Management: Septic Shock: Lactate Clearance Rate ≥ 10%
Effective Clinical Care
Outcome

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: Gastrointestinal bleeding, Stroke, Acute myocardial infarction or Acute trauma
  • COVID-19 diagnosis

Denominator Exceptions

None

ACEP31
Appropriate Foley Catheter Use in the Emergency Department
Patient Safety
Process

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

ACEP48
Sepsis Management: Septic Shock: Lactate Level Measurement, Antibiotics Ordered, and Fluid Resuscitation
Effective Clinical Care
Process

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: Gastrointestinal bleeding, Stroke, Acute myocardial infarction or Acute trauma
  • COVID-19 diagnosis

Denominator Exceptions

Patient is admitted within 1hr of ED Arrival

ACEP50
ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients
Person and Caregiver Centered Experience and Outcomes
Outcome

Measure Description

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

Denominator

All Emergency Department encounters for patients aged 18 years and older discharged from the ED.

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

ACEP51
ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients
Person and Caregiver Centered Experience and Outcomes
Outcome

Measure Description

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

Denominator

All Emergency Department encounters for patients aged 17 years and younger discharged from the ED.

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

ACEP52
Appropriate Emergency Department Utilization of Lumbar Spine Imaging for Atraumatic Low Back Pain
Efficiency and Cost Reduction
Process

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

ACEP53
Appropriate Use of Imaging for Recurrent Renal Colic
Efficiency and Cost Reduction
Process

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 (e.g., 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

ACEP54
Appropriate Utilization of FAST Exam in the Emergency Department
Efficiency & Cost Reduction
Process

Measure Description

Percentage of emergency department visits for patients aged 18 years and older presenting with hemodynamically unstable blunt abdominal trauma (blunt trauma and a systolic blood pressure <90 mmHg or heart rate >120 bpm) or penetrating thoracoabdominal trauma who had a FAST exam ordered and/or performed during the emergency department visit.

Denominator

All emergency department visits for patients aged 18 years and older presenting with hemodynamically unstable blunt abdominal trauma (blunt trauma and a systolic blood pressure <90 mmHg or heart rate >120 bpm) or penetrating thoracoabdominal trauma.

Numerator

Emergency department visits for patients who had a FAST exam ordered and/or performed during the emergency department visit.

Denominator Exclusions

  • Patients who received emergent thoracotomy
  • Patients who received emergent operative management

Denominator Exceptions

None

ACEP55
Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years
Efficiency & Cost Reduction
Process

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 high risk according to the 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 high risk according to the Pediatric Emergency Care Applied Research Network (PECARN) prediction rules for traumatic brain injury.

Denominator Exclusions

  • Ventricular shunt
  • Brain Tumor
  • Coagulopathy
  • Multisystem Trauma

Denominator Exceptions

None

ACEP56
Follow-Up Care Coordination Documented in Discharge Summary
Communication & Care Coordination
Process

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

ACEP57
Avoidance of Opioid therapy for migraine, low back pain, dental pain
Effective Clinical Care
Process

Measure Description

All ED encounters for patients aged 18 years and older with diagnosis of migraine or low back pain or dental pain who were prescribed or administered Opioids or Opiates.

Denominator

All ED encounters for patients aged 18 years and older with diagnosis of migraine or low back pain or dental pain.

Numerator

All ED encounters for patients who were prescribed or administered Opioids or Opiates.

Denominator Exclusions

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

Denominator Exceptions

None

ACEP58
Appropriate Treatment for Adults with Upper Respiratory Infection (URI)
Effective Clinical Care
Process

Measure Description

Percentage of adults 18 years and older who were diagnosed with upper respiratory infection (URI) and were dispensed or administered an antibiotic prescription on or up to three days after the ED encounter.

Denominator

Adults aged 18 years and older who had an emergency department (ED) visit with a diagnosis of upper respiratory infection (URI).

Numerator

Adults who were dispensed or administered an antibiotic prescription on or up to three days after the ED encounter.

Denominator Exclusions

Patient prescribed or dispensed antibiotic for documented medical reason(s) within three days after the initial diagnosis of URI (e.g., intestinal infection, pertussis, bacterial infection, Lyme disease, otitis media, 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, and acne).

Denominator Exceptions

None

ECPR39
Avoid Head CT for Patients with Uncomplicated Syncope
Efficiency & Cost Reduction
Process

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).

ECPR40
Initiation of the Initial Sepsis Bundle
Effective Clinical Care
Process

Measure Description

Percentage of Adult Emergency Department Patients Diagnosed with Severe Sepsis or Septic Shock That Have Initiation of the Initial Sepsis Bundle.

Denominator

Any patient > 18 years of age evaluated by the Eligible Professional in the Emergency Department PLUS ED diagnosis of either Severe Sepsis OR Septic Shock. (Not including transferred, eloped or AMA patients, or patients with Advanced Directives indicating preference for limited intervention are excluded).

Numerator

Emergency Department Patients Diagnosed with Severe Sepsis or Septic Shock Who Have Initiation of the Initial Sepsis Bundle.

Denominator Exclusions

None

Denominator Exceptions

Patients who did not have initiation of the initial sepsis bundle for documented medical reason(s) (i.e. IV fluids not ordered given patient is in congestive heart failure, or other medical reason). Patients who did not have initiation of the initial sepsis bundle for documented patient reason(s) (i.e. blood cultures not ordered because patient refused or other patient reason).

ECPR41
Rh Status Evaluation and Treatment of Pregnant Women at Risk of Fetal Blood Exposure
Effective Clinical Care
Process

Measure Description

Percentage of Women Aged 14-50 Years at Risk of Fetal Blood Exposure Who Had Their Rh Status Evaluated in the Emergency Department (ED) and Received Rh-Immunoglobulin (Rhogam) if Rh-negative.

Denominator

Any Female Patient ≥ 14 Years of Age and < 51 Years of Age Evaluated by the Eligible Professional in the ED PLUS ED Diagnosis of high risk pregnancy complication. (Not including transferred, eloped or AMA patients).

Numerator

Percentage of Women Aged 14-50 Years at Risk of Fetal Blood Exposure Who Had Their Rh Status Evaluated in the Emergency Department (ED) and Received Rh-Immunoglobulin (Rhogam) if Rh-negative.

Denominator Exclusions

None

Denominator Exceptions

Patients who did not have Rh status evaluated or did not receive an order of Rh-Immunoglobulin (Rhogam) if Rh-negative for documented medical reasons. Patients who did not have Rh status evaluated or did not receive an order of Rh-Immunoglobulin (Rhogam) if Rh-negative for documented patient reason(s) (e.g., patient refused Rh testing or Rhogam).

ECPR46
Avoidance of Opiates for Low Back Pain or Migraines
Effective Clinical Care
Process

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 in the Emergency Department or Urgent Care Clinic PLUS Diagnosis of low back pain OR Diagnosis of migraine PLUS Disposition of Discharged.

Numerator

Patients who were not prescribed an opiate.

Denominator Exclusions

None

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).

ECPR50
Door to Diagnostic Evaluation by a Provider Within 30 Minutes – Urgent Care Patients
Patient Safety
Process

Measure Description

Percentage of Urgent Care Patients Who Made Provider Contact Within 30 Minutes of Urgent Care Clinic (UCC) Arrival.

Denominator

Any Patient Evaluated by the Eligible Professional (MD/DO/PA/NP) in the Urgent Care Clinic.

Numerator

Urgent Care Patients Who Made Provider (MD/DO/PA/NP) Contact Within 30 Minutes of Urgent Care Clinic Arrival.

Denominator Exclusions

None

Denominator Exceptions

None

ECPR51
Discharge Prescription of Naloxone after Opioid Poisoning or Overdose
Effective Clinical Care
Process

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 Emergency Department (ED) PLUS ICD-10 diagnosis codes for opioid poisoning from heroin, methadone, morphine, opium, codeine, hydrocodone, or another opioid substance (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.

ECPR52
Appropriate Treatment of Psychosis and Agitation in the Emergency Department
Effective Clinical Care
Process

Measure Description

Percentage of Adult Patients With Psychosis or Agitation Who Were Ordered an Oral Antipsychotic Medication in the Emergency Department.

Denominator

Any patient ≥ 18 years of age evaluated by the Eligible Professional in the Emergency Department (ED) PLUS ED length of stay of 4 hours or more PLUS ICD-10 diagnosis codes for psychosis, psychotic disorder NOS, psychotic features, hallucinations, schizophrenia, schizoaffective disorder, agitation due to psychosis (Not including eloped or AMA patients).

Numerator

Patients who were ordered at least one oral dose of a typical or atypical antipsychotic or an antipsychotic combination medication.

Denominator Exclusions

None

Denominator Exceptions

Oral dose of a typical or atypical antipsychotic or an antipsychotic combination medication not prescribed for medical reason documented by the eligible professional (e.g., patient refusal, inability to tolerate, allergy, other documented medical reason).

ECPR53
Clinician Reporting of Loss of Consciousness to State Department of Public Health or Department of Motor Vehicles
Communication & Care Coordination
Process

Measure Description

Percentage of Patients At Risk for Recurrent Loss of Consciousness For Whom Loss of Consciousness Information Was Submitted to Department of Public Health or Department of Motor Vehicles.

Denominator

Any patient ≥ 14 years of age evaluated by the Eligible Professional in the Emergency Department PLUS loss of consciousness PLUS ICD-10 diagnosis codes for seizure disorder, narcolepsy, hyperglycemia due to diabetes, hypoglycemia due to diabetes PLUS resides in state without mandatory reporting to DPH/DMV.

Numerator

Patients For Whom Loss of Consciousness Information Was Submitted to the State Department of Public Health (DPH) or Department of Motor Vehicles (DMV).

Denominator Exclusions

None

Denominator Exceptions

Information was previously reported, patient does not drive, condition not recurrent or other medical exclusion.

ECPR55
Avoidance of Long-Acting (LA) or Extended-Release (ER) Opiate Prescriptions and Opiate Prescriptions for Greater Than 3 Days Duration for Acute Pain
Effective Clinical Care
Process

Measure Description

Percentage of Adult Patients Who Were Prescribed an Opiate Who Were Not Prescribed a Long-Acting (LA) or Extended-Release (ER) Formulation.

Denominator

Any patient ≥ 18 years of age evaluated by the Eligible Professional in the Emergency Department or Urgent Care Clinic PLUS Opiate prescribed PLUS ICD-10 diagnosis codes for pain, strains, sprains, lacerations, open wounds and fractures PLUS Disposition of Discharged.

Numerator

Patients who were not prescribed a long-acting (LA) or extended-release (ER) opiate, and not prescribed an opiate and any opiate prescription for greater than 3 days duration.

Denominator Exclusions

None

Denominator Exceptions

LA/ER formulation opiate prescribed for terminal (late-stage) cancer, comfort care measures, palliative care, or coordinated plan of care for Medication Assisted Treatment (MAT).

87MIPS Measures Supported

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ID
Description
Domain
Type
High Priority
QPP5
Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Effective Clinical Care
Process

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)
QPP6
Coronary Artery Disease (CAD): Antiplatelet Therapy
Effective Clinical Care
Process

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)
QPP8
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Effective Clinical Care
Process

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)

QPP47
Advance Care Plan
Communication & Care Coordination
Process

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

QPP65
Appropriate Treatment for Children with Upper Respiratory Infection (URI)
Efficiency & Cost Reduction
Process

Measure Description

Percentage of children 3 months-18 years 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

Children age 3 months to 18 years 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

  • Patient prescribed or dispensed antibiotic for documented medical reason(s) within three days after the initial diagnosis of URI (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.
  • Children who are taking antibiotics in the 30 days prior to the date of the encounter during which the diagnosis was established.
  • Patients who use hospice services any time during the measurement period.

Denominator Exceptions

None

QPP66
Appropriate Testing for Children with Pharyngitis
Efficiency & Cost Reduction
Process

Measure Description

Percentage of children 3-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode

Denominator

Children 3-18 years of age who had an outpatient or emergency department (ED) visit with a diagnosis of pharyngitis during the measurement period and an antibiotic ordered on or three days after the visit

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

  • Patients who use hospice services any time during the measurement period.
  • Children who are taking antibiotics in the 30 days prior to the diagnosis of pharyngitis
  • Children with a competing diagnosis for Upper Respiratory Infection within three days of diagnosis of pharyngitis (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)

Denominator Exceptions

None

QPP76
Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections
Patient Safety
Process

Measure Description

Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed

Denominator

All patients, regardless of age, who undergo CVC insertion

Numerator

Patients for whom central venous catheter (CVC) was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed

Denominator Exclusions

None

Denominator Exceptions

Documentation of medical reason(s) for not following all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques during CVC insertion (including increased risk of harm to patient if adherence to aseptic technique would cause delay in CVC insertion)

QPP93
Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy Avoidance of Inappropriate Use
Efficiency & Cost Reduction
Process

Measure Description

Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed systemic antimicrobial therapy.

Denominator

All patients aged 2 years and older with a diagnosis of AOE.

Numerator

Patients who were not prescribed systemic antimicrobial therapy.

Denominator Exclusions

None

Denominator Exceptions

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

QPP116
Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis
Efficiency & Cost Reduction
Process

Measure Description

The percentage of adults 18–64 years of age with a diagnosis of acute bronchitis who were not prescribed or dispensed an antibiotic prescription.

Denominator

All patients aged 18 through 64 years of age with an outpatient, observation or emergency department (ED) visit with a diagnosis of acute bronchitis 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.

QPP118
Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)
Effective Clinical Care
Process

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)
QPP130
Documentation of Current Medications in the Medical Record
Patient Safety
Process

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

QPP154
Falls: Risk Assessment
Patient Safety
Process

Measure Description

Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months

Denominator

All patients aged 65 years and older who have a history of falls (history of falls is defined as 2 or more falls in the past year or any fall with injury in the past year). Documentation of patient reported history of falls is sufficient

Numerator

Patients who had a risk assessment for falls completed within 12 months

Denominator Exclusions

Hospice services for patient provided any time during the measurement period

Denominator Exceptions

Documentation of medical reason(s) for not completing a risk assessment for falls (i.e., patient is not ambulatory, bed ridden, immobile, confined to chair, wheelchair bound, dependent on helper pushing wheelchair, independent in wheelchair or minimal help in wheelchair)

QPP187
Stroke and Stroke Rehabilitation: Thrombolytic Therapy (tPA)
Effective Clinical Care
Process

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).

QPP254
Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain
Effective Clinical Care
Process

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]).

QPP317
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Community - Population Health
Process

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
QPP326
Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy
Effective Clinical Care
Process

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
QPP331
Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse)
Efficiency and Cost Reduction
Process

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

QPP332
Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patient with Acute Bacterial Sinusitis (Appropriate Use)
Efficiency and Cost Reduction
Process

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

QPP333
Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse)
Efficiency and Cost Reduction
Process

Measure Description

Percentage of patients aged 18 years and older, with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis.

Denominator

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

Numerator

Patients who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis

Denominator Exclusions

None

Denominator Exceptions

CT scan of the paranasal sinuses ordered at the time of diagnosis for documented reasons.

QPP415
Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older
Efficiency and Cost Reduction
Efficiency

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

QPP416
Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years
Efficiency and Cost Reduction
Efficiency

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

QPP419
Overuse Of Neuroimaging For Patients With Primary Headache
Efficiency and Cost Reduction
Process

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)

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