Pqrs Nqf Join Table: round 1 of 8

8/12/2019 Pqrs Nqf Join Table: round 1 of 8

1/99

PQRS Number NQF Number Measure Title & Description Meets Performance

1 59 Diabetes Mellitus: Hemoglobin A1c Poor Contro3046F

3046F-8P

(Note: Measures poor contro

2 64 Diabetes Mellitus: Low Density Lipoprotein (LD 3048F

3 61 Diabetes Mellitus: High Blood Pressure Control G8919 & G8921

*5 81 Individual Measures Reporting: Heart Failure: A 4010F

*5 81 Measures Group Reporting: Heart Failure: Angi 4010F & 3021F

6 67 Coronary Artery Disease (CAD): Antiplatelet The4086F

*7 70 Coronary Artery Disease (CAD): Beta-Blocker Th 4008F

------------

4008F

*8 83 Individual Measures Reporting: Heart Failure: B G8450

*8 83 Measures Group Reporting: Heart Failure: Beta-G8450 & G8923

9 105 Major Depressive Disorder (MDD): Antidepress G8126

12 86 Primary Open Angle Glaucoma (POAG): Optic N 2027F

14 87 Age-Related Macular Degeneration (AMD): Dila 2019F

18 88 Diabetic Retinopathy: Documentation of Presen2021F

19 89 Diabetic Retinopathy: Communication with the 5010F & G8397

20 270 Perioperative Care: Timing of Prophylactic Pare G8629

G8630

21 268 Perioperative Care: Selection of Prophylactic An4041F

22 271 Perioperative Care: Discontinuation of Prophyla4049F & 4046F

23 239 Perioperative Care: Venous Thromboembolism 4044F

24 45 Osteoporosis: Communication with the Physicia5015F

28 92 Aspirin at Arrival for Acute Myocardial Infarctio 4084F

30 269 Perioperative Care: Timely Administration of Pr 4048F

31 420 Stroke and Stroke Rehabilitation: Deep Vein Thr4070F

32 325 Stroke and Stroke Rehabilitation: Discharged on G8696

*33 241 Stroke and Stroke Rehabilitation: Anticoagulant 4075F


2/99

35 243 Stroke and Stroke Rehabilitation: Screening for 6010F & 6015F

36 244 Stroke and Stroke Rehabilitation: Rehabilitation G8699

39 46 Screening or Therapy for Osteoporosis for WomG8399

40 45 Osteoporosis: Management Following Fracture 3096F3095F

G8633

41 49 Osteoporosis: Pharmacologic Therapy for Men 4005F

43 516 Coronary Artery Bypass Graft (CABG): Use of Int4110F

44 235 Coronary Artery Bypass Graft (CABG): Preopera 4115F

45 637 Perioperative Care: Discontinuation of Prophyla4043F & G8702

46 97 Medication Reconciliation 1111F

47 326 Advance Care Plan 1123F

1124F

48 98 Urinary Incontinence: Assessment of Presence 1090F

49 99 Urinary Incontinence: Characterization of Urina 1091F

50 100 Urinary Incontinence: Plan of Care for Urinary I 0509F

51 91 Chronic Obstructive Pulmonary Disease (COPD): 3023F

52 102 Chronic Obstructive Pulmonary Disease (COPD): 4025F & G8924

53 47 Asthma: Pharmacologic Therapy for Persistent 4140F & 1038F

4144F & 1038F

54 90 Emergency Medicine: 12-Lead Electrocardiogra 3120F

55 93 Emergency Medicine: 12-Lead Electrocardiogra G8704

56 232 Emergency Medicine: Community-Acquired Pne2010F

59 96 Emergency Medicine: Community-Acquired Pne4045F

64 1 Asthma: Assessment of Asthma Control Ambu2015F & 2016F

65 69 Appropriate Treatment for Children with Upper G8708

66 2 Appropriate Testing for Children with Pharyngiti3210F & G8711

67 377 Hematology: Myelodysplastic Syndrome (MDS) 3 155F

68 378 Hematology: Myelodysplastic Syndrome (MDS): 3160F & 4090F

69 380 Hematology: Multiple Myeloma: Treatment wit 4100F

70 379 Hematology: Chronic Lymphocytic Leukemia (C 3170F

71 387 Breast Cancer: Hormonal Therapy for Stage IC - 4179F & 3374F & 3315F

4179F & 3376F & 3315F

4179F & 3378F & 3315F


3/99

72 385 Colon Cancer: Chemotherapy for AJCC Stage III G8927 & 3388F

76 464 Prevention of Catheter-Related Bloodstream Inf6030F

*81 323 Adult Kidney Disease: Hemodialysis Adequacy: G8713

*82 321 Adult Kidney Disease: Peritoneal Dialysis AdequG8718

*83 393 Hepatitis C: Testing for Chronic Hepatitis C Co 3265F

84 395 Hepatitis C: Ribonucleic Acid (RNA) Testing Befo3218F & 4150F

85 396 Hepatitis C: HCV Genotype Testing Prior to Trea 3266F & G8459

86 397 Hepatitis C: Antiviral Treatment Prescribed 4153F

87 398 Hepatitis C: HCV Ribonucleic Acid (RNA) Testing 3220F & G8461

89 401 Hepatitis C: Counseling Regarding Risk of Alcoh 4158F

90 394 Hepatitis C: Counseling Regarding Use of Contra4159F & G8463

91 653 Acute Otitis Externa (AOE): Topical Therapy 4130F

93 654 Acute Otitis Externa (AOE): Systemic Antimicrob4132F

99 391 Breast Cancer Resection Pathology Reporting: p 3260F

100 392 Colorectal Cancer Resection Pathology ReportinG8721

102 389 Prostate Cancer: Avoidance of Overuse of Bone 3270F & 3271F

104 390 Prostate Cancer: Adjuvant Hormonal Therapy fo4164F & G8465

106 103 Adult Major Depressive Disorder (MDD): Compr1040F & G8930

107 104 Adult Major Depressive Disorder (MDD): Suicid G8932

108 54 Rheumatoid Arthritis (RA): Disease Modifying A 4187F

109 50 Osteoarthritis (OA): Function and Pain Assessm 1006F

110 41 Preventive Care and Screening: Influenza Immu G8482

111 43 Preventive Care and Screening: Pneumococcal 4040F

112 31 Preventive Care and Screening: Breast Cancer S 3014F


4/99

113 34 Preventive Care and Screening: Colorectal Canc 3017F

116 58 Antibiotic Treatment for Adults with Acute Bron4124F

117 55 Diabetes Mellitus: Dilated Eye Exam 2022F

2024F

2026F

3072F

*118 66 Coronary Artery Disease (CAD): Angiotensin-Co G8935------------

G8473

119 62 Diabetes: Medical Attention for Nephropathy 3060F

3061F

3062F

3066F

G8506

121 AQA Adult Kidney Disease: LaboratoryTesting (Lipid G8725

122 AQA Adult Kidney Disease: Blood Pressure ManagemG8476

G8477 & 0513F

123 AQA Adult Kidney Disease: Patients On Erythropoiesi G0908 & 4171F

(NOTE: A lower performance

126 417 Diabetes Mellitus: Diabetic Foot and Ankle Care G8404

127 416 Diabetes Mellitus: Diabetic Foot and Ankle Care G8410

128 421 Preventive Care and Screening: Body Mass Inde G8420G8417

G8418

130 419 Documentation of Current Medications in the G8427

131 420 Pain Assessment and Follow-Up G8730

G8731

134 418 Preventive Care and Screening: Screening for CliG8431

G8510

*137 650 Melanoma: Continuity of Care Recall System 7010F

*138 561 Melanoma: Coordination of Care 5050F

140 566 Age-Related Macular Degeneration (AMD): Cou 4177F

141 563 Primary Open-Angle Glaucoma (POAG): Reducti 3284F

0517F & 3285F

142 51 Osteoarthritis (OA): Assessment for Use of Anti-1007F

*143 384 Oncology: Medical and Radiation Pain Intensit1125F

1126F

*144 383 Oncology: Medical and Radiation Plan of Care 0521F


5/99

145 510 Radiology: Exposure Time Reported for Procedu6045F

146 508 Radiology: Inappropriate Use of Probably Beni 3343F


147 511 Nuclear Medicine: Correlation with Existing Ima 3570F

148 322 Back Pain: Initial Visit 1130F

149 319 Back Pain: Physical Exam 2040F

150 315 Back Pain: Advice for Normal Activities 4245F

151 313 Back Pain: Advice Against Bed Rest 4248F

154 AQA Falls: Risk Assessment 3288F & 1100F

155 AQA Falls: Plan of Care 0518F

156 382 Oncology: Radiation Dose Limits to Normal Tiss 0520F

157 455 Thoracic Surgery: Recording of Clinical Stage Pri 3323F

*159 404 HIV/AIDS: CD4+ Cell Count or CD4+ Percentage 3500F

*160 405 Individual Measures Reporting: HIV/AIDS: Pneu 4280F

*160 405 Measures Group Reporting: HIV/AIDS: Pneumo 4280F & 3494F

*161 406 Individual Measures Reporting: HIV/AIDS: Adole4276F*161 406 Measures Group Reporting: HIV/AIDS: Adolesce4276F & 3492F

4276F & 3490F

*162 407 Individual Measures Reporting: HIV/AIDS: HIV R 3502F

3503F & 0575F

*162 407 Measures Group Reporting: HIV/AIDS: HIV RNA 3502F & 4270F

3503F & 0575F & 4270F

163 56 Diabetes Mellitus: Foot Exam 2028F

*164 129 Coronary Artery Bypass Graft (CABG): Prolonge G8569


*165 130 Coronary Artery Bypass Graft (CABG): Deep Ste G8571


*166 131 Coronary Artery Bypass Graft (CABG): Stroke G8573


*167 114 Coronary Artery Bypass Graft (CABG): Postoper G8575


*168 115 Coronary Artery Bypass Graft (CABG): Surgical R G8577


*169 237 Coronary Artery Bypass Graft (CABG): AntiplatelG8579


6/99

*170 238 Coronary Artery Bypass Graft (CABG): Beta-Bloc G8582

*171 118 Coronary Artery Bypass Graft (CABG): Anti-Lipid G8585

172 259 Hemodialysis Vascular Access Decision-Making G8530

173 AQA Preventive Care and Screening: Unhealthy Alco 3016F176 AQA Rheumatoid Arthritis (RA): Tuberculosis Screeni 3455F & 4195F

177 AQA Rheumatoid Arthritis (RA): Periodic Assessment 3470F

3471F

3472F

178 AQA Rheumatoid Arthritis (RA): Functional Status As 1170F

179 AQA Rheumatoid Arthritis (RA): Assessment and Clas 3475F

3476F

180 AQA Rheumatoid Arthritis (RA): Glucocorticoid Mana4192F

4193F

4194F & 0540F

181 AQA Elder Maltreatment Screen and Follow-Up Plan G8733

G8734

182 AQA Functional Outcome Assessment G8539

G8542

G8942

183 399 Hepatitis C: Hepatitis A Vaccination in Patients 4148F

3215F

184 400 Hepatitis C: Hepatitis B Vaccination in Patients 4149F

3216F185 659 Endoscopy & Polyp Surveillance: Colonoscopy I 0529F

*187 437 Stroke and Stroke Rehabilitation: Thrombolytic G8600

188 N/A Referral for Otologic Evaluation for Patients wit G8556

*191 565 Cataracts: 20/40 or Better Visual Acuity within 4175F

*192 564 Cataracts: Complications within 30 Days Followi G8627


193 454 Perioperative Temperature Management 4250F & 4255F

194 386 Oncology: Cancer Stage Documented 3300F

3301F

195 507 Radiology: Stenosis Measurement in Carotid Im 3100F

*197 74 Coronary Artery Disease (CAD): Lipid Control G8736

G8737 & 4013F & 0556F

*198 79 Heart Failure: Left Ventricular Ejection Fraction G8738

G8739

201 73 Ischemic Vascular Disease (IVD): Blood Pressure G8588 & G8590


7/99

204 68 Ischemic Vascular Disease (IVD): Use of Aspirin G8598

*205 409 HIV/AIDS: Sexually Transmitted Disease Screeni 3511F

*208 410 HIV/AIDS: Sexually Transmitted Disease Screeni 3512F

*209 445 Functional Communication Measure - Spoken L G8603

*210 449 Functional Communication Measure - Attention G8606

*211 448 Functional Communication Measure - Memory G8609

*212 447 Functional Communication Measure - Motor Sp G8612

*213 446 Functional Communication Measure - Reading G8615

*214 444 Functional Communication Measure - Spoken L G8618

*215 442 Functional Communication Measure - Writing G8621

*216 443 Functional Communication Measure - Swallowi G8624

*217 422 Functional Deficit: Change in Risk-Adjusted Fun G8647

G8648


G8652


G8656*220 425 Functional Deficit: Change in Risk-Adjusted Fun G8659

G8660

221 426 Functional Deficit: Change in Risk-Adjusted Fun G8663

G8664


G8668


G8672

*224 562 Melanoma: Overutilization of Imaging Studies i 3320F

225 509 Radiology: Reminder System for Mammograms 7025F

226 28 Preventive Care and Screening: Tobacco Use: Sc4004F

1036F

*228 N/A Heart Failure (HF): Left Ventricular Function (LV G8682

231 N/A Asthma: Tobacco Use: Screening - Ambulatory 1031F

232 N/A Asthma: Tobacco Use: Intervention - Ambulator4000F & 1032F

4001F & 1032F

*233 457 Thoracic Surgery: Recording of Performance Sta3328F


8/99

*234 458 Thoracic Surgery: Pulmonary Function Tests Bef3038F

236 18 Hypertension (HTN): Controlling High Blood Pre G8752 & G8754

241 75 Ischemic Vascular Disease (IVD): Complete Lipid G8593 & G8595

242* N/A Individual Reporting via Registry: Coronary Arte 1011F & 0557F

1012F

242* N/A Measures Group Reporting: Coronary Artery Di 1010F & 1011F & 0557F

1010F & 1012F

243* 643 Cardiac Rehabilitation Patient Referral from an 4500F

244* N/A Hypertension: Blood Pressure Management G8790 & G8793

G8790 & G8794

G8791 & G8793

G8791 & G8794

G8790 & G8795 & 4145F

G8791 & G8795 & 4145F

G8792 & G8793 & 4145F

G8792 & G8794 & 4145F

G8792 & G8795 & 4145F

245 AQA Chronic Wound Care: Use of Wound Surface Cul4261F

246 AQA Chronic Wound Care: Use of Wet to Dry Dressin4266F

247 AQA Substance Use Disorders: Counseling Regarding 4320F

248 AQA Substance Use Disorders: Screening for Depress1220F

249 N/A Barrett's Esophagus 3125F

250 N/A Radical Prostatectomy Pathology Reporting 3267F

251 N/A Immunohistochemical (IHC) Evaluation of Hum 3394F

252 503 Anticoagulation for Acute Pulmonary Embolus PG8799

254 651 Ultrasound Determination of Pregnancy LocatioG8806

255 652 Rh Immunoglobulin (Rhogam) for Rh-Negative PG8809

256* N/A Surveillance after Endovascular Abdominal Aort G8813

257* N/A Statin Therapy at Discharge after Lower ExtremiG8816

258* N/A Rate of Open Repair of Small or Moderate Non- G8818

259* N/A Rate of Endovascular Aneurysm Repair (EVAR) oG8826

260* N/A Rate of Carotid Endarterectomy (CEA) for Asym G8834

261 N/A Referral for Otologic Evaluation for Patients wit G8856


9/99

262 N/A Image Confirmation of Successful Excision of Im G8872

263 N/A Preoperative Diagnosis of Breast Cancer G8875

264* N/A Sentinel Lymph Node Biopsy for Invasive Breast G8878

265* 645 Biopsy Follow-Up G8883

266 N/A Epilepsy: Seizure Type(s) and Current Seizure Fr 1200F

267 N/A Epilepsy: Documentation of Etiology of Epilepsy 1205F

268 N/A Epilepsy: Counseling for Women of Childbearin 4340F

269* N/A Inflammatory Bowel Disease (IBD): Type, Anato G0920

270* N/A Inflammatory Bowel Disease (IBD): Preventive G8859 & 4142F

271* N/A Inflammatory Bowel Disease (IBD): Preventive G8860 & G8861

272* N/A Inflammatory Bowel Disease (IBD): Preventive 4035F

4037F

273* N/A Inflammatory Bowel Disease (IBD): Preventive G8864

274* N/A Inflammatory Bowel Disease (IBD): Testing for L 3510F & G8868

6150F

275* N/A Inflammatory Bowel Disease (IBD): Assessment 3517F

G8869

G8870

276* N/A Sleep Apnea: Assessment of Sleep Symptoms G8839

277* N/A Sleep Apnea: Severity Assessment at Initial DiagG8842

278* N/A Sleep Apnea: Positive Airway Pressure Therapy G8845 & G8846

279* N/A Sleep Apnea: Assessment of Adherence to PositG8851 & G8852

280* N/A Dementia: Staging of Dementia 1490F

1491F

1493F

281* N/A Dementia: Cognitive Assessment 1494F

282* N/A Dementia: Functional Status Assessment 1175F

283* N/A Dementia: Neuropsychiatric Symptom Assessm 1181F

284* N/A Dementia: Management of Neuropsychiatric Sy G8947 & 4525F

G8947 & 4526F

285* N/A Dementia: Screening for Depressive Symptoms 3725F

286* N/A Dementia: Counseling Regarding Safety Concer 6101F


10/99

6102F

287* N/A Dementia: Counseling Regarding Risks of Drivin 6110F

288* N/A Dementia: Caregiver Education and Support 4322F

289* N/A Parkinsons Disease: Annual Parkinsons Diseas 1400F

290* N/A Parkinsons Disease: Psychiatric Disorders or Di 3700F

291* N/A Parkinsons Disease: Cognitive Impairment or D 3720F

292* N/A Parkinsons Disease: Querying about Sleep Dist 4328F293* N/A Parkinsons Disease: Rehabilitative Therapy Opt 4400F

294* N/A Parkinsons Disease: Parkinsons Disease Medic 4325F

295* N/A Hypertension: Appropriate Use of Aspirin or Ot G8895

296* N/A Hypertension: Complete Lipid Profile G8767

297* N/A Hypertension: Urine Protein Test G8770

G8771

298* N/A Hypertension: Annual Serum Creatinine Test G8774

299* N/A Hypertension: Diabetes Mellitus Screening Test G8777

300* N/A Hypertension: Blood Pressure Control G8886

301* N/A Hypertension: Low Density Lipoprotein (LDL-C) G8890

302* N/A Hypertension: Dietary and Physical Activity Mo G8780

303* N/A Cataracts: Improvement in Patients Visual FuncG0913

304* N/A Cataracts: Patient Satisfaction within 90 Days F G0916

317 N/A Preventive Care and Screening: Screening for HiG8783

G8950

320 658 Endoscopy/Polyp Surveillance: Appropriate Foll 0528F

321 493 Participation by a Hospital, Physician or Other C G8954

322* 670 Cardiac Stress Imaging Not Meeting Appropriat G8961






325* N/A Adult Major Depressive Disorder (MDD): Coordi G8959

326 1525 Atrial Fibrillation and Atrial Flutter: Chronic Anti G8967 & G8972


11/99

327 N/A Pediatric Kidney Disease: Adequacy of Volume G8955 & G8956

328 1667 Pediatric Kidney Disease: ESRD Patients Receivi G8973



12/99

Medical PePatient Pe System Pe Other Perf Performance

Exclusion Exclusion Exclusion Exclusion Not Met

N/A N/A N/A No Report 3044F

3045F

l. A lower performance rate indicates better control.)


3050F3048F-8P

N/A N/A N/A No Report G8919 & G8922

G8920 & G8921

G8920 & G8922

2000F-8P

4010F-1P 4010F-2P 4010F-3P No Report 4010F-8P

4010F-1P 4010F-2P 4010F-3P 3022F 4010F-8P & 3021F

3021F-8P

No Report



------------ ------------ ------------ ------------ ------------


N/A N/A N/A G8451 G8452

No Report

N/A N/A N/A G8541 G8452

G8395 G8923

G8396

No Report

N/A N/A N/A G8128 G8127

No Report2027F-1P N/A N/A No Report 2027F-8P

2019F-1P 2019F-2P N/A No Report 2019F-8P


5010F-1P 5010F-2P N/A G8398 5010F-8P & G8397

No Report

N/A N/A N/A G8631 G8632

No Report

4041F-1P N/A N/A No Report 4041F-8P

4049F-1P N/A N/A 4042F 4049F-8P & 4046F

No Report




4048F-1P N/A N/A 4047F-8P 4048F-8P

No Report


N/A N/A N/A G8697 G8698

No Report



13/99

6010F-1P 6010F-2P N/A 6020F 6010F-8P & 6015F

No Report

N/A N/A N/A G8700 G8701

No Report

N/A N/A N/A G8401 G8400

No Report

3096F-1P 3096F-2P 3096F-3P G8634 3096F-8P3095F-1P 3095F-2P 3095F-3P No Report 3095F-8P

G8635




4043F-1P N/A N/A G8703 4043F-8P & G8702

No Report

N/A N/A N/A No Report 1111F-8P






4025F-1P 4025F-2P 4025F-3P G8925 4025F-8P & G8924

G8926

No Report

N/A 4140F-2P N/A 1039F 4140F-8P & 1038F

No Report


N/A N/A N/A G8705 G8707G8706

No Report




2016F-8P

N/A N/A N/A G8709 G8710

No Report

3210F-1P N/A N/A G8712 3210F-8P & G8711

No Report


N/A N/A 3160F-3P 4095F 3160F-8P & 4090F

No Report



4179F-1P 4179F-2P 4179F-3P 3316F 4179F-8P & 3374F & 3315F

4179F-1P 4179F-2P 4179F-3P 3370F 4179F-8P & 3376F & 3315F

4179F-1P 4179F-2P 4179F-3P 3372F 4179F-8P & 3378F & 3315F

3380F


14/99

3316F-8P

3370F-8P

No Report

N/A N/A N/A G8928 & 3 G8929 & 3388F

3382F

3384F

3386F3390F

3382F-8P

No Report


N/A N/A N/A No Report G8717



3218F-1P N/A N/A 4151F 3218F-8P & 4150F

No Report

N/A N/A N/A G8458 3266F-8P & G8459

No Report


3220F-1P 3220F-2P N/A G8460 3220F-8P & G8461

No Report


4159F-1P N/A N/A G8462 4159F-8P & G8463

No Report


4131F-1P N/A N/A No Report 4131F

3260F-1P N/A N/A 3250F 3260F-8P

No ReportN/A N/A N/A G8722 G8724

G8723

No Report

3269F-1P N/A 3269F-3P 3272F 3269F & 3271F

3273F

3274F

No Report

4164F-1P 4164F-2P N/A G8464 4164F-8P & G8465

No Report

N/A N/A N/A No Report 1040F-8P & G8931

N/A N/A N/A 3092F G8933

No Report



N/A N/A N/A G8483 G8484

G0919

No Report




15/99




2024F-8P

2026F-8P

N/A N/A N/A G8936 G8937No Report ------------

------------ G8475

G8474

No Report


3061F-8P

3062F-8P

N/A N/A N/A G8726 G8728

No Report


0513F-8P & G8477

N/A N/A N/A G0909 & 4 G0910 & 4171F

rate is desirable for this measure) 4172F

No Report

N/A N/A N/A G8406 G8405

No Report

N/A N/A N/A G8416 G8415

No Report

N/A N/A N/A G8422 G8421G8938 G8419

No Report

N/A N/A N/A G8430 G8428

No Report

N/A N/A N/A G8442 G8732

G8939 G8509

No Report

N/A N/A N/A G8433 G8432

G8940 G8511

No Report

N/A N/A 7010F-3P No Report 7010F-8P

N/A 5050F-2P 5050F-3P No Report 5050F-8P


N/A N/A N/A No Report 0517F-8P & 3285F

3284F-8P





16/99



rate is desirable for this measure) 3341F

3342F

3344F

3345F

3350FN/A N/A 3570F-3P No Report 3570F-8P

N/A N/A N/A 0526F 1130F-8P

No Report

N/A N/A N/A 0526F 2040F8P

No Report

N/A N/A N/A 0526F 4245F-8P

No Report

N/A N/A N/A 0526F 4248F-8P

No Report

3288F-1P N/A N/A 1101F 3288F-8P & 1100F

1101F-8P

No Report







3495F 4280F-8P & 3494F

3496F

N/A N/A N/A No Report 4276F-8PN/A N/A N/A 3493F 4276F-8P & 3492F

No Report 4276F-8P & 3490F


0575F-8P & 3503F

N/A N/A N/A 4271F 3502F-8P & 4270F

No Report 0575F-8P & 3503F & 4270F



rate is desirable for this measure)



N.A N/A N/A No Report G8574






N/A N/A N/A G8580 G8581

No Report


17/99

N/A N/A N/A G8583 G8584

No Report

N/A N/A N/A G8586 G8587

No Report

N/A N/A N/A G8531 G8532

No Report

3016F-1P N/A N/A No Report 3016F-8P3455F-1P N/A N/A 4196F 3455F-8P & 4195F

No Report





0540F-8P & 4194F

N/A N/A N/A G8535 G8536

G8941 G8735

No Report

N/A N/A N/A G8540 G8541

No Report G8543



0529F-1P N/A 0529F-3P No Report 0529F-8P

N/A N/A N/A G8601 G8602

No Report

N/A N/A N/A G8557 G8558

No Report




4250F-1P N/A N/A 4256F 4250F-8P & 4255F

No Report



G8737 & 0 G8737 & 0 G8737 & 0 No Report G8737 & 4013F-8P

G8737 & 0556F-8P

G8943




18/99

G8589 & G8590

G8589 & G8591

G8592


N/A 3511F-2P N/A No Report 3511F-8P

N/A 3512F-2P N/A No Report 3512F-8P

N/A N/A N/A No Report G8604G8605


G8608


G8611


G8614


G8617


G8620


G8623


G8626

N/A N/A N/A G8649 G8650

No Report

N/A N/A N/A G8653 G8654

No Report

N/A N/A N/A G8657 G8658


No Report

N/A N/A N/A G8665 G8666

No Report

N/A N/A N/A G8669 G8670

No Report

N/A N/A N/A G8673 G8674

No Report

3319F-1P N/A 3319F-3P No Report 3319F



N/A N/A N/A G8683 G8685

No Report


N/A N/A N/A 1033F G8751

No Report 4000F-8P & 1032F

4001F-8P & 1032F



19/99



G8753 & G8754

G8753 & G8755

G8756


G8593 & G85971011F & 0 N/A N/A No Report 1011F & 0557F-8P

1010F & 1 N/A N/A No Report 1010F & 1011F & 0557F-8P

1010F-8P

4500F-1P 4500F-2P 4500F-3P 4510F 4500F-8P

No Report


G8796





3125F-1P N/A N/A G8797 3125F-8P

No Report3267F-1P N/A N/A G8798 3267F-8P

No Report

N/A N/A N/A 3395F 3394F-8P

No Report

N/A N/A N/A G8800 G8801

No Report

N/A N/A N/A G8807 G8808

No Report

N/A N/A N/A G8810 G8811

No Report

N/A N/A N/A G8812 G8814

No Report

N/A N/A N/A G8815 G8817

No Report




N/A N/A N/A G8857 G8858

No Report


20/99

N/A N/A N/A G8873 G8874

No Report

N/A N/A N/A G8876 G8877

G8946

No Report

N/A N/A N/A G8880 G8882


No Report




N/A G0921 N/A No Report G0922

G8859 & 4 G8859 & 4 N/A 3750F G8859 & 4142F-8P

No Report

N/A N/A N/A G8862 G8860 & G8863

No Report


4037F-1P 4037F-2P 4037F-3P 4037F-8P

N/A N/A N/A G8865 G8867

G8866

No Report

3510F-1P 3510F-2P N/A No Report 3510F-8P & G8868

3517F-1P 3517F-2P N/A G8871 3517F-8P

No Report

N/A N/A N/A G8840 G8841No Report

N/A N/A N/A G8843 G8844

No Report

N/A N/A N/A G8848 G8850 & G8846

G8849 & G8846

No Report

N/A N/A N/A G8853 G8855 & G8852

G8854 & G8852

No Report





N/A N/A N/A G8948 G8947 & 4525F-8P

No Report G8947 & 4526F-8P




21/99

6102F-1P 6102F-8P






4328F-1P N/A N/A No Report 4328F-8P4400F-1P N/A N/A No Report 4400F-8P


N/A N/A N/A G8896 G8897

No Report

N/A N/A N/A G8768 G8769

No Report

N/A N/A N/A G8772 G8773

No Report

N/A N/A N/A G8775 G8776

No Report

N/A N/A N/A G8778 G8779

No Report

N/A N/A N/A G8887 G8888

No Report G8889

N/A N/A N/A G8891 G8893

G8892 G8894

No Report

N/A N/A N/A G8781 G8782

G8949

No Report

N/A N/A N/A G0914 G0915No Report

N/A N/A N/A G0917 G0918

No Report

N/A N/A N/A G8784 G8785

G8951 G8952

No Report


N/A N/A N/A No Report N/A








N/A N/A N/A G8968 & G G8971 & G8972

G8969 & G8972

G8970

No Report


22/99

N/A N/A N/A G8957 G8958 & G8956

No Report

N/A N/A N/A G8974 G8976

rate is desirable for this measure) G8975

No Report


23/99

PQRS_NumNQF_Num Measure Title_Description

1 0059 Diabetes Mellitus: Hemoglobin A1c Poor Control

2 0064 Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control

3 0061 Diabetes Mellitus: High Blood Pressure Control

5 0081 Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Rec

6 0067 Coronary Artery Disease (CAD): Antiplatelet Therapy

7 0070 Coronary Artery Disease (CAD): Beta-Blocker Therapy- Prior Myocardial Infarctio8 0083 Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVS

9 0105 Major Depressive Disorder (MDD): Antidepressant Medication During Acute Pha

12 0086 Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation

14 0087 Age-Related Macular Degeneration (AMD): Dilated Macular Examination

18 0088 Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edem

19 0089 Diabetic Retinopathy: Communication with the Physician Managing Ongoing Dia

20 0270 Perioperative Care: Timing of Prophylactic Parenteral Antibiotic Ordering Physi

21 0268 Perioperative Care: Selection of Prophylactic Antibiotic First OR Second Gener

22 0271 Perioperative Care: Discontinuation of Prophylactic Parenteral Antibiotics (Non-

23 0239 Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicat

24 0045 Osteoporosis: Communication with the Physician Managing On-going Care Post-

28 0092 Aspirin at Arrival for Acute Myocardial Infarction (AMI)

30 0269 Perioperative Care: Timely Administration of Prophylactic Parenteral Antibiotics

31 0420 Stroke and Stroke Rehabilitation: Deep Vein Thrombosis (DVT) Prophylaxis for Is

32 0325 Stroke and Stroke Rehabilitation: Discharged on Antithrombotic Therapy

33 0241 Stroke and Stroke Rehabilitation: Anticoagulant Therapy Prescribed for Atrial Fib

35 0243 Stroke and Stroke Rehabilitation: Screening for Dysphagia

36 0244 Stroke and Stroke Rehabilitation: Rehabilitation Services Ordered

39 0046 Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older

40 0045 Osteoporosis: Management Following Fracture of Hip, Spine or Distal Radius for

41 0049 Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years and43 0516 Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in

44 0235 Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with

45 0637 Perioperative Care: Discontinuation of Prophylactic Parenteral Antibiotics (Cardi

46 0097 Medication Reconciliation

47 0326 Advance Care Plan

48 0098 Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinen

49 0099 Urinary Incontinence: Characterization of Urinary Incontinence in Women Aged

50 0100 Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65

51 0091 Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation

52 0102 Chronic Obstructive Pulmonary Disease (COPD): Bronchodilator Therapy

53 0047 Asthma: Pharmacologic Therapy for Persistent Asthma Ambulatory Care Settin

54 0090 Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for Non-Trau

55 0093 Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for Syncope

56 0232 Emergency Medicine: Community-Acquired Pneumonia (CAP): Vital Signs

59 0096 Emergency Medicine: Community-Acquired Pneumonia (CAP): Empiric Antibiotic

64 0001 Asthma: Assessment of Asthma Control Ambulatory Care Setting

65 0069 Appropriate Treatment for Children with Upper Respiratory Infection (URI)

66 0002 Appropriate Testing for Children with Pharyngitis

67 0377 Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline C


24/99

68 0378 Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in

69 0380 Hematology: Multiple Myeloma: Treatment with Bisphosphonates

70 0379 Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry

71 0387 Breast Cancer: Hormonal Therapy for Stage IC - IIIC Estrogen Receptor/Progester

72 0385 Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients

76 0464 Prevention of Catheter-Related Bloodstream Infections (CRBSI): Central Venous

81 0323 Adult Kidney Disease: Hemodialysis Adequacy: Solute82 0321 Adult Kidney Disease: Peritoneal Dialysis Adequacy: Solute

83 0393 Hepatitis C: Testing for Chronic Hepatitis C Confirmation of Hepatitis C Viremia

84 0395 Hepatitis C: Ribonucleic Acid (RNA) Testing Before Initiating Treatment

85 0396 Hepatitis C: HCV Genotype Testing Prior to Treatment

86 0397 Hepatitis C: Antiviral Treatment Prescribed

87 0398 Hepatitis C: HCV Ribonucleic Acid (RNA) Testing at Week 12 of Treatment

89 0401 Hepatitis C: Counseling Regarding Risk of Alcohol Consumption

90 0394 Hepatitis C: Counseling Regarding Use of Contraception Prior to Antiviral Therap

91 0653 Acute Otitis Externa (AOE): Topical Therapy

93 0654 Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy Avoidance of Inapp

99 0391 Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and

100 0392 Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor)

102 0389 Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prosta

104 0390 Prostate Cancer: Adjuvant Hormonal Therapy for High Risk Prostate Cancer Pati

106 0103 Adult Major Depressive Disorder (MDD): Comprehensive Diagnostic Evaluation:

107 0104 Adult Major Depressive Disorder (MDD): Suicide Risk Assessment

108 0054 Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug (DMARD) Th

109 0050 Osteoarthritis (OA): Function and Pain Assessment

110 0041 Preventive Care and Screening: Influenza Immunization

111 0043 Preventive Care and Screening: Pneumococcal Vaccination for Patients 65 Years

112 0031 Preventive Care and Screening: Breast Cancer Screening113 0034 Preventive Care and Screening: Colorectal Cancer Screening

116 0058 Antibiotic Treatment for Adults with Acute Bronchitis: Avoidance of Inappropriat

117 0055 Diabetes Mellitus: Dilated Eye Exam

118 0066 Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor

119 0062 Diabetes: Medical Attention for Nephropathy

121 AQA Adult Kidney Disease: LaboratoryTesting (Lipid Profile)

122 AQA Adult Kidney Disease: Blood Pressure Management

123 AQA Adult Kidney Disease: Patients On Erythropoiesis-Stimulating Agent (ESA) - Hem

126 0417 Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy Neuro

127 0416 Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention Evaluation o

128 0421 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up

130 0419 Documentation of Current Medications in the Medical Record

131 0420 Pain Assessment and Follow-Up

134 0418 Preventive Care and Screening: Screening for Clinical Depression and Follow-Up

137 0650 Melanoma: Continuity of Care Recall System

138 0561 Melanoma: Coordination of Care

140 0566 Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Suppleme

141 0563 Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP)

142 0051 Osteoarthritis (OA): Assessment for Use of Anti-Inflammatory or Analgesic Over-


25/99

143 0384 Oncology: Medical and Radiation Pain Intensity Quantified

144 0383 Oncology: Medical and Radiation Plan of Care for Pain

145 0510 Radiology: Exposure Time Reported for Procedures Using Fluoroscopy

146 0508 Radiology: Inappropriate Use of Probably Benign Assessment Category in Mam

147 0511 Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Und

148 0322 Back Pain: Initial Visit

149 0319 Back Pain: Physical Exam150 0315 Back Pain: Advice for Normal Activities

151 0313 Back Pain: Advice Against Bed Rest

154 AQA Falls: Risk Assessment

155 AQA Falls: Plan of Care

156 0382 Oncology: Radiation Dose Limits to Normal Tissues

157 0455 Thoracic Surgery: Recording of Clinical Stage Prior to Lung Cancer or Esophageal

159 0404 HIV/AIDS: CD4+ Cell Count or CD4+ Percentage

160 0405 HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis

161 0406 HIV/AIDS: Adolescent and Adult Patients with HIV/AIDS Who Are Prescribed Pot

162 0407 HIV/AIDS: HIV RNA Control After Six Months of Potent Antiretroviral Therapy

163 0056 Diabetes Mellitus: Foot Exam

164 0129 Coronary Artery Bypass Graft (CABG): Prolonged Intubation

165 0130 Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate

166 0131 Coronary Artery Bypass Graft (CABG): Stroke

167 0114 Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure

168 0115 Coronary Artery Bypass Graft (CABG): Surgical Re-exploration

169 0237 Coronary Artery Bypass Graft (CABG): Antiplatelet Medications at Discharge

170 0238 Coronary Artery Bypass Graft (CABG): Beta-Blockers Administered at Discharge

171 0118 Coronary Artery Bypass Graft (CABG): Anti-Lipid Treatment at Discharge

172 0259 Hemodialysis Vascular Access Decision-Making by Surgeon to Maximize Placeme

173 AQA Preventive Care and Screening: Unhealthy Alcohol Use Screening176 AQA Rheumatoid Arthritis (RA): Tuberculosis Screening

177 AQA Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity

178 AQA Rheumatoid Arthritis (RA): Functional Status Assessment

179 AQA Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis

180 AQA Rheumatoid Arthritis (RA): Glucocorticoid Management

181 AQA Elder Maltreatment Screen and Follow-Up Plan

182 AQA Functional Outcome Assessment

183 0399 Hepatitis C: Hepatitis A Vaccination in Patients with HCV

184 0400 Hepatitis C: Hepatitis B Vaccination in Patients with HCV

185 0659 Endoscopy & Polyp Surveillance: Colonoscopy Interval for Patients with a Histor

*187 0437 Stroke and Stroke Rehabilitation: Thrombolytic Therapy

188 N/A Referral for Otologic Evaluation for Patients with Congenital or Traumatic Defor

*191 0565 Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surge

*192 0564 Cataracts: Complications within 30 Days Following Cataract Surgery Requiring A

193 0454 Perioperative Temperature Management

194 0386 Oncology: Cancer Stage Documented

195 0507 Radiology: Stenosis Measurement in Carotid Imaging Studies

197 0074 Coronary Artery Disease (CAD): Lipid Control

198 0079 Heart Failure: Left Ventricular Ejection Fraction (LVEF) Assessment


26/99

201 0073 Ischemic Vascular Disease (IVD): Blood Pressure Management

204 0068 Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic

205 0409 HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia and Gonorrhea

208 0410 HIV/AIDS: Sexually Transmitted Disease Screening for Syphilis

209 0445 Functional Communication Measure - Spoken Language Comprehension

210 0449 Functional Communication Measure - Attention

211 0448 Functional Communication Measure - Memory212 0447 Functional Communication Measure - Motor Speech

213 0446 Functional Communication Measure - Reading

214 0444 Functional Communication Measure - Spoken Language Expression

215 0442 Functional Communication Measure - Writing

216 0443 Functional Communication Measure - Swallowing

217 0422 Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with K

218 0423 Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Hi

219 0424 Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Lo

220 0425 Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with Lu

221 0426 Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with S

222 0427 Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with El

223 0428 Functional Deficit: Change in Risk-Adjusted Functional Status for Patients with N

224 0562 Melanoma: Overutilization of Imaging Studies in Melanoma

225 0509 Radiology: Reminder System for Mammograms

226 0028 Preventive Care and Screening: Tobacco Use: Screening and Cessation Interventi

228 N/A Heart Failure (HF): Left Ventricular Function (LVF) Testing

231 N/A Asthma: Tobacco Use: Screening - Ambulatory Care Setting

232 N/A Asthma: Tobacco Use: Intervention - Ambulatory Care Setting

233 0457 Thoracic Surgery: Recording of Performance Status Prior to Lung or Esophageal

234 0458 Thoracic Surgery: Pulmonary Function Tests Before Major Anatomic Lung Resect

236 0018 Hypertension (HTN): Controlling High Blood Pressure241 0075 Ischemic Vascular Disease (IVD): Complete Lipid Panel and Low Density Lipoprot

242 N/A Coronary Artery Disease (CAD): Symptom Management

243 0643 Cardiac Rehabilitation Patient Referral from an Outpatient Setting

244 N/A Hypertension: Blood Pressure Management

245 AQA Chronic Wound Care: Use of Wound Surface Culture Technique in Patients with

246 AQA Chronic Wound Care: Use of Wet to Dry Dressings in Patients with Chronic Skin

247 AQA Substance Use Disorders: Counseling Regarding Psychosocial and Pharmacologic

248 AQA Substance Use Disorders: Screening for Depression Among Patients with Substa

249 N/A Barrett's Esophagus

250 N/A Radical Prostatectomy Pathology Reporting

251 N/A Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor Rece

252 0503 Anticoagulation for Acute Pulmonary Embolus Patients

254 0651 Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abd

255 0652 Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal

256 N/A Surveillance after Endovascular Abdominal Aortic Aneurysm Repair (EVAR)

257 N/A Statin Therapy at Discharge after Lower Extremity Bypass (LEB)

258 N/A Rate of Open Repair of Small or Moderate Non-Ruptured Abdominal Aortic Ane

259 N/A Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptur

260 N/A Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Majo


27/99

261 N/A Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness

262 N/A Image Confirmation of Successful Excision of ImageLocalized Breast Lesion

263 N/A Preoperative Diagnosis of Breast Cancer

264 N/A Sentinel Lymph Node Biopsy for Invasive Breast Cancer

265 0645 Biopsy Follow-Up

266 N/A Epilepsy: Seizure Type(s) and Current Seizure Frequency(ies)

267 N/A Epilepsy: Documentation of Etiology of Epilepsy or Epilepsy Syndrome268 N/A Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy

269 N/A Inflammatory Bowel Disease (IBD): Type, Anatomic Location and Activity All Doc

270 N/A Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Sparing Ther

271 N/A Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatro

272 N/A Inflammatory Bowel Disease (IBD): Preventive Care: Influenza Immunization

273 N/A Inflammatory Bowel Disease (IBD): Preventive Care: Pneumococcal Immunizatio

274 N/A Inflammatory Bowel Disease (IBD): Testing for Latent Tuberculosis (TB) Before In

275 N/A Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status

276 N/A Sleep Apnea: Assessment of Sleep Symptoms

277 N/A Sleep Apnea: Severity Assessment at Initial Diagnosis

278 N/A Sleep Apnea: Positive Airway Pressure Therapy Prescribed

279 N/A Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy

280 N/A Dementia: Staging of Dementia

281 N/A Dementia: Cognitive Assessment

282 N/A Dementia: Functional Status Assessment

283 N/A Dementia: Neuropsychiatric Symptom Assessment

284 N/A Dementia: Management of Neuropsychiatric Symptoms

285 N/A Dementia: Screening for Depressive Symptoms

286 N/A Dementia: Counseling Regarding Safety Concerns

287 N/A Dementia: Counseling Regarding Risks of Driving

288 N/A Dementia: Caregiver Education and Support289 N/A Parkinsons Disease: Annual Parkinsons Disease Diagnosis Review

290 N/A Parkinsons Disease: Psychiatric Disorders or Disturbances Assessment

291 N/A Parkinsons Disease: Cognitive Impairment or Dysfunction Assessment

292 N/A Parkinsons Disease: Querying about Sleep Disturbances

293 N/A Parkinsons Disease: Rehabilitative Therapy Options

294 N/A Parkinsons Disease: Parkinsons Disease Medical and Surgical Treatment Option

295 N/A Hypertension: Appropriate Use of Aspirin or Other Anththrombotic Therapy

296 N/A Hypertension: Complete Lipid Profile

297 N/A Hypertension: Urine Protein Test

298 N/A Hypertension: Annual Serum Creatinine Test

299 N/A Hypertension: Diabetes Mellitus Screening Test

300 N/A Hypertension: Blood Pressure Control

301 N/A Hypertension: Low Density Lipoprotein (LDL-C) Control

302 N/A Hypertension: Dietary and Physical Activity Modifications Appropriately Prescrib

303 N/A Cataracts: Improvement in Patients Visual Function within 90 Days Following Ca

304 N/A Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery

317 N/A Preventive Care and Screening: Screening for High Blood Pressure and Follow-U

320 0658 Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colon

321 0493 Participation by a Hospital, Physician or Other Clinician in a Systematic Clinical D


28/99

322 0670 Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evalu

323 0671 Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing Af

324 0672 Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asyptom

325 N/A Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with C

326 1525 Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy

327 N/A Pediatric Kidney Disease: Adequacy of Volume Management

328 1667 Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level < 1


29/99

eptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)

n (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%)D)

se for Patients with MDD

and Level of Severity of Retinopathy

betes Care

cian

tion Cephalosporin

ardiac Procedures)

d in ALL Patients)

Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older

chemic Stroke or Intracranial Hemorrhage

rillation (AF) at Discharge

Men and Women Aged 50 Years and Older

lderatients with Isolated CABG Surgery

Isolated CABG Surgery

ac Procedures)

ce in Women Aged 65 Years and Older

65 Years and Older

ears and Older

g

matic Chest Pain

ytogenetic Testing Performed on Bone Marrow


30/99

Patients Receiving Erythropoietin Therapy

one Receptor (ER/PR) Positive Breast Cancer

Catheter (CVC) Insertion Protocol

y

ropriate Use

pN Category (Regional Lymph Nodes) with Histologic Grade

nd pN Category (Regional Lymph Nodes) with Histologic Grade

te Cancer Patients

nts

Diagnosis and Severity

rapy

and Older

e Use

r Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF

globin Level > 12.0 g/dL

logical Evaluation

f Footwear

Plan

nt

y 15% OR Documentation of a Plan of Care

the-Counter (OTC) Medications


31/99

mography Screening

rgoing Bone Scintigraphy

Cancer Resection

nt Antiretroviral Therapy

nt of Autogenous Arterial Venous (AV) Fistula

of Adenomatous Polyps Avoidance of Inappropriate Use

ity of the Ear

ry

ditional Surgical Procedures


32/99

ee Impairments

p Impairments

wer Leg, Foot or Ankle Impairments

mbar Spine Impairments

oulder Impairments

bow, Wrist or Hand Impairments

ck, Cranium, Mandible, Thoracic Spine, Ribs, or Other General Orthopedic Impairments

on

ancer Resection

ion (Pneumonectomy, Lobectomy, or Formal Segmentectomy)

ein (LDL-C) Control

hronic Skin Ulcers (Overuse Measure)

lcers (Overuse Measure)

Treatment Options for Alcohol Dependence

ce Abuse or Dependence

ptor 2 Testing (HER2) for Breast Cancer Patients

ominal Pain

Blood Exposure

rysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7)

ed Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Oper

Complications (Discharged to Home Post-Operative Day #2)


33/99

umented

py

genic Injury Bone Loss Assessment

n

itiating Anti-TNF (Tumor Necrosis Factor) Therapy

Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy

s Reviewed

ed

taract Surgery

Documented

oscopy in Average Risk Patients

atabase Registry that Includes Consensus Endorsed Quality


34/99

ation in Low Risk Surgery Patients

ter Percutaneous Coronary Intervention (PCI)

atic, Low-Risk Patients

omorbid Conditions

0 g/dL


35/99


36/99

40%)


37/99


38/99

ative Day #2)


39/99

------------ G8868

------------ G8924

(NOTE: A lower performance rate is desirable for this measure) G8702




(NOTE: A lower performance rate is desirable for this measure) G0908(NOTE: A lower performance rate is desirable for this measure) G0913







(Note: Measures poor control. A lower performance rate indicates better control.) G8417

0509F G8418

0517F & 3285F G8420

0518F G8427

0520F G8431

0521F G8450

0528F G8450 & G8923

0529F G8473

1006F G8476

1007F G8477 & 0513F

1010F & 1011F & 0557F G8482

1010F & 1012F G8506

1011F & 0557F G8510

1012F G85301031F G8539

1036F G8542

1040F & G8930 G8556

1090F G8569

1091F G8571

1111F G8573

1123F G8575

1124F G8577

1125F G8579

1126F G8582

1130F G8585

1170F G8588 & G8590

1175F G8593 & G8595

1181F G8598

1200F G8600

1205F G8603

1220F G8606

1400F G8609

1490F G8612


40/99

1491F G8615

1493F G8618

1494F G8621

2010F G8624

2015F & 2016F G8627

2019F G8629

2021F G86302022F G8633

2024F G8647

2026F G8648

2027F G8651

2028F G8652

2040F G8655

3014F G8656

3016F G8659

3017F G8660

3023F G8663

3038F G8664

3046F G8667

3046F-8P G8668

3048F G8671

3060F G8672

3061F G8682

3062F G8696

3066F G8699

3072F G8704

3095F G8708

3096F G87133100F G8718

3120F G8721

3125F G8725

3155F G8730

3160F & 4090F G8731

3170F G8733

3210F & G8711 G8734

3215F G8736

3216F G8737 & 4013F & 055

3218F & 4150F G8738

3220F & G8461 G8739

3260F G8752 & G8754

3265F G8767

3266F & G8459 G8770

3267F G8771

3270F & 3271F G8774

3284F G8777

3288F & 1100F G8780

3300F G8783


41/99

3301F G8790 & G8793

3320F G8790 & G8794

3323F G8790 & G8795 & 414

3328F G8791 & G8793

3343F G8791 & G8794

3394F G8791 & G8795 & 414

3455F & 4195F G8792 & G8793 & 4143470F G8792 & G8794 & 414

3471F G8792 & G8795 & 414

3472F G8799

3475F G8806

3476F G8809

3500F G8813

3502F G8816

3502F & 4270F G8818

3503F & 0575F G8826

3503F & 0575F & 4270F G8834

3510F & G8868 G8839

3511F G8842

3512F G8845 & G8846

3517F G8851 & G8852

3570F G8856

3700F G8859 & 4142F

3720F G8860 & G8861

3725F G8864

4000F & 1032F G8869

4001F & 1032F G8870

4004F G88724005F G8875

4008F G8878

4008F G8883

4010F G8886

4010F & 3021F G8890

4025F & G8924 G8895

4035F G8919 & G8921

4037F G8927 & 3388F

4040F G8932

4041F G8935

4043F & G8702 G8942

4044F G8947 & 4525F

4045F G8947 & 4526F

4048F G8950

4049F & 4046F G8954

4070F G8955 & G8956

4075F G8959

4084F G8961

4086F G8963


42/99

4100F G8965

4110F G8967 & G8972

4115F G8973

4124F Meets Performance

4130F

4132F

4140F & 1038F4144F & 1038F

4148F

4149F

4153F

4158F

4159F & G8463

4164F & G8465

4175F

4177F

4179F & 3374F & 3315F

4179F & 3376F & 3315F

4179F & 3378F & 3315F

4187F

4192F

4193F

4194F & 0540F

4245F

4248F

4250F & 4255F

4261F

4266F4276F

4276F & 3490F

4276F & 3492F

4280F

4280F & 3494F

4320F

4322F

4325F

4328F

4340F

4400F

4500F

5010F & G8397

5015F

5050F

6010F & 6015F

6030F

6045F

6101F


43/99

6102F

6110F

6150F

7010F

7025F

G0908

G0913G0916

G0920

G8126

G8399

G8404

G8410

G8417

G8418

G8420

G8427

G8431

G8450

G8450 & G8923

G8473

G8476

G8477 & 0513F

G8482

G8506

G8510

G8530

G8539G8542

G8556

G8569

G8571

G8573

G8575

G8577

G8579

G8582

G8585

G8588 & G8590

G8593 & G8595

G8598

G8600

G8603

G8606

G8609

G8612

G8615


44/99


45/99

G8790 & G8794

G8790 & G8795 & 4145F

G8791 & G8793

G8791 & G8794

G8791 & G8795 & 4145F

G8792 & G8793 & 4145F

G8792 & G8794 & 4145FG8792 & G8795 & 4145F

G8799

G8806

G8809

G8813

G8816

G8818

G8826

G8834

G8839

G8842

G8845 & G8846

G8851 & G8852

G8856

G8859 & 4142F

G8860 & G8861

G8864

G8869

G8870

G8872

G8875G8878

G8883

G8886

G8890

G8895

G8919 & G8921

G8927 & 3388F

G8932

G8935

G8942

G8947 & 4525F

G8947 & 4526F

G8950

G8954

G8955 & G8956

G8959

G8961

G8963

G8965


46/99

G8967 & G8972

G8973

Meets Performance


47/99


48/99

F


49/99

5F

5F

5F5F

5F


50/99

PQRS Number

1

2

3

*5

*5

6

*7

*8

*8

9

12

14

18

19

20

21

22

23

24

28

30

31

32

*33


51/99

35

36

39

40

41

43

44

45

46

47

48

49

50

51

52

53

54

55

56

59

64

65

66

67

68

69

70

71


52/99

72

76

*81

*82

*83

84

85

86

87

89

90

91

93

99

100

102

104

106

107

108

109

110

111

112


53/99

113

116

117

*118

119

121

122

123

126

127

128

130

131

134

*137

*138

140

141

142

*143

*144


54/99

145

146

147

148

149

150

151

154

155

156

157

*159

*160

*160

*161*161

*162

*162

163

*164

*165

*166

*167

*168

*169


55/99

*170

*171

172

173176

177

178

179

180

181

182

183

184

185

*187

188

*191

*192

193

194

195

*197

*198

201


56/99

204

*205

*208

*209

*210

*211

*212

*213

*214

*215

*216

*217

*218

*219

*220

221

*222

*223

*224

225

226

*228

231

232

*233


57/99

*234

236

241

242*

242*

243*

244*

245

246

247

248

249

250

251

252

254

255

256*

257*

258*

259*

260*

261


58/99

262

263

264*

265*

266

267

268

269*

270*

271*

272*

273*

274*

275*

276*

277*

278*

279*

280*

281*

282*

283*

284*

285*

286*


59/99

287*

288*

289*

290*

291*

292*293*

294*

295*

296*

297*

298*

299*

300*

301*

302*

303*

304*

317

320

321

322*

323*

324*

325*

326


60/99

327

328


61/99

PQRS N NQF Number Measure Title & Description

1 59 Diabetes Mellitus: Hemoglobin A1c Poor Control

2 64 Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control

3 61 Diabetes Mellitus: High Blood Pressure Control

5 81 Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin

6 67 Coronary Artery Disease (CAD): Antiplatelet Therapy

7 70 Coronary Artery Disease (CAD): Beta-Blocker Therapy- Prior Myocardial Infa8 83 Individual Measures Reporting: Heart Failure: Beta-Blocker Therapy for Left

9 105 Major Depressive Disorder (MDD): Antidepressant Medication During Acute

12 86 Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation

14 87 Age-Related Macular Degeneration (AMD): Dilated Macular Examination

18 88 Diabetic Retinopathy: Documentation of Presence or Absence of Macular Ed

19 89 Diabetic Retinopathy: Communication with the Physician Managing Ongoin

20 270 Perioperative Care: Timing of Prophylactic Parenteral Antibiotic Ordering

21 268 Perioperative Care: Selection of Prophylactic Antibiotic First OR Second Ge

22 271 Perioperative Care: Discontinuation of Prophylactic Parenteral Antibiotics (N

23 239 Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indi

24 45 Osteoporosis: Communication with the Physician Managing On-going Care P

28 92 Aspirin at Arrival for Acute Myocardial Infarction (AMI)

30 269 Perioperative Care: Timely Administration of Prophylactic Parenteral Antibio

31 420 Stroke and Stroke Rehabilitation: Deep Vein Thrombosis (DVT) Prophylaxis f

32 325 Stroke and Stroke Rehabilitation: Discharged on Antithrombotic Therapy

33 241 Stroke and Stroke Rehabilitation: Anticoagulant Therapy Prescribed for Atria

35 243 Stroke and Stroke Rehabilitation: Screening for Dysphagia

36 244 Stroke and Stroke Rehabilitation: Rehabilitation Services Ordered

39 46 Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older

40 45 Osteoporosis: Management Following Fracture of Hip, Spine or Distal Radiu

41 49 Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years a43 516 Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA

44 235 Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients

45 637 Perioperative Care: Discontinuation of Prophylactic Parenteral Antibiotics (C

46 97 Medication Reconciliation

47 326 Advance Care Plan

48 98 Urinary Incontinence: Assessment of Presence or Absence of Urinary Inconti

49 99 Urinary Incontinence: Characterization of Urinary Incontinence in Women A

50 100 Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged

51 91 Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation

52 102 Chronic Obstructive Pulmonary Disease (COPD): Bronchodilator Therapy

53 47 Asthma: Pharmacologic Therapy for Persistent Asthma Ambulatory Care S

54 90 Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for Non-

55 93 Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for Sync

56 232 Emergency Medicine: Community-Acquired Pneumonia (CAP): Vital Signs

59 96 Emergency Medicine: Community-Acquired Pneumonia (CAP): Empiric Antib

64 1 Asthma: Assessment of Asthma Control Ambulatory Care Setting

65 69 Appropriate Treatment for Children with Upper Respiratory Infection (URI)

66 2 Appropriate Testing for Children with Pharyngitis


62/99

67 377 Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseli

68 378 Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stor

69 380 Hematology: Multiple Myeloma: Treatment with Bisphosphonates

70 379 Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry

71 387 Breast Cancer: Hormonal Therapy for Stage IC - IIIC Estrogen Receptor/Prog

72 385 Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients

76 464 Prevention of Catheter-Related Bloodstream Infections (CRBSI): Central Ven*81 323 Adult Kidney Disease: Hemodialysis Adequacy: Solute

*82 321 Adult Kidney Disease: Peritoneal Dialysis Adequacy: Solute

*83 393 Hepatitis C: Testing for Chronic Hepatitis C Confirmation of Hepatitis C Vir

84 395 Hepatitis C: Ribonucleic Acid (RNA) Testing Before Initiating Treatment

85 396 Hepatitis C: HCV Genotype Testing Prior to Treatment

86 397 Hepatitis C: Antiviral Treatment Prescribed

87 398 Hepatitis C: HCV Ribonucleic Acid (RNA) Testing at Week 12 of Treatment

89 401 Hepatitis C: Counseling Regarding Risk of Alcohol Consumption

90 394 Hepatitis C: Counseling Regarding Use of Contraception Prior to Antiviral Th

91 653 Acute Otitis Externa (AOE): Topical Therapy

93 654 Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy Avoidance of I

99 391 Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor)

100 392 Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tum

102 389 Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Pr

104 390 Prostate Cancer: Adjuvant Hormonal Therapy for High Risk Prostate Cancer

106 103 Adult Major Depressive Disorder (MDD): Comprehensive Diagnostic Evaluati

107 104 Adult Major Depressive Disorder (MDD): Suicide Risk Assessment

108 54 Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug (DMARD

109 50 Osteoarthritis (OA): Function and Pain Assessment

110 41 Preventive Care and Screening: Influenza Immunization

111 43 Preventive Care and Screening: Pneumococcal Vaccination for Patients 65 Y112 31 Preventive Care and Screening: Breast Cancer Screening

113 34 Preventive Care and Screening: Colorectal Cancer Screening

116 58 Antibiotic Treatment for Adults with Acute Bronchitis: Avoidance of Inappro

117 55 Diabetes Mellitus: Dilated Eye Exam

118 66 Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibi

119 62 Diabetes: Medical Attention for Nephropathy

121 AQA Adult Kidney Disease: LaboratoryTesting (Lipid Profile)

122 AQA Adult Kidney Disease: Blood Pressure Management

123 AQA Adult Kidney Disease: Patients On Erythropoiesis-Stimulating Agent (ESA) -

126 417 Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy N

127 416 Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention Evaluati

128 421 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follo

130 419 Documentation of Current Medications in the Medical Record

131 420 Pain Assessment and Follow-Up

134 418 Preventive Care and Screening: Screening for Clinical Depression and Follow

137 650 Melanoma: Continuity of Care Recall System

138 561 Melanoma: Coordination of Care

140 566 Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Suppl

141 563 Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (I


63/99

142 51 Osteoarthritis (OA): Assessment for Use of Anti-Inflammatory or Analgesic

*143 384 Oncology: Medical and Radiation Pain Intensity Quantified

*144 383 Oncology: Medical and Radiation Plan of Care for Pain

145 510 Radiology: Exposure Time Reported for Procedures Using Fluoroscopy

146 508 Radiology: Inappropriate Use of Probably Benign Assessment Category in

147 511 Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients

148 322 Back Pain: Initial Visit149 319 Back Pain: Physical Exam

150 315 Back Pain: Advice for Normal Activities

151 313 Back Pain: Advice Against Bed Rest

154 AQA Falls: Risk Assessment

155 AQA Falls: Plan of Care

156 382 Oncology: Radiation Dose Limits to Normal Tissues

157 455 Thoracic Surgery: Recording of Clinical Stage Prior to Lung Cancer or Esopha

*159 404 HIV/AIDS: CD4+ Cell Count or CD4+ Percentage

*160 405 Individual Measures Reporting: HIV/AIDS: Pneumocystis Jiroveci Pneumonia

*160 405 Measures Group Reporting: HIV/AIDS: Pneumocystis Jiroveci Pneumonia (P

*161 406 Individual Measures Reporting: HIV/AIDS: Adolescent and Adult Patients wit

*161 406 Measures Group Reporting: HIV/AIDS: Adolescent and Adult Patients with HI

*162 407 Individual Measures Reporting: HIV/AIDS: HIV RNA Control After Six Months

*162 407 Measures Group Reporting: HIV/AIDS: HIV RNA Control After Six Months of

163 56 Diabetes Mellitus: Foot Exam

*164 129 Coronary Artery Bypass Graft (CABG): Prolonged Intubation

*165 130 Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate

*166 131 Coronary Artery Bypass Graft (CABG): Stroke

*167 114 Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure

*168 115 Coronary Artery Bypass Graft (CABG): Surgical Re-exploration

*169 237 Coronary Artery Bypass Graft (CABG): Antiplatelet Medications at Discharge*170 238 Coronary Artery Bypass Graft (CABG): Beta-Blockers Administered at Discha

*171 118 Coronary Artery Bypass Graft (CABG): Anti-Lipid Treatment at Discharge

172 259 Hemodialysis Vascular Access Decision-Making by Surgeon to Maximize Plac

173 AQA Preventive Care and Screening: Unhealthy Alcohol Use Screening

176 AQA Rheumatoid Arthritis (RA): Tuberculosis Screening

177 AQA Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity

178 AQA Rheumatoid Arthritis (RA): Functional Status Assessment

179 AQA Rheumatoid Arthritis (RA): Assessment and Classification of Disease Progno

180 AQA Rheumatoid Arthritis (RA): Glucocorticoid Management

181 AQA Elder Maltreatment Screen and Follow-Up Plan

182 AQA Functional Outcome Assessment

183 399 Hepatitis C: Hepatitis A Vaccination in Patients with HCV

184 400 Hepatitis C: Hepatitis B Vaccination in Patients with HCV

185 659 Endoscopy & Polyp Surveillance: Colonoscopy Interval for Patients with a Hi

*187 437 Stroke and Stroke Rehabilitation: Thrombolytic Therapy

188 N/A Referral for Otologic Evaluation for Patients with Congenital or Traumatic D

*191 565 Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract S

*192 564 Cataracts: Complications within 30 Days Following Cataract Surgery Requirin

193 454 Perioperative Temperature Management


64/99

194 386 Oncology: Cancer Stage Documented

195 507 Radiology: Stenosis Measurement in Carotid Imaging Studies

*197 74 Coronary Artery Disease (CAD): Lipid Control

*198 79 Heart Failure: Left Ventricular Ejection Fraction (LVEF) Assessment

201 73 Ischemic Vascular Disease (IVD): Blood Pressure Management

204 68 Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic

*205 409 HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia and Gonor*208 410 HIV/AIDS: Sexually Transmitted Disease Screening for Syphilis

*209 445 Functional Communication Measure - Spoken Language Comprehension

*210 449 Functional Communication Measure - Attention

*211 448 Functional Communication Measure - Memory

*212 447 Functional Communication Measure - Motor Speech

*213 446 Functional Communication Measure - Reading

*214 444 Functional Communication Measure - Spoken Language Expression

*215 442 Functional Communication Measure - Writing

*216 443 Functional Communication Measure - Swallowing

*217 422 Functional Deficit: Change in Risk-Adjusted Functional Status for Patients wit




221 426 Functional Deficit: Change in Risk-Adjusted Functional Status for Patients wit



*224 562 Melanoma: Overutilization of Imaging Studies in Melanoma

225 509 Radiology: Reminder System for Mammograms

226 28 Preventive Care and Screening: Tobacco Use: Screening and Cessation Interv

*228 N/A Heart Failure (HF): Left Ventricular Function (LVF) Testing

231 N/A Asthma: Tobacco Use: Screening - Ambulatory Care Setting232 N/A Asthma: Tobacco Use: Intervention - Ambulatory Care Setting

*233 457 Thoracic Surgery: Recording of Performance Status Prior to Lung or Esophag

*234 458 Thoracic Surgery: Pulmonary Function Tests Before Major Anatomic Lung Re

236 18 Hypertension (HTN): Controlling High Blood Pressure

241 75 Ischemic Vascular Disease (IVD): Complete Lipid Panel and Low Density Lipo

242* N/A Individual Reporting via Registry: Coronary Artery Disease (CAD): Symptom

242* N/A Measures Group Reporting: Coronary Artery Disease (CAD): Symptom Mana

243* 643 Cardiac Rehabilitation Patient Referral from an Outpatient Setting

244* N/A Hypertension: Blood Pressure Management

245 AQA Chronic Wound Care: Use of Wound Surface Culture Technique in Patients

246 AQA Chronic Wound Care: Use of Wet to Dry Dressings in Patients with Chronic S

247 AQA Substance Use Disorders: Counseling Regarding Psychosocial and Pharmacol

248 AQA Substance Use Disorders: Screening for Depression Among Patients with Su

249 N/A Barrett's Esophagus

250 N/A Radical Prostatectomy Pathology Reporting

251 N/A Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor

252 503 Anticoagulation for Acute Pulmonary Embolus Patients

254 651 Ultrasound Determination of Pregnancy Location for Pregnant Patients with

255 652 Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of F


65/99

256* N/A Surveillance after Endovascular Abdominal Aortic Aneurysm Repair (EVAR)

257* N/A Statin Therapy at Discharge after Lower Extremity Bypass (LEB)

258* N/A Rate of Open Repair of Small or Moderate Non-Ruptured Abdominal Aortic

259* N/A Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ru

260* N/A Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without

261 N/A Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness

262 N/A Image Confirmation of Successful Excision of ImageLocalized Breast Lesion263 N/A Preoperative Diagnosis of Breast Cancer

264* N/A Sentinel Lymph Node Biopsy for Invasive Breast Cancer

265* 645 Biopsy Follow-Up

266 N/A Epilepsy: Seizure Type(s) and Current Seizure Frequency(ies)

267 N/A Epilepsy: Documentation of Etiology of Epilepsy or Epilepsy Syndrome

268 N/A Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy

269* N/A Inflammatory Bowel Disease (IBD): Type, Anatomic Location and Activity All

270* N/A Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Sparing

271* N/A Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related I

272* N/A Inflammatory Bowel Disease (IBD): Preventive Care: Influenza Immunization

273* N/A Inflammatory Bowel Disease (IBD): Preventive Care: Pneumococcal Immuniz

274* N/A Inflammatory Bowel Disease (IBD): Testing for Latent Tuberculosis (TB) Befo

275* N/A Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) St

276* N/A Sleep Apnea: Assessment of Sleep Symptoms

277* N/A Sleep Apnea: Severity Assessment at Initial Diagnosis

278* N/A Sleep Apnea: Positive Airway Pressure Therapy Prescribed

279* N/A Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy

280* N/A Dementia: Staging of Dementia

281* N/A Dementia: Cognitive Assessment

282* N/A Dementia: Functional Status Assessment

283* N/A Dementia: Neuropsychiatric Symptom Assessment284* N/A Dementia: Management of Neuropsychiatric Symptoms

285* N/A Dementia: Screening for Depressive Symptoms

286* N/A Dementia: Counseling Regarding Safety Concerns

287* N/A Dementia: Counseling Regarding Risks of Driving

288* N/A Dementia: Caregiver Education and Support

289* N/A Parkinsons Disease: Annual Parkinsons Disease Diagnosis Review

290* N/A Parkinsons Disease: Psychiatric Disorders or Disturbances Assessment

291* N/A Parkinsons Disease: Cognitive Impairment or Dysfunction Assessment

292* N/A Parkinsons Disease: Querying about Sleep Disturbances

293* N/A Parkinsons Disease: Rehabilitative Therapy Options

294* N/A Parkinsons Disease: Parkinsons Disease Medical and Surgical Treatment Op

295* N/A Hypertension: Appropriate Use of Aspirin or Other Anththrombotic Therapy

296* N/A Hypertension: Complete Lipid Profile

297* N/A Hypertension: Urine Protein Test

298* N/A Hypertension: Annual Serum Creatinine Test

299* N/A Hypertension: Diabetes Mellitus Screening Test

300* N/A Hypertension: Blood Pressure Control

301* N/A Hypertension: Low Density Lipoprotein (LDL-C) Control

302* N/A Hypertension: Dietary and Physical Activity Modifications Appropriately Pre


66/99

303* N/A Cataracts: Improvement in Patients Visual Function within 90 Days Followin

304* N/A Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery

317 N/A Preventive Care and Screening: Screening for High Blood Pressure and Follo

320 658 Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal C

321 493 Participation by a Hospital, Physician or Other Clinician in a Systematic Clinic

322* 670 Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative

323* 671 Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testin324* 672 Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asy

325* N/A Adult Major Depressive Disorder (MDD): Coordination of Care of Patients wi

326 1525 Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy

327 N/A Pediatric Kidney Disease: Adequacy of Volume Management

328 1667 Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Leve


67/99

Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)

ction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%)entricular Systolic Dysfunction (LVSD)

Phase for Patients with MDD

ema and Level of Severity of Retinopathy

Diabetes Care

hysician

neration Cephalosporin

on-Cardiac Procedures)

icated in ALL Patients)

ost-Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older

tics

r Ischemic Stroke or Intracranial Hemorrhage

l Fibrillation (AF) at Discharge

for Men and Women Aged 50 Years and Older

nd Older) in Patients with Isolated CABG Surgery

with Isolated CABG Surgery

ardiac Procedures)

nence in Women Aged 65 Years and Older

ed 65 Years and Older

65 Years and Older

tting

raumatic Chest Pain

pe

iotic


68/99

ne Cytogenetic Testing Performed on Bone Marrow

es in Patients Receiving Erythropoietin Therapy

sterone Receptor (ER/PR) Positive Breast Cancer

ous Catheter (CVC) Insertion Protocol

mia

rapy

appropriate Use

and pN Category (Regional Lymph Nodes) with Histologic Grade

or) and pN Category (Regional Lymph Nodes) with Histologic Grade

ostate Cancer Patients

atients

on: Diagnosis and Severity

) Therapy

ars and Older

priate Use

or or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (L

emoglobin Level > 12.0 g/dL

urological Evaluation

on of Footwear

-Up

-Up Plan

ement

P) by 15% OR Documentation of a Plan of Care


69/99

ver-the-Counter (OTC) Medications

ammography Screening

ndergoing Bone Scintigraphy

eal Cancer Resection

(PCP) Prophylaxis

P) Prophylaxis

h HIV/AIDS Who Are Prescribed Potent Antiretroviral Therapy

IV/AIDS Who Are Prescribed Potent Antiretroviral Therapy

of Potent Antiretroviral Therapy

otent Antiretroviral Therapy

Pqrs Nqf Join Table: round 1 of 8

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