2017 MIPS Quality Measures

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ID Name Type High Priority
CAHPS_1 CAHPS for MIPS SSM: Getting Timely Care, Appointments and Information Patient Engagement and Experience Yes
CAHPS_2 CAHPS for MIPS SSM: How Well Providers Communicate Patient Engagement and Experience Yes
CAHPS_3 CAHPS for MIPS SSM: Patient's Rating of Provider Patient Engagement and Experience Yes
CAHPS_4 CAHPS for MIPS SSM: Access to Specialists Patient Engagement and Experience Yes
CAHPS_5 CAHPS for MIPS SSM: Health Promotion and Education Patient Engagement and Experience Yes
CAHPS_6 CAHPS for MIPS SSM: Shared Decision-Making Patient Engagement and Experience Yes
CAHPS_7 CAHPS for MIPS SSM: Health Status and Functional Status Patient Engagement and Experience Yes
CAHPS_8 CAHPS for MIPS SSM: Care Coordination Patient Engagement and Experience Yes
CAHPS_9 CAHPS for MIPS SSM: Courteous and Helpful Office Staff Patient Engagement and Experience Yes
CAHPS_10 CAHPS for MIPS SSM: Helping You Take Medications as Directed Patient Engagement and Experience Yes
CAHPS_11 CAHPS for MIPS SSM: Stewardship of Patient Resources Patient Engagement and Experience Yes
CAHPS_12 CAHPS for MIPS SSM: Between Visit Communication Patient Engagement and Experience Yes
DM_COMPOSITE Diabetes Mellitus (DM) Composite (All or Nothing Scoring) Intermediate Outcome and Process Yes
093 Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy - Avoidance of Inappropriate Use Process Yes
091 Acute Otitis Externa (AOE): Topical Therapy Process Yes
366 ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication Process No
383 Adherence to Antipsychotic Medications For Individuals with Schizophrenia Intermediate Outcome Yes
122 Adult Kidney Disease: Blood Pressure Management Intermediate Outcome Yes
329 Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis Outcome Yes
330 Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days Outcome Yes
403 Adult Kidney Disease: Referral to Hospice Process Yes
325 Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions Process Yes
107 Adult Major Depressive Disorder (MDD): Suicide Risk Assessment Process No
384 Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery Outcome Yes
385 Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery Outcome Yes
331 Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse) Process Yes
332 Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use) Process Yes
333 Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse) Efficiency Yes
334 Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse) Efficiency Yes
439 Age Appropriate Screening Colonoscopy Efficiency Yes
140 Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement Process No
014 Age-Related Macular Degeneration (AMD): Dilated Macular Examination Process No
458 All-cause Hospital Readmission Outcome No
386 Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences Process Yes
354 Anastomotic Leak Intervention Outcome Yes
404 Anesthesiology Smoking Abstinence Intermediate Outcome Yes
387 Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users Process No
009 Anti-Depressant Medication Management Process No
421 Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal Process No
405 Appropriate Follow-up Imaging for Incidental Abdominal Lesions Process Yes
406 Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients Process Yes
320 Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients Process Yes
066 Appropriate Testing for Children with Pharyngitis Process Yes
065 Appropriate Treatment for Children with Upper Respiratory Infection (URI) Process Yes
407 Appropriate Treatment of Methicillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia Process Yes
448 Appropriate Workup Prior to Endometrial Ablation Process Yes
326 Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy Process No
116 Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis Process Yes
249 Barrett's Esophagus Process No
440 Basal Cell Carcinoma (BCC)/Squamous Cell Carcinoma: Biopsy Reporting Time - Pathologist to Clinician Process Yes
265 Biopsy Follow-Up Process Yes
367 Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance use Process No
099 Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade Process No
112 Breast Cancer Screening Process No
321 CAHPS for MIPS Clinician/Group Survey Patient Engagement and Experience Yes
243 Cardiac Rehabilitation Patient Referral from an Outpatient Setting Process Yes
322 Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low Risk Surgery Patients Efficiency Yes
323 Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI) Efficiency Yes
324 Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low-Risk Patients Efficiency Yes
047 Care Plan Process Yes
191 Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery Outcome Yes
192 Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures Outcome Yes
303 Cataracts: Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery Outcome Yes
304 Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery Outcome Yes
389 Cataract Surgery: Difference Between Planned and Final Refraction Outcome Yes
388 Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy) Outcome Yes
309 Cervical Cancer Screening Process No
382 Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment Process Yes
240 Childhood Immunization Status Process No
378 Children Who Have Dental Decay or Cavities Outcome Yes
447 Chlamydia Screening and Follow Up Process No
310 Chlamydia Screening for Women Process No
052 Chronic Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled Bronchodilator Therapy Process No
051 Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation Process No
409 Clinical Outcome Post Endovascular Stroke Treatment Outcome Yes
374 Closing the Referral Loop: Receipt of Specialist Report Process Yes
185 Colonoscopy Interval for Patients with a History of Adenomatous Polyps - Avoidance of Inappropriate Use Process Yes
100 Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade Process No
113 Colorectal Cancer Screening Process No
024 Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older Process Yes
236 Controlling High Blood Pressure Intermediate Outcome Yes
165 Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate Outcome Yes
167 Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure Outcome Yes
044 Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery Process No
164 Coronary Artery Bypass Graft (CABG): Prolonged Intubation Outcome Yes
166 Coronary Artery Bypass Graft (CABG): Stroke Outcome Yes
168 Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration Outcome Yes
043 Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery Process No
118 Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%) Process No
006 Coronary Artery Disease (CAD): Antiplatelet Therapy Process No
007 Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%) Process No
288 Dementia: Caregiver Education and Support Process Yes
281 Dementia: Cognitive Assessment Process No
286 Dementia: Counseling Regarding Safety Concerns Process Yes
282 Dementia: Functional Status Assessment Process No
284 Dementia: Management of Neuropsychiatric Symptoms Process No
283 Dementia: Neuropsychiatric Symptom Assessment Process No
411 Depression Remission at Six Months Outcome Yes
370 Depression Remission at Twelve Months Outcome Yes
371 Depression Utilization of the PHQ-9 Tool Process No
117 Diabetes: Eye Exam Process No
163 Diabetes: Foot Exam Process No
001 Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) Intermediate Outcome Yes
119 Diabetes: Medical Attention for Nephropathy Process No
126 Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy - Neurological Evaluation Process No
127 Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention - Evaluation of Footwear Process No
019 Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care Process Yes
018 Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy Process No
130 Documentation of Current Medications in the Medical Record Process Yes
412 Documentation of Signed Opioid Treatment Agreement Process No
413 Door to Puncture Time for Endovascular Stroke Treatment Intermediate Outcome Yes
181 Elder Maltreatment Screen and Follow-Up Plan Process Yes
415 Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older Efficiency Yes
416 Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years Efficiency Yes
268 Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy Process No
414 Evaluation or Interview for Risk of Opioid Misuse Process No
155 Falls: Plan of Care Process Yes
154 Falls: Risk Assessment Process Yes
318 Falls: Screening for Future Fall Risk Process Yes
391 Follow-Up After Hospitalization for Mental Illness (FUH) Process Yes
182 Functional Outcome Assessment Process Yes
376 Functional Status Assessment for Total Hip Replacement Process Yes
375 Functional Status Assessment for Total Knee Replacement Process Yes
377 Functional Status Assessments for Congestive Heart Failure Process Yes
222 Functional Status Change for Patients with Elbow, Wrist or Hand Impairments Outcome Yes
219 Functional Status Change for Patients with Foot or Ankle Impairments Outcome Yes
223 Functional Status Change for Patients with General Orthopaedic Impairments Outcome Yes
218 Functional Status Change for Patients with Hip Impairments Outcome Yes
217 Functional Status Change for Patients with Knee Impairments Outcome Yes
220 Functional Status Change for Patients with Lumbar Impairments Outcome Yes
221 Functional Status Change for Patients with Shoulder Impairments Outcome Yes
005 Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) Process No
008 Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) Process No
070 Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry Process No
069 Hematology: Multiple Myeloma: Treatment with Bisphosphonates Process No
067 Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow Process No
068 Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy Process No
390 Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options Process Yes
401 Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis Process No
449 HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment with HER2-Targeted Therapies Process Yes
160 HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis Process No
205 HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis Process No
340 HIV Medical Visit Frequency Process Yes
338 HIV Viral Load Suppression Outcome Yes
392 HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation Outcome Yes
348 HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate Outcome Yes
393 HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision Outcome Yes
373 Hypertension: Improvement in Blood Pressure Intermediate Outcome Yes
262 Image Confirmation of Successful Excision of Image-Localized Breast Lesion Process Yes
394 Immunizations for Adolescents Process No
275 Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy Process No
271 Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury - Bone Loss Assessment Process No
305 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment Process No
441 Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control) Intermediate Outcome Yes
204 Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet Process No
451 KRAS Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy Process No
395 Lung Cancer Reporting (Biopsy/Cytology Specimens) Outcome Yes
396 Lung Cancer Reporting (Resection Specimens) Outcome Yes
372 Maternal Depression Screening Process No
335 Maternity Care: Elective Delivery or Early Induction Without Medical Indication at >= 37 and < 39 Weeks (Overuse) Outcome Yes
336 Maternity Care: Post-Partum Follow-Up and Care Coordination Process Yes
444 Medication Management for People with Asthma Process Yes
046 Medication Reconciliation Post-Discharge Process Yes
137 Melanoma: Continuity of Care - Recall System Structure Yes
138 Melanoma: Coordination of Care Process Yes
224 Melanoma: Overutilization of Imaging Studies in Melanoma Process Yes
397 Melanoma Reporting Outcome Yes
443 Non-Recommended Cervical Cancer Screening in Adolescent Females Process Yes
147 Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy Process Yes
143 Oncology: Medical and Radiation - Pain Intensity Quantified Process Yes
144 Oncology: Medical and Radiation - Plan of Care for Pain Process Yes
156 Oncology: Radiation Dose Limits to Normal Tissues Process Yes
400 One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk Process No
446 Operative Mortality Stratified by the Five STS-EACTS Mortality Categories Outcome Yes
408 Opioid Therapy Follow-up Evaluation Process No
398 Optimal Asthma Control Outcome Yes
364 Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines Process Yes
362 Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison Purposes Structure Yes
360 Optimizing Patient Exposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies Process Yes
361 Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry Structure Yes
363 Optimizing Patient Exposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Studies Through a Secure, Authorized, Media-Free, Shared Archive Structure Yes
359 Optimizing Patient Exposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging Description Process Yes
109 Osteoarthritis (OA): Function and Pain Assessment Process Yes
418 Osteoporosis Management in Women Who Had a Fracture Process No
419 Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination Efficiency Yes
131 Pain Assessment and Follow-Up Process Yes
342 Pain Brought Under Control Within 48 Hours Outcome Yes
291 Parkinson's Disease: Cognitive Impairment or Dysfunction Assessment Process No
294 Parkinson's Disease: Parkinson's Disease Medical and Surgical Treatment Options Reviewed Process Yes
290 Parkinson's Disease: Psychiatric Symptoms Assessment for Patients with Parkinson's Disease Process No
293 Parkinson's Disease: Rehabilitative Therapy Options Process Yes
358 Patient-Centered Surgical Risk Assessment and Communication Process Yes
452 Patients with Metastatic Colorectal Cancer and KRAS Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies Process Yes
327 Pediatric Kidney Disease: Adequacy of Volume Management Process Yes
328 Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level < 10 g/dL Intermediate Outcome Yes
428 Pelvic Organ Prolapse: Preoperative Assessment of Occult Stress Urinary Incontinence Process No
429 Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy Process Yes
422 Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury Process Yes
423 Perioperative Anti-platelet Therapy for Patients Undergoing Carotid Endarterectomy Process No
021 Perioperative Care: Selection of Prophylactic Antibiotic - First OR Second Generation Cephalosporin Process Yes
023 Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) Process Yes
424 Perioperative Temperature Management Outcome Yes
442 Persistence of Beta-Blocker Treatment After a Heart Attack Process No
425 Photodocumentation of Cecal Intubation Process No
111 Pneumococcal Vaccination Status for Older Adults Process No
426 Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU) Process Yes
427 Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU) Process Yes
369 Pregnant women that had HBsAg testing Process No
263 Preoperative Diagnosis of Breast Cancer Process No
076 Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections Process Yes
430 Prevention of Post-Operative Nausea and Vomiting (PONV) - Combination Therapy Process Yes
128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan Process No
110 Preventive Care and Screening: Influenza Immunization Process No
134 Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan Process No
317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented Process No
226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Process No
431 Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling Process No
379 Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists Process No
012 Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation Process No
141 Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care Outcome Yes
457 Proportion Admitted to Hospice for less than 3 days Outcome Yes
455 Proportion Admitted to the Intensive Care Unit (ICU) in the Last 30 Days of Life Outcome Yes
456 Proportion Not Admitted To Hospice Process Yes
432 Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair Outcome Yes
433 Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair Outcome Yes
434 Proportion of Patients Sustaining a Ureter Injury at the Time of any Pelvic Organ Prolapse Repair Outcome Yes
454 Proportion of Patients who Died from Cancer with more than One Emergency Department Visit in the Last 30 Days of Life Outcome Yes
453 Proportion Receiving Chemotherapy in the Last 14 Days of Life Process Yes
104 Prostate Cancer: Adjuvant Hormonal Therapy for High Risk or Very High Risk Prostate Cancer Process No
102 Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients Process Yes
410 Psoriasis: Clinical Response to Oral Systemic or Biologic Medications Outcome Yes
435 Quality of Life Assessment For Patients With Primary Headache Disorders Outcome Yes
251 Quantitative Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) for Breast Cancer Patients Structure No
436 Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques Process No
250 Radical Prostatectomy Pathology Reporting Process No
145 Radiology: Exposure Dose or Time Reported for Procedures Using Fluoroscopy Process Yes
146 Radiology: Inappropriate Use of "Probably Benign" Assessment Category in Screening Mammograms Process Yes
225 Radiology: Reminder System for Screening Mammograms Structure Yes
195 Radiology: Stenosis Measurement in Carotid Imaging Reports Process No
344 Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2) Outcome Yes
260 Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2) Outcome Yes
347 Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) Who Die While in Hospital Outcome Yes
259 Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post Operative Day #2) Outcome Yes
417 Rate of Open Repair of Small or Moderate Abdominal Aortic Aneurysms (AAA) Where Patients Are Discharged Alive Outcome Yes
258 Rate of Open Repair of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7) Outcome Yes
345 Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS) Outcome Yes
346 Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Endarterectomy (CEA) Outcome Yes
437 Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure Outcome Yes
261 Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness Process Yes
179 Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis Process No
178 Rheumatoid Arthritis (RA): Functional Status Assessment Process No
180 Rheumatoid Arthritis (RA): Glucocorticoid Management Process No
177 Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity Process No
176 Rheumatoid Arthritis (RA): Tuberculosis Screening Process No
255 Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure Process No
445 Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG) Outcome Yes
343 Screening Colonoscopy Adenoma Detection Rate Outcome Yes
039 Screening for Osteoporosis for Women Aged 65-85 Years of Age Process No
264 Sentinel Lymph Node Biopsy for Invasive Breast Cancer Process No
279 Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy Process No
276 Sleep Apnea: Assessment of Sleep Symptoms Process No
278 Sleep Apnea: Positive Airway Pressure Therapy Prescribed Process No
277 Sleep Apnea: Severity Assessment at Initial Diagnosis Process No
257 Statin Therapy at Discharge after Lower Extremity Bypass (LEB) Process No
438 Statin Therapy for the Prevention and Treatment of Cardiovascular Disease Process No
032 Stroke and Stroke Rehabilitation: Discharged on Antithrombotic Therapy Process No
187 Stroke and Stroke Rehabilitation: Thrombolytic Therapy Process No
357 Surgical Site Infection (SSI) Outcome Yes
402 Tobacco Use and Help with Quitting Among Adolescents Process No
353 Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report Process Yes
352 Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet Process Yes
350 Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy Process Yes
351 Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation Process Yes
450 Trastuzumab Received By Patients With AJCC Stage I (T1c) - III And HER2 Positive Breast Cancer Receiving Adjuvant Chemotherapy Process Yes
337 Tuberculosis (TB) Prevention for Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier Process No
254 Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain Process No
356 Unplanned Hospital Readmission within 30 Days of Principal Procedure Outcome Yes
355 Unplanned Reoperation within the 30 Day Postoperative Period Outcome Yes
048 Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older Process No
050 Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older Process Yes
238 Use of High-Risk Medications in the Elderly Process Yes
312 Use of Imaging Studies for Low Back Pain Process Yes
420 Varicose Vein Treatment with Saphenous Ablation: Outcome Survey Outcome No
239 Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents Process No

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