Report Summary

Report Released
2020-10-13 10:16:49 -0400
Vendor
test
Product
All
Bundle
Cypress bundle for the 2021 Reporting/Performance period (eCQM value sets as of May 7, 2020) v2020.0.3
Certification Edition
2015 Edition Cures Update
Cypress Version
6.0.0

Measure Tests

Measure Name Submeasures C1 QRDA Category I C2 QRDA Category III C3 QRDA Category I C3 QRDA Category III
CMS111v9 Median time (in minutes) from admit decision time to time of departure from the emergency department for emergency department patients admitted to inpatient status
  • PopulationSet_1
  • PopulationSet_1_Stratification_1
  • PopulationSet_1_Stratification_2
 failing failing failing
CMS9v9 PC-05 Exclusive breast milk feeding during the newborn's entire hospitalization. The measure is reported as an overall rate which includes all newborns that were exclusively fed breast milk during the entire hospitalization. failing failing failing
CMS50v9 Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred failing failing failing
CMS142v9 Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months failing failing failing
CMS2v10 Percentage of patients aged 12 years and older screened for depression on the date of the encounter or up to 14 days prior to the date of the encounter using an age-appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the eligible encounter failing failing passing
CMS22v9 Percentage of patient visits for patients aged 18 years and older seen during the measurement period who were screened for high blood pressure AND a recommended follow-up plan is documented, as indicated, if blood pressure is pre-hypertensive or hypertensive failing failing failing
CMS69v9 Percentage of patients aged 18 years and older with a BMI documented during the current encounter or within the previous twelve months AND who had a follow-up plan documented if most recent BMI was outside of normal parameters failing failing failing
CMS75v9 Percentage of children, 6 months - 20 years of age, who have had tooth decay or cavities during the measurement period failing failing failing
CMS117v9 Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three or four H influenza type B (Hib); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday failing failing failing
CMS127v9 Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine failing failing failing
CMS138v9 Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 12 months AND who received tobacco cessation intervention if identified as a tobacco user Three rates are reported: a. Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 12 months b. Percentage of patients aged 18 years and older who were identified as a tobacco user who received tobacco cessation intervention c. Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 12 months AND who received tobacco cessation intervention if identified as a tobacco user
  • PopulationSet_1
  • PopulationSet_2
  • PopulationSet_3
 failing failing failing
CMS147v10 Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization failing failing failing
CMS153v9 Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period
  • PopulationSet_1
  • PopulationSet_1_Stratification_1
  • PopulationSet_1_Stratification_2
 failing failing failing
CMS155v9 Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported. - Percentage of patients with height, weight, and body mass index (BMI) percentile documentation - Percentage of patients with counseling for nutrition - Percentage of patients with counseling for physical activity
  • PopulationSet_1
  • PopulationSet_1_Stratification_1
  • PopulationSet_1_Stratification_2
  • PopulationSet_2
  • PopulationSet_2_Stratification_1
  • PopulationSet_2_Stratification_2
  • PopulationSet_3
  • PopulationSet_3_Stratification_1
  • PopulationSet_3_Stratification_2
 failing failing failing
CMS349v3 Percentage of patients aged 15-65 at the start of the measurement period who were between 15-65 years old when tested for HIV failing failing failing
CMS74v10 Percentage of children, 6 months - 20 years of age, who received a fluoride varnish application during the measurement period
  • PopulationSet_1
  • PopulationSet_1_Stratification_1
  • PopulationSet_1_Stratification_2
  • PopulationSet_1_Stratification_3
 failing failing failing
CMS122v9 Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period failing failing failing
CMS124v9 Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria: * Women age 21-64 who had cervical cytology performed within the last 3 years * Women age 30-64 who had cervical human papillomavirus (HPV) testing performed within the last 5 years failing failing failing
CMS125v9 Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the Measurement Period failing failing failing
CMS128v9 Percentage of patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported. a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks). b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months).
  • PopulationSet_1
  • PopulationSet_2
 failing failing failing
CMS130v9 Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer failing failing failing
CMS131v9 Percentage of patients 18-75 years of age with diabetes and an active diagnosis of retinopathy overlapping the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or diabetics with no diagnosis of retinopathy overlapping the measurement period who had a retinal or dilated eye exam by an eye care professional during the measurement period or in the 12 months prior to the measurement period failing failing failing
CMS133v9 Percentage of cataract surgeries for patients aged 18 and older with a diagnosis of uncomplicated cataract and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved in the operative eye within 90 days following the cataract surgery failing failing failing
CMS134v9 The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period failing failing failing
CMS135v9 Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB or ARNI therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge
  • PopulationSet_1
  • PopulationSet_2
 failing failing failing
CMS136v10 Percentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported. a. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase. b. Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.
  • PopulationSet_1
  • PopulationSet_2
 failing failing failing
CMS137v9 Percentage of patients 13 years of age and older with a new episode of alcohol or other drug abuse or (AOD) dependence who received the following. Two rates are reported. a. Percentage of patients who initiated treatment including either an intervention or medication for the treatment of AOD abuse or dependence within 14 days of the diagnosis b. Percentage of patients who engaged in ongoing treatment including two additional interventions or a medication for the treatment of AOD abuse or dependence within 34 days of the initiation visit. For patients who initiated treatment with a medication, at least one of the two engagement events must be a treatment intervention.
  • PopulationSet_1
  • PopulationSet_1_Stratification_1
  • PopulationSet_1_Stratification_2
  • PopulationSet_2
  • PopulationSet_2_Stratification_1
  • PopulationSet_2_Stratification_2
 failing failing failing
CMS143v9 Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more office visits within 12 months failing failing failing
CMS144v9 Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge
  • PopulationSet_1
  • PopulationSet_2
 failing failing failing
CMS145v9 Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12-month period who also have a prior MI or a current or prior LVEF <40% who were prescribed beta-blocker therapy
  • PopulationSet_1
  • PopulationSet_2
 failing failing failing
CMS149v9 Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period failing failing failing
CMS159v9 The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event.
  • PopulationSet_1
  • PopulationSet_1_Stratification_1
  • PopulationSet_1_Stratification_2
 failing failing failing
CMS161v9 All patient visits during which a new diagnosis of MDD or a new diagnosis of recurrent MDD was identified for patients aged 18 years and older with a suicide risk assessment completed during the visit failing failing failing
CMS165v9 Percentage of patients 18-85 years of age who had a diagnosis of hypertension overlapping the measurement period or the year prior to the measurement period, and whose most recent blood pressure was adequately controlled (<140/90mmHg) during the measurement period failing failing failing
CMS347v4 Percentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the measurement period: *Adults aged >= 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR *Adults aged >= 21 years who have ever had a fasting or direct low-density lipoprotein cholesterol (LDL-C) level >= 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia; OR *Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL
  • PopulationSet_1
  • PopulationSet_2
  • PopulationSet_3
 failing failing failing
CMS645v4 Patients determined as having prostate cancer who are currently starting or undergoing androgen deprivation therapy (ADT), for an anticipated period of 12 months or greater and who receive an initial bone density evaluation. The bone density evaluation must be prior to the start of ADT or within 3 months of the start of ADT. failing failing failing
CMS129v10 Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy who did not have a bone scan performed at any time since diagnosis of prostate cancer failing failing failing
CMS146v9 The percentage of episodes for patients 3 years and older with a diagnosis of pharyngitis that resulted in an antibiotic dispensing event and a group A streptococcus (strep) test
  • PopulationSet_1
  • PopulationSet_1_Stratification_1
  • PopulationSet_1_Stratification_2
  • PopulationSet_1_Stratification_3
 failing failing failing
CMS154v9 Percentage of episodes for patients 3 months of age and older with a diagnosis of upper respiratory infection (URI) that did not result in an antibiotic dispensing event.
  • PopulationSet_1
  • PopulationSet_1_Stratification_1
  • PopulationSet_1_Stratification_2
  • PopulationSet_1_Stratification_3
 failing failing failing
CMS249v3 Percentage of female patients 50 to 64 years of age without select risk factors for osteoporotic fracture who received an order for a dual-energy x-ray absorptiometry (DXA) scan during the measurement period failing failing failing
CMS68v10 Percentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter failing failing failing
CMS139v9 Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period failing failing failing
CMS156v9 Percentage of patients 65 years of age and older who were ordered at least two of the same high-risk medications. failing failing failing
CMS177v9 Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk failing failing failing
CMS56v9 Percentage of patients 18 years of age and older who received an elective primary total hip arthroplasty (THA) and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgery failing failing failing
CMS66v9 Percentage of patients 18 years of age and older who received an elective primary total knee arthroplasty (TKA) and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgery failing failing failing
CMS90v10 Percentage of patients 18 years of age and older with congestive heart failure who completed initial and follow-up patient-reported functional status assessments failing failing failing
CMS157v9 Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified
  • PopulationSet_1
  • PopulationSet_2
 failing failing failing
CMS771v2 Percentage of patients with an office visit within the measurement period and with a new diagnosis of clinically significant Benign Prostatic Hyperplasia who have International Prostate Symptoms Score (IPSS) or American Urological Association (AUA) Symptom Index (SI) documented at time of diagnosis and again 6-12 months later with an improvement of 3 points failing failing failing
CMS71v10 Ischemic stroke patients with atrial fibrillation/flutter who are prescribed or continuing to take anticoagulation therapy at hospital discharge failing failing failing
CMS72v9 Ischemic stroke patients administered antithrombotic therapy by the end of hospital day 2 failing failing failing
CMS104v9 Ischemic stroke patients prescribed or continuing to take antithrombotic therapy at hospital discharge failing failing failing
CMS105v9 Ischemic stroke patients who are prescribed or continuing to take statin medication at hospital discharge failing failing failing
CMS108v9 This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission failing failing failing
CMS190v9 This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after the initial admission (or transfer) to the Intensive Care Unit (ICU) or surgery end date for surgeries that start the day of or the day after ICU admission (or transfer) failing failing failing
CMS506v3 Proportion of inpatient hospitalizations for patients 18 years of age and older prescribed, or continued on, two or more opioids or an opioid and benzodiazepine concurrently at discharge failing failing failing
CMS529v1 This logic is intended to extract electronic clinical data. This is not an electronic clinical quality measure and this logic will not produce measure results. Instead, it will produce a file containing the data that CMS will link with administrative claims to risk adjust the Hybrid HWR outcome measure. It is designed to extract the first resulted set of vital signs and basic laboratory results obtained from encounters for adult Medicare Fee-For-Service patients admitted to acute care short stay hospitals. failing failing failing

C1 Record Sample

Data Criteria Verification Status
CMS22v9 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented Not Started
CMS108v9 Venous Thromboembolism Prophylaxis Not Started
CMS144v9 Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) Not Started
CMS147v10 Preventive Care and Screening: Influenza Immunization Not Started

C4 Filtering

Filters QRDA Category I QRDA Category III
Races: ["White (code: 2106-3)"]
Ethnicities: ["Not Hispanic or Latino (code: 2186-5)"]
 failing failing
Payers: [349]
Age: [{:Maximum=>4}]
 failing failing
Providers: [{:NPIs=>"1586110979"}, {:TINs=>"419839697"}, {:Addresses=>"64292 Erica Orchard Flats, North Katarinastad, TX, 79866, US"}]
 failing failing
Providers: [{:NPIs=>"1071632826"}, {:TINs=>"101844969"}]
 failing failing
Problems: ["SNOMEDCT codes in Anaphylactic Reaction to Hepatitis A Vaccine (code: 2.16.840.1.113883.3.464.1003.199.12.1026)"]
 failing failing

C1 - Capture and Export

C1 Record Sample

CMS22v9 Percentage of patient visits for patients aged 18 years and older seen during the measurement period who were screened for high blood pressure AND a recommended follow-up plan is documented, as indicated, if blood pressure is pre-hypertensive or hypertensive
Description Attribute
failing Intervention, Order: ReferraltoPrimaryCareorAlternateProvider reason
failing Physical Exam, Performed: Systolic blood pressure negationRationale
failing Laboratory Test, Order: LaboratoryTestsforHypertension negationRationale
failing Medication, Order: PharmacologicTherapyforHypertension negationRationale
failing Diagnostic Study, Order: EKG study negationRationale
failing Encounter, Performed: EncountertoScreenforBloodPressure relevantPeriod
failing Patient Characteristic Ethnicity: Ethnicity
failing Diagnosis: DiagnosisofHypertension prevalencePeriod
CMS144v9 Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge
Description Attribute
failing Medication, Discharge: BetaBlockerTherapyforLVSD negationRationale
failing Medication, Order: BetaBlockerTherapyforLVSD negationRationale
failing Diagnosis: LeftVentricularSystolicDysfunction severity
failing Patient Characteristic Sex: ONCAdministrativeSex
failing Medication, Active: BetaBlockerTherapyforLVSD relevantPeriod
failing Physical Exam, Performed: HeartRate result
CMS108v9 This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission
Description Attribute
failing Encounter, Performed: EncounterInpatient facilityLocations
failing Assessment, Performed: Risk for venous thromboembolism result
failing Medication, Administered: LowDoseUnfractionatedHeparinforVTEProphylaxis negationRationale
failing Medication, Order: LowDoseUnfractionatedHeparinforVTEProphylaxis route
failing Device, Applied: Venousfootpumps(VFP) negationRationale
failing Device, Order: Venousfootpumps(VFP) negationRationale
failing Patient Characteristic Birthdate: Birth date birthDatetime
failing Intervention, Performed: ComfortMeasures authorDatetime
failing Patient Characteristic Sex: ONCAdministrativeSex
CMS147v10 Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization
Description Attribute
failing Procedure, Performed: InfluenzaVaccination negationRationale
failing Immunization, Administered: InfluenzaVaccine negationRationale
failing Patient Characteristic Payer: Payer
failing Allergy/Intolerance: InfluenzaVaccine authorDatetime
failing Diagnosis: AllergytoInfluenzaVaccine prevalencePeriod

C1 Not Started Measure Tests

  • CMS111v9 Median Admit Decision Time to ED Departure Time for Admitted Patients
  • CMS9v9 Exclusive Breast Milk Feeding
  • CMS50v9 Closing the Referral Loop: Receipt of Specialist Report
  • CMS142v9 Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
  • CMS2v10 Preventive Care and Screening: Screening for Depression and Follow-Up Plan
  • CMS22v9 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
  • CMS69v9 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
  • CMS75v9 Children Who Have Dental Decay or Cavities
  • CMS117v9 Childhood Immunization Status
  • CMS127v9 Pneumococcal Vaccination Status for Older Adults
  • CMS138v9 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
  • CMS147v10 Preventive Care and Screening: Influenza Immunization
  • CMS153v9 Chlamydia Screening for Women
  • CMS155v9 Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
  • CMS349v3 HIV Screening
  • CMS74v10 Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists
  • CMS122v9 Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%)
  • CMS124v9 Cervical Cancer Screening
  • CMS125v9 Breast Cancer Screening
  • CMS128v9 Anti-depressant Medication Management
  • CMS130v9 Colorectal Cancer Screening
  • CMS131v9 Diabetes: Eye Exam
  • CMS133v9 Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery
  • CMS134v9 Diabetes: Medical Attention for Nephropathy
  • CMS135v9 Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
  • CMS136v10 Follow-Up Care for Children Prescribed ADHD Medication (ADD)
  • CMS137v9 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
  • CMS143v9 Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation
  • CMS144v9 Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
  • CMS145v9 Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)
  • CMS149v9 Dementia: Cognitive Assessment
  • CMS159v9 Depression Remission at Twelve Months
  • CMS161v9 Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
  • CMS165v9 Controlling High Blood Pressure
  • CMS347v4 Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
  • CMS645v4 Bone density evaluation for patients with prostate cancer and receiving androgen deprivation therapy
  • CMS129v10 Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients
  • CMS146v9 Appropriate Testing for Pharyngitis
  • CMS154v9 Appropriate Treatment for Upper Respiratory Infection (URI)
  • CMS249v3 Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture
  • CMS68v10 Documentation of Current Medications in the Medical Record
  • CMS139v9 Falls: Screening for Future Fall Risk
  • CMS156v9 Use of High-Risk Medications in Older Adults
  • CMS177v9 Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment
  • CMS56v9 Functional Status Assessment for Total Hip Replacement
  • CMS66v9 Functional Status Assessment for Total Knee Replacement
  • CMS90v10 Functional Status Assessments for Congestive Heart Failure
  • CMS157v9 Oncology: Medical and Radiation - Pain Intensity Quantified
  • CMS771v2 Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia
  • CMS71v10 Anticoagulation Therapy for Atrial Fibrillation/Flutter
  • CMS72v9 Antithrombotic Therapy By End of Hospital Day 2
  • CMS104v9 Discharged on Antithrombotic Therapy
  • CMS105v9 Discharged on Statin Medication
  • CMS108v9 Venous Thromboembolism Prophylaxis
  • CMS190v9 Intensive Care Unit Venous Thromboembolism Prophylaxis
  • CMS506v3 Safe Use of Opioids - Concurrent Prescribing
  • CMS529v1 Core Clinical Data Elements for the Hybrid Hospital-Wide Readmission (HWR) Measure with Claims and Electronic Health Record Data

C2 - Import and Calculate

C2 Not Started Measure Tests

  • CMS111v9 Median Admit Decision Time to ED Departure Time for Admitted Patients
  • CMS9v9 Exclusive Breast Milk Feeding
  • CMS50v9 Closing the Referral Loop: Receipt of Specialist Report
  • CMS142v9 Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
  • CMS22v9 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
  • CMS69v9 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
  • CMS75v9 Children Who Have Dental Decay or Cavities
  • CMS117v9 Childhood Immunization Status
  • CMS127v9 Pneumococcal Vaccination Status for Older Adults
  • CMS138v9 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
  • CMS147v10 Preventive Care and Screening: Influenza Immunization
  • CMS153v9 Chlamydia Screening for Women
  • CMS155v9 Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
  • CMS349v3 HIV Screening
  • CMS74v10 Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists
  • CMS122v9 Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%)
  • CMS124v9 Cervical Cancer Screening
  • CMS125v9 Breast Cancer Screening
  • CMS128v9 Anti-depressant Medication Management
  • CMS130v9 Colorectal Cancer Screening
  • CMS131v9 Diabetes: Eye Exam
  • CMS133v9 Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery
  • CMS134v9 Diabetes: Medical Attention for Nephropathy
  • CMS135v9 Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
  • CMS136v10 Follow-Up Care for Children Prescribed ADHD Medication (ADD)
  • CMS137v9 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
  • CMS143v9 Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation
  • CMS144v9 Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
  • CMS145v9 Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)
  • CMS149v9 Dementia: Cognitive Assessment
  • CMS159v9 Depression Remission at Twelve Months
  • CMS161v9 Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
  • CMS165v9 Controlling High Blood Pressure
  • CMS347v4 Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
  • CMS645v4 Bone density evaluation for patients with prostate cancer and receiving androgen deprivation therapy
  • CMS129v10 Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients
  • CMS146v9 Appropriate Testing for Pharyngitis
  • CMS154v9 Appropriate Treatment for Upper Respiratory Infection (URI)
  • CMS249v3 Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture
  • CMS68v10 Documentation of Current Medications in the Medical Record
  • CMS139v9 Falls: Screening for Future Fall Risk
  • CMS156v9 Use of High-Risk Medications in Older Adults
  • CMS177v9 Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment
  • CMS56v9 Functional Status Assessment for Total Hip Replacement
  • CMS66v9 Functional Status Assessment for Total Knee Replacement
  • CMS90v10 Functional Status Assessments for Congestive Heart Failure
  • CMS157v9 Oncology: Medical and Radiation - Pain Intensity Quantified
  • CMS771v2 Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia
  • CMS71v10 Anticoagulation Therapy for Atrial Fibrillation/Flutter
  • CMS72v9 Antithrombotic Therapy By End of Hospital Day 2
  • CMS104v9 Discharged on Antithrombotic Therapy
  • CMS105v9 Discharged on Statin Medication
  • CMS108v9 Venous Thromboembolism Prophylaxis
  • CMS190v9 Intensive Care Unit Venous Thromboembolism Prophylaxis
  • CMS506v3 Safe Use of Opioids - Concurrent Prescribing
  • CMS529v1 Core Clinical Data Elements for the Hybrid Hospital-Wide Readmission (HWR) Measure with Claims and Electronic Health Record Data

C2 Failing Measure Tests

CMS2v10 Preventive Care and Screening: Screening for Depression and Follow-Up Plan
    The following errors were identified for DENEXCEP D64A72F7-224F-486A-805C-CBA9BD06354F.
    • Reported DENEXCEP value 6 does not match sum 5 of supplemental key PAYER values
    Population ID Supplemental Data Type Code Expected Value Reported Value
    DENEXCEP PAYER 2 3

C3 - Submission

C3 Record Sample has not been started

C3 QRDA Category I Not Started Measure Tests

  • CMS111v9 Median Admit Decision Time to ED Departure Time for Admitted Patients
  • CMS9v9 Exclusive Breast Milk Feeding
  • CMS71v10 Anticoagulation Therapy for Atrial Fibrillation/Flutter
  • CMS72v9 Antithrombotic Therapy By End of Hospital Day 2
  • CMS104v9 Discharged on Antithrombotic Therapy
  • CMS105v9 Discharged on Statin Medication
  • CMS108v9 Venous Thromboembolism Prophylaxis
  • CMS190v9 Intensive Care Unit Venous Thromboembolism Prophylaxis
  • CMS506v3 Safe Use of Opioids - Concurrent Prescribing
  • CMS529v1 Core Clinical Data Elements for the Hybrid Hospital-Wide Readmission (HWR) Measure with Claims and Electronic Health Record Data

C3 QRDA Category III Not Started Measure Tests

  • CMS50v9 Closing the Referral Loop: Receipt of Specialist Report
  • CMS142v9 Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
  • CMS22v9 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
  • CMS69v9 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
  • CMS75v9 Children Who Have Dental Decay or Cavities
  • CMS117v9 Childhood Immunization Status
  • CMS127v9 Pneumococcal Vaccination Status for Older Adults
  • CMS138v9 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
  • CMS147v10 Preventive Care and Screening: Influenza Immunization
  • CMS153v9 Chlamydia Screening for Women
  • CMS155v9 Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
  • CMS349v3 HIV Screening
  • CMS74v10 Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists
  • CMS122v9 Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%)
  • CMS124v9 Cervical Cancer Screening
  • CMS125v9 Breast Cancer Screening
  • CMS128v9 Anti-depressant Medication Management
  • CMS130v9 Colorectal Cancer Screening
  • CMS131v9 Diabetes: Eye Exam
  • CMS133v9 Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery
  • CMS134v9 Diabetes: Medical Attention for Nephropathy
  • CMS135v9 Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
  • CMS136v10 Follow-Up Care for Children Prescribed ADHD Medication (ADD)
  • CMS137v9 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
  • CMS143v9 Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation
  • CMS144v9 Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
  • CMS145v9 Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)
  • CMS149v9 Dementia: Cognitive Assessment
  • CMS159v9 Depression Remission at Twelve Months
  • CMS161v9 Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
  • CMS165v9 Controlling High Blood Pressure
  • CMS347v4 Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
  • CMS645v4 Bone density evaluation for patients with prostate cancer and receiving androgen deprivation therapy
  • CMS129v10 Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients
  • CMS146v9 Appropriate Testing for Pharyngitis
  • CMS154v9 Appropriate Treatment for Upper Respiratory Infection (URI)
  • CMS249v3 Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture
  • CMS68v10 Documentation of Current Medications in the Medical Record
  • CMS139v9 Falls: Screening for Future Fall Risk
  • CMS156v9 Use of High-Risk Medications in Older Adults
  • CMS177v9 Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment
  • CMS56v9 Functional Status Assessment for Total Hip Replacement
  • CMS66v9 Functional Status Assessment for Total Knee Replacement
  • CMS90v10 Functional Status Assessments for Congestive Heart Failure
  • CMS157v9 Oncology: Medical and Radiation - Pain Intensity Quantified
  • CMS771v2 Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia

C4 - Filtering

C4 QRDA Category I Not Started Measure Tests

  • Races: ["White (code: 2106-3)"] , Ethnicities: ["Not Hispanic or Latino (code: 2186-5)"]
  • Payers: [349] , Age: [{:Maximum=>4}]
  • Providers: [{:NPIs=>"1586110979"}, {:TINs=>"419839697"}, {:Addresses=>"64292 Erica Orchard Flats, North Katarinastad, TX, 79866, US"}]
  • Providers: [{:NPIs=>"1071632826"}, {:TINs=>"101844969"}]
  • Problems: ["SNOMEDCT codes in Anaphylactic Reaction to Hepatitis A Vaccine (code: 2.16.840.1.113883.3.464.1003.199.12.1026)"]

C4 QRDA Category III Not Started Measure Tests

  • Races: ["White (code: 2106-3)"] , Ethnicities: ["Not Hispanic or Latino (code: 2186-5)"]
  • Payers: [349] , Age: [{:Maximum=>4}]
  • Providers: [{:NPIs=>"1586110979"}, {:TINs=>"419839697"}, {:Addresses=>"64292 Erica Orchard Flats, North Katarinastad, TX, 79866, US"}]
  • Providers: [{:NPIs=>"1071632826"}, {:TINs=>"101844969"}]
  • Problems: ["SNOMEDCT codes in Anaphylactic Reaction to Hepatitis A Vaccine (code: 2.16.840.1.113883.3.464.1003.199.12.1026)"]