| Setting |
CMS Program |
Developed by |
Measure ID |
Title |
Description |
| Outpatient | Quality Payment Program - Merit-based incentive payment system (MIPS) (***)
| US Wound Registry | USWR22 | Patient Reported Measure: Patient Reported Nutritional Assessment in Patients with Wounds and Ulcers
| The percentage of patients aged 18 years and older with a diagnosis of a wound or ulcer of any type who self-report nutritional screening with a validated tool (such as the Self-MNA® by Nestlé) as well as food insecurity assessment, AND for whom the clinician provides and documents a follow up/ intervention plan within the 12-month reporting period.
|
| Outpatient | Quality Payment Program - Merit-based incentive payment system (MIPS) (***)
| US Wound Registry
| USWR30
| Non Invasive Arterial Assessment of patients with lower extremity wounds or ulcers for determination of healing potential
| Percentage of patients aged 18 years or older with a non healing lower extremity wounds or ulcers that undergo a non-invasive arterial assessment once in a 12 month period. In 2020, clinician performance ranged from 0% to 100% with an average of 57.6% for practitioners that submitted data to CMS and 44.6% among clinicians who did not submit quality data, suggesting that QCDR participation improves the performance of arterial screening. |
| Outpatient | Quality Payment Program - Merit-based incentive payment system (MIPS) (***)
| Medicare | MIPS 128
| Process: Preventative Care and Screening: Body Mass Index (BMI) Screening and Follow-Up
| Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter
|
Outpatient
| Quality Payment Program - Merit-based incentive payment system (MIPS) (***)
| Medicare | MIPS 130 | Process: Documentation of Current Medications in the Medical Record
| 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. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration
|
Outpatient
| Quality Payment Program - Merit-based incentive payment system (MIPS) (***)
| Medicare
| MIPS 134 | Process:Preventive Care and Screening: Screening for Depression and Follow-Up Plan
| Percentage of patients aged 12 years and older screened for depression on 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 positive screen
|
Outpatient
| Quality Payment Program - Merit-based incentive payment system (MIPS) (***)
| Medicare
| MIPS 318 | Process: Falls: Screening for Future Fall Risk | Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period.
|
| Outpatient | Quality Payment Program - Merit-based incentive payment system (MIPS) (***)
| Medicare | MIPS 155 | Falls: Plan of Care
| Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months.
|
Outpatient
| Quality Payment Program - Merit-based incentive payment system (MIPS) (***)
| Medicare
| MIPS 431 | Process: Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling | Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user
|
Outpatient
| Quality Payment Program - Merit-based incentive payment system (MIPS) (***)
| Medicare
| MIPS 181 | Process: Elder Maltreatment Screen and Follow-Up Plan | Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening tool on the date of encounter AND a documented follow-up plan on the date of the positive screen
|
Outpatient
| Quality Payment Program - Merit-based incentive payment system (MIPS) (***)
| Medicare
| MIPS 182 | Process: Functional Outcome Assessment | Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies
|
Outpatient
| Quality Payment Program - Merit-based incentive payment system (MIPS) (***)
| Medicare
| MIPS 217-223 | Outcome: Functional Status Change | See Quality Payment Program website for descriptions related to functional status change of various body sites |
Outpatient
| Quality Payment Program - Merit-based incentive payment system (MIPS) (***)
| Medicare
| MIPS 226 | Process: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
| Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user
|
Outpatient
| Quality Payment Program - Merit-based incentive payment system (MIPS) (***)
| Medicare
| MIPS 236 | Intermediate outcome: Controlling High Blood Pressure | Percentage of patients 18 - 85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (< 140/90 mmHg) during the measurement period
|
