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</script>   <main id="top-content" role="main">  <section id="main-content" class="content-wrap"> <link href="https://acepteamstorage.blob.core.windows.net/epi-resources/_Multisites/ACEP/Areas/CEDR/static/resources/css/content.css" rel="stylesheet" media="all"> <h1>2024 Measures</h1>  <div class="page-content-wrap"> <div><div class="block richtextblock col-lg-12 col-md-12 col-sm-12 col-xs-12"><p>With the CEDR Qualified Clinical Data Registry (QCDR) option in 2024, clinicians may choose to report the following QCDR Measures & MIPS Measures to receive credit for MIPS quality reporting. Note: A link to the 2023 measures is available below.</p></div><div class="block richtextblock col-lg-12 col-md-12 col-sm-12 col-xs-12"><div class="measures-wrap"> <h3>QCDR Measures Supported</h3> <p class="footnote scrollMessage">Scroll → to View</p> <div class="table-scroll"> <div class="tb-5col-wrap"> <div class="tb-row-h"> <div class="tb-col1">ID</div> <div class="tb-col2">Description</div> <div class="tb-col3">Domain</div> <div class="tb-col4">Type</div> <div class="tb-col5">High Priority</div> </div> <div class="tb-row"> <div class="tb-col1">ACEP22 <a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Appropriate Emergency Department Utilization of CT for Pulmonary Embolism</div> <div class="tb-col3">Efficiency & Cost Reduction</div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/check-cedrgrn-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of emergency department visits during which patients aged 18 years and older had a CT pulmonary angiogram (CTPA) ordered by an emergency care provider, regardless of discharge disposition, with either moderate or high pre-test clinical probability for pulmonary embolism OR positive result or elevated D-dimer level.</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>All emergency department visits during which patients aged 18 years and older had a CT pulmonary angiogram (CTPA) ordered by an emergency care provider, regardless of discharge disposition.</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Emergency department visits for patients with either:</p> <ul> <li>Moderate or high pre-test clinical probability for pulmonary embolism OR</li> <li>Elevated D-dimer level</li> </ul> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <p>Pregnancy</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <ul> <li>Medical reason for ordering a CTPA without moderate or high pre-test clinical probability for pulmonary embolism AND no positive result or elevated D-dimer level (e.g., CT ordered for aortic dissection)</li> <li>Patients who had CT pulmonary angiogram (CTPA) ordered during an emergency department visit for trauma or dangerous mechanism of injury</li> </ul> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">ACEP25 <a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Tobacco Use: Screening and Cessation Intervention for Patients with Asthma and COPD</div> <div class="tb-col3">Community/Population Health</div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/ex-grey-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of patients aged 18 years and older with a diagnosis of asthma or COPD seen in the ED who were screened for tobacco use during any ED encounter AND who received tobacco cessation intervention if identified as a tobacco user.</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>All patients aged 18 years and older with a diagnosis of asthma or COPD seen in the ED and were discharged.</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Patients who were screened for tobacco use during any ED encounter AND who received tobacco cessation intervention if identified as a tobacco user.</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <p>None</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>Documented medical reason(s) for not screening for tobacco use OR for not providing tobacco cessation intervention for patients identified as tobacco users (e.g., limited life expectancy, other medical reasons).</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">ACEP30 <a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Sepsis Management: Septic Shock: Lactate Clearance Rate ≥ 10</div> <div class="tb-col3">Effective Clinical Care</div> <div class="tb-col4">Outcome</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/check-cedrgrn-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of emergency department visits for patients aged 18 years and older with septic shock who had an elevated serum lactate result (>2mmol/L) and a subsequent serum lactate level measurement performed following the elevated serum lactate result with a lactate clearance rate of ≥10% during the emergency department visit.</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>All emergency department visits resulting in hospital admission for patients aged 18 years and older with septic shock who had an elevated serum lactate result (>2mmol/L) and a subsequent serum lactate level measurement performed following the elevated serum lactate result.</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Emergency department visits for patients with a lactate clearance rate of ≥ 10% during the emergency department visit.</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <ul> <li>Transferred to the emergency department from another acute care facility or other in-patient hospital setting</li> <li>Left before treatment was complete</li> <li>Died during the emergency department visit</li> <li>Cardiac arrest within the emergency department visit</li> <li>Patient or surrogate decision maker declined care</li> <li>Advanced care directives present in patient medical record for comfort care</li> <li>Status epilepticus</li> <li>Receiving epinephrine</li> <li>Liver dysfunction or cirrhosis with decompensation</li> <li>Liver failure</li> <li>End-stage liver disease</li> <li>Secondary diagnosis of: Gastrointestinal bleeding, Stroke, Acute myocardial infarction or Acute trauma</li> <li>COVID-19 diagnosis</li> </ul> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>None</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">ACEP31 <a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Appropriate Foley Catheter Use in the Emergency Department</div> <div class="tb-col3">Patient Safety</div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/check-cedrgrn-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of emergency department (ED) visits for admitted patients aged 18 years and older where an indwelling Foley catheter is ordered and the patient had at least one indication for an indwelling Foley catheter.</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>All emergency department visits for admitted patients aged 18 years and older where an indwelling Foley catheter is ordered</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>"Emergency department visits where the patient had at least one of the following indications for an indwelling Foley catheter:</p> <ul> <li>Acute urinary retention or bladder outlet obstruction</li> <li>Need for accurate measurement of urinary output with no reasonable alternative</li> <li>Pre-operative use for selected surgical procedures</li> <li>Open sacral or perineal wounds in incontinent patients</li> <li>Patient requires prolonged immobilization</li> <li>Comfort for end of life care</li> <li>Other institution-specific indication</li> </ul> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <p>Patients who had an existing indwelling Foley catheter at ED arrival.</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>None</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">ACEP48 <a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Sepsis Management: Septic Shock: Lactate Level Measurement, Antibiotics Ordered, and Fluid Resuscitation</div> <div class="tb-col3">Effective Clinical Care</div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/ex-grey-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of emergency department visits resulting in hospital admission for patients aged 18 years and older with septic shock who had an order for all the following during the emergency department visit: a serum lactate level, antibiotics, and >1L of crystalloids.</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>All emergency department visits resulting in hospital admission for patients aged 18 years and older with septic shock.</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Emergency department visits for patients who had an order for all of the following during the emergency department visit: a serum lactate level, antibiotics, and >1L of crystalloids.</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <ul> <li>Transferred to the emergency department from another acute care facility or other in-patient hospital setting</li> <li>Left before treatment was complete</li> <li>Died during the emergency department visit</li> <li>Cardiac arrest within the emergency department visit</li> <li>Patient or surrogate decision maker declined care</li> <li>Advanced care directives present in patient medical record for comfort care</li> <li>Severe Heart Failure (LVEF<20%)</li> <li>Left Ventricular Assist Device (LVAD)</li> <li>Acute Pulmonary Edema</li> <li>Toxicological emergencies</li> <li>Burn</li> <li>Seizures</li> <li>Anuria</li> <li>End stage renal disease</li> <li>Secondary diagnosis of: Gastrointestinal bleeding, Stroke, Acute myocardial infarction or Acute trauma</li> <li>COVID-19 diagnosis</li> </ul> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>Patient is admitted within 1hr of ED Arrival</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">ACEP50 <a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">ED Median Time from ED arrival to ED departure for all <strong>Adult</strong> Patients</div> <div class="tb-col3">Person and Caregiver Centered Experience and Outcomes</div> <div class="tb-col4">Outcome</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/check-cedrgrn-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Time (in minutes) from ED arrival to ED departure for all Adult Patients.</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>All Emergency Department encounters for patients aged 18 years and older with documented discharge disposition.</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Time (in minutes) from ED arrival to ED departure for discharged Adult patients.</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <ul> <li>Transfers</li> <li>Psychiatric and mental health patients</li> <li>Patients who expired in the emergency department</li> <li>Patients transferred to observation</li> <li>Admissions</li> </ul> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>None</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">ACEP51 <a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">ED Median Time from ED arrival to ED departure for all <strong>Pediatric</strong> ED Patients</div> <div class="tb-col3">Person and Caregiver Centered Experience and Outcomes</div> <div class="tb-col4">Outcome</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/check-cedrgrn-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Time (in minutes) from ED arrival to ED departure for all Pediatric Patients.</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>All Emergency Department encounters for patients aged 17 years and younger with documented discharge disposition.</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Time (in minutes) from ED arrival to ED departure for discharged Pediatric patients.</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <ul> <li>Transfers</li> <li>Psychiatric and mental health patients</li> <li>Patients who expired in the emergency department</li> <li>Patients transferred to observation</li> <li>Admissions</li> </ul> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>None</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">ACEP52 <a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Appropriate Emergency Department Utilization of Lumbar Spine Imaging for Atraumatic Low Back Pain</div> <div class="tb-col3">Efficiency and Cost Reduction</div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/check-cedrgrn-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of emergency department visits during which patients aged 18 years and older had a CT or MRI of the Lumbar Spine ordered by an emergency care provider, regardless of discharge disposition, presenting with acute, non-complex low back pain..</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>All emergency department visits for patients aged 18 years and older who presented with acute, non-complex low back pack for whom a lumbar spine CT or MRI was ordered by an emergency care provider.</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Emergency department visits for patients who have an indication for a lumbar spine CT or MRI.</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <p>None</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>None</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">ACEP53 <a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Appropriate Use of Imaging for Recurrent Renal Colic</div> <div class="tb-col3">Efficiency and Cost Reduction</div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/check-cedrgrn-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of emergency department (ED) visits for patients aged 18-50 years presenting with flank pain with a history of kidney stones during which no imaging is ordered, OR appropriate imaging (i.e., plain film radiography or ultrasound) is ordered.</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>All emergency department visits for patients aged 18 - 50 years presenting with flank pain with any history of kidney stones.</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Emergency department visits during which no imaging is ordered OR appropriate imaging (i.e., plain film radiography or ultrasound) is ordered.</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <ul> <li>Infection (fever, elevated white blood cell count, laboratory confirmation of urinary tract infection)</li> <li>Cancer</li> <li>Known acute or chronic renal disease (e.g., transplant, creatinine >1.5 mg/dL, renal insufficiency, polycystic kidney disease, acute kidney failure)</li> <li>Patient on anticoagulants</li> <li>Stone episode duration ≥ 72 hours</li> <li>Pregnancy</li> <li>Trauma</li> <li>Persistent pain that cannot be controlled during the ED visit</li> <li>Urologic procedure performed in the past 48 hours</li> <li>BMI>35</li> </ul> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>None</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">ACEP56 <a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Follow-Up Care Coordination Documented in Discharge Summary</div> <div class="tb-col3">Communication & Care Coordination</div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/check-cedrgrn-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of patients aged 18 years and older for which follow-up care coordination was documented in Hospital Discharge Summary.</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>Any patient ≥18 years of age and patient encounter during the performance period (CPT or HPCS): 99238, 99239, 99234, 99235, 99236, 99218, 99219, 99220.</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Patients discharged with communication to follow-up provider documented in discharge summary.</p> <p>Definition of follow-up care coordination attempt:</p> <ul> <li>Specific date and time of scheduled follow-up with provider.</li> <li>Communication documented to follow-up provider performed.</li> <li>If hospital guideline, policy or similar rule provides guaranteed follow-up visit and time at a specific clinic, documentation of such follow-up coordination in discharge summary.</li> </ul> <p>Numerator Options:</p> <ul> <li>Performance Met: Patients discharged with communication to follow-up provider documented in discharge summary.</li> <li>Performance Not Met: Patients discharged without communication to follow-up provider documented in discharge summary.</li> </ul> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <p>Disposition of transferred, eloped or AMA patients.</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>None</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">ACEP59 <a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Chest Pain – Avoidance of admission for adult patients with low-risk chest pain.</div> <div class="tb-col3">Effective Clinical Care</div> <div class="tb-col4">Outcome</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/check-cedrgrn-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of adult patients who came to the Emergency Department with low-risk chest pain and were discharged.</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>All adult patients 35-64 years of age with an ED diagnosis of chest pain.</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>All adult patients 35-64 years of age with an ED diagnosis of chest pain who were discharged.</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <ul> <li>Diagnosis warranting admission: MI, pneumonia, PE, aortic dissection, PTX, dysrhythmia, esophageal rupture, cholecystitis, pancreatitis</li> <li>Other Diagnosis: Active cancer, ESRD, ESLD, SLE, AIDS, cardiomyopathy, coagulopathy, LBBB</li> </ul> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>None</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">ACEP60 <a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Syncope – Avoidance of admission for adult patients with low-risk syncope</div> <div class="tb-col3">Effective Clinical Care</div> <div class="tb-col4">Outcome</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/check-cedrgrn-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of emergency department (ED) visits for patients aged 18-50 years with a diagnosis of low-risk syncope who were discharged.</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>All ED encounters for patients aged 18 to 50 years of age with the diagnosis of syncope.</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>All ED encounters for patients aged 18 to 50 years of age with diagnosis of syncope who were discharged.</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <ul> <li>Heart Disease (coronary artery disease, Myocardial Infarction, CHF, cardiomyopathy, etc.)</li> <li>Heart Rhythm Disorders (Arrhythmias, Sinus Node Dysfunction, Uncontrolled Atrial Fibrillation, etc.)</li> <li>Aortic Dissection, Pulmonary Embolism, Subarachnoid Hemorrhage Coagulation Disorder</li> </ul> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>Death & LAMA</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">ACEP61 <a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Avoidance of Chest X-ray in pediatric patients with Asthma, Bronchiolitis or Croup.</div> <div class="tb-col3">Effective Clinical Care</div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/check-cedrgrn-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of ED visits for pediatric patients with Asthma, Bronchiolitis or Croup for whom a Chest X-ray was ordered/performed.</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>AAll patients <18 years of age coming to the Emergency Department with a diagnosis of Asthma, Bronchiolitis or Croup.</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>AAll patients <18 years of age with a diagnosis of Asthma, Bronchiolitis or Croup and for whom a chest x-ray was ordered/performed.</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <ul> <li>History of Cystic Fibrosis</li> <li>Airway Malformations</li> <li>Immunodeficiency Syndromes</li> <li>Pneumonia</li> </ul> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>None</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">ACEP62 <a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Avoidance of Opioid therapy for dental pain.</div> <div class="tb-col3">Effective Clinical Care</div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/check-cedrgrn-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>All acute encounters for patients aged 18 years and older with, diagnosis of dental pain, who were not prescribed Opioids or Opiates.</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>All acute encounters for patients aged 18 years and older evaluated by the Eligible Professional with a diagnosis of dental pain.</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>All acute encounters for patients who were not prescribed Opioids or Opiates.</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <ul> <li>Patients with active cancer</li> <li>Palliative care</li> <li>End-of-life care</li> </ul> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>Opiate prescribed for acute dental trauma (e.g., tooth or facial fracture, etc.)</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">ACEP63 <a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Avoidance of Acute High-Risk Prescriptions in Geriatric Patients at Discharge.</div> <div class="tb-col3">Effective Clinical Care</div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/check-cedrgrn-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>The percentage of adults 65 years of age and older who were prescribed an Acute High-Risk Medication at discharge.</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>All patients 65 years of age and older with an ED visit and were discharged.</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>All patients included in the Denominator, who were prescribed one/more of the acute high-risk medications.</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <ul> <li>Seizure disorder</li> <li>Rapid eye movement sleep disorder</li> <li>Ethanol withdrawal</li> <li>Benzodiazepine withdrawal</li> <li>Severe generalized anxiety disorder</li> <li>End-of-life care</li> <li>Allergic Reactions</li> <li>Dermatitis</li> <li>Vertigo</li> <li>Labyrinthitis</li> <li>ED Visit for prescription refill</li> </ul> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>None</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">ACEP64 <a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Avoidance of admission for adult patients in Emergency Department with low-risk Deep Vein Thrombosis (DVT).</div> <div class="tb-col3"> </div> <div class="tb-col4">Outcome</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/check-cedrgrn-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of patients 18 years and older who present to the Emergency Department with low-risk Deep Vein Thrombosis (DVT) and are discharged home.</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>All patients aged 18 years and older with an Emergency Department diagnosis of DVT.</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Patients who were discharged.</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <p>Diagnosis-related:</p> <ul> <li>Syncope</li> <li>Pulmonary embolism</li> <li>Proximal DVT</li> </ul> <p>Patient-related: Already on anticoagulation at time of DVT diagnosis based on listed home medications.</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>LAMA, LWT, LWBS, Death</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">ACEP65 <a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Appropriate Utilization of Imaging in rAAA (ruptured Abdominal Aortic Aneurysm) patients in Emergency Department.</div> <div class="tb-col3"> </div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/check-cedrgrn-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of adult patients aged 55 years and older presenting to the Emergency Department with abdominal pain or back pain and hypotension for whom a POC Ultrasound or CT scan was performed.</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>All patients aged 55 years and older presenting to the Emergency Department with abdominal pain or back pain and hypotension.</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Patients for whom a POC Ultrasound performed or CT scan was ordered/performed.</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <p>None</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <ul> <li>Patient Refusal</li> <li>US/CT done in last one year</li> <li>Previously screened for AAA</li> <li>Transferred to operating room</li> <li>LAMA, LWT, LWBS, Death</li> </ul> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">ACEP66 <a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Co-testing for HIV in high-risk patients in Emergency Department who are being tested for other sexually transmitted infections (STI) (Gonorrhea, Chlamydia, Syphilis or Trichomonas).</div> <div class="tb-col3"> </div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/ex-grey-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of patients aged 18 and older in the Emergency Department who are being tested for other sexually transmitted infections (STI) (Gonorrhea, Chlamydia, Syphilis or Trichomonas) are also tested for HIV.</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>All patients aged 18 years and older who were tested for a STI (Gonorrhea, Chlamydia, Syphilis or Trichomonas).</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Patients who were tested for HIV.</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <p>Patients with HIV disease.</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>LAMA, LWT, LWBS, Death, Patient refusal to be tested</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">ECPR39 <a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Avoid Head CT for Patients with Uncomplicated Syncope</div> <div class="tb-col3">Efficiency & Cost Reduction</div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/check-cedrgrn-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of Adult Syncope Patients Who Did Not Receive a Head CT Scan Ordered by the Provider.</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>Any patient ≥18 years of age evaluated by the Eligible Professional in the Emergency Department or Urgent Care Clinic PLUS Diagnosis of Syncope. (Not including transferred, eloped or AMA patients).</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Syncope Patients Who Did Not Have a Head CT Ordered by the Provider.</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <p>None</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>Patients who did have a head CT ordered for medical reason documented by the eligible professional(i.e., seizure; alcohol/drug intoxication; vomiting; altered mental status; abnormal neurologic exam; concern for intracranial injury/hemorrhage, stroke, or mass lesion).</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">ECPR46 <a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Avoidance of Opiates for Low Back Pain or Migraines</div> <div class="tb-col3">Effective Clinical Care</div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/check-cedrgrn-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of Patients with Low Back Pain and/or Migraines Who Were Not Prescribed an Opiate.</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>Any patient ≥18 years of age evaluated by the Eligible Professional PLUS Diagnosis of low back pain OR Diagnosis of migraine PLUS Disposition of Discharged.</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Patients who were not prescribed an opiate.</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <p>Patients with active cancer, palliative care, end-of-life care./p></p> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>Opiate prescribed for medical reason documented by the Eligible Professional (e.g., headache pain refractory to other medications, severe headache, suspected or diagnosed herniated disk, fracture, sciatica, radiculopathy).</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">ECPR51 <a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Discharge Prescription of Naloxone after Opioid Poisoning or Overdose</div> <div class="tb-col3">Effective Clinical Care</div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/check-cedrgrn-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of Opioid Poisoning or Overdose Patients Presenting to An Acute Care Facility Who Were Prescribed Naloxone at Discharge.</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>Any patient evaluated by the Eligible Professional in the acute care setting PLUS diagnoses of opioid poisoning from heroin, methadone, morphine, opium, codeine, hydrocodone, or another opioid substance PLUS Disposition of Discharged (Not including transferred, eloped or AMA patients).</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Patients Who Were Prescribed Naloxone AND Educated About Utilization at Discharge.</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <p>None</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>Naloxone was not prescribed at discharge due to medical reasons such as allergy.</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">HCPR20 <a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Clostridium Difficile – Risk Assessment and Plan of Care</div> <div class="tb-col3"> </div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/check-cedrgrn-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of Adult Patients Who Had a Risk Assessment for C. difficile Infection and, If High-Risk, Had a Plan of Care for C. difficile Completed on the Day Of or Day After Hospital Admission.</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>AAny patient greater or equal to 18 years of age evaluated by the Eligible Professional in the hospital setting (Not including transferred, eloped, AMA patients).</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Patients that had a risk assessment for C. difficile infection and, if high-risk, a plan of care documented on the day of or day after hospital admission.</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <p>None</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>Patients who did not have a C. difficile infection risk assessment, AND if high risk, a plan of care for C. difficile for medical reasons documented by the Eligible Professional (e.g., C. difficile infection already documented prior to hospital admission, patients unable to provide history, patients on comfort measures).</p> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">HCPR24 <a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Appropriate Utilization of Vancomycin for Cellulitis</div> <div class="tb-col3"> </div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/check-cedrgrn-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of Patients with Cellulitis Who Did Not Receive Vancomycin Unless MRSA Infection or Risk for MRSA Infection Was Identified.</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>Any patient greater than or equal to 18 years of age evaluated by the Eligible Professional PLUS Admitted or Placed in Observation Status PLUS Diagnosis of Cellulitis (Transferred, eloped, AMA or expired patients are excluded).</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Patients who did NOT have Vancomycin ordered unless known MRSA infection was identified or specific risk for MRSA infection was indicated.</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <p>None</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>None</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">THEPQR1 <a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">High Intensity Statin Prescribed for Acute and Subacute Ischemic Stroke and Transient Ischemic Attack (TIA).</div> <div class="tb-col3"> </div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/ex-grey-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Acute and subacute ischemic stroke and confirmed Transient Ischemic Attack (TIA) patients prescribed or continuing to take a high intensity statin at time of hospital discharge.</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>Instructions: This measure is to be submitted for each episode of acute ischemic stroke, subacute ischemic stroke, or transient ischemic attack</p> <p>Denominator Population: Patients aged >=18 on date of encounter with a diagnosis of Ischemic Stroke or TIAAND CPT: 99217, 99234, 99235, 99236, 99238, 99239.</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Patients who were prescribed or continued on a high-intensity statin at time of hospital discharge. Performance Met: High-Intensity Statin prescribed or currently being taken Performance Not Met: High-Intensity Statin neither prescribed or active - Reason not given. HIGH-Intensity STATIN Medication List and Dosage:</p> <ul> <li>Atorvastatin 40mg per day, OR</li> <li>Rosuvastatin 20 mg per day</li> </ul> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <ul> <li>Chronic stroke</li> <li>Enrolled in clinical trial</li> <li>Transferred</li> <li>Eloped or left Against Medical Advice (AMA)</li> <li>Expired</li> <li>Comfort measures documented</li> <li>Discharged to hospice</li> </ul> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>None</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">THEPQR2 <a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Discontinuation of Proton Pump Inhibitors for patients who do not meet criteria for long-term utilization.</div> <div class="tb-col3"> </div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/check-cedrgrn-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>The percentage of patients on a Proton Pump Inhibitor with an appropriately documented indication or an order for discontinuation for not meeting criteria for long-term utilization.</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>Patients aged ≥50 years of age AND Place of Service (POS) 21, 31, 32 AND CPT Code: 99238, 99239, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316 AND active Proton Pump Inhibitor on Medication List. Proton Pump Inhibitor (PPI) Medication List:</p> <ul> <li>Omeprazole (Prilosec, Prilosec OTC, Zegerid)</li> <li>Lansoprazole (Prevacid)</li> <li>Pantoprazole (Protonix)</li> <li>Rabeprazole (Aciphex)</li> <li>Esomeprazole (Nexium)</li> </ul> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Performance Met (Inpatient): Proton Pump Inhibitors discontinued by discharge OR Performance Met (PAC/SNF): Proton Pump Inhibitors discontinued OR Performance Not Met: Proton Pump Inhibitors not discontinued, reason not given.</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <p>Patients who have an active diagnosis that meets criteria for long-term utilization of Proton Pump Inhibitors.</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>None</p> </div> </div> </div> </div> </div> </div> </div> <div class="measures-cta"><a class="btn" title="CEDR 2024 QCDR Measure Specifications" href="/siteassets/sites/cedr/cedrmeasures_2024.pdf">Download 2024 QCDR Measures (PDF)</a></div> <div class="measures-cta"><a class="btn" title="CEDR 2023 QCDR Measure Specifications" href="/siteassets/sites/cedr/cedrmeasures_2023.pdf">Download 2023 QCDR Measures (PDF)</a></div> </div> <h3>QPP Measures Supported</h3> <p class="footnote scrollMessage">Scroll → to View</p> <div class="table-scroll"> <div class="tb-5col-wrap"> <div class="tb-row-h"> <div class="tb-col1">ID</div> <div class="tb-col2">Description</div> <div class="tb-col3">Domain</div> <div class="tb-col4">Type</div> <div class="tb-col5">High Priority</div> </div> <div class="tb-row"> <div class="tb-col1">QPP5<a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">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)</div> <div class="tb-col3">Effective Clinical Care</div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/ex-grey-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>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</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <ul> <li>SUBMISSION CRITERIA 1: All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF < 40%, OR</li> <li>SUBMISSION CRITERIA 2: All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF < 40%</li> </ul> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <ul> <li>SUBMISSION CRITERIA 1:Patients who were prescribed ACE inhibitor or ARB or ARNI therapy within a 12-month period when seen in the outpatient setting, OR</li> <li>SUBMISSION CRITERIA 2: Patients who were prescribed ACE inhibitor or ARB therapy at hospital discharge</li> </ul> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <p>None</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <ul> <li>Documentation of medical reason(s) for not prescribing ACE inhibitor or ARB therapy (eg, hypotensive patients who are at immediate risk of cardiogenic shock, hospitalized patients who have experienced marked azotemia, allergy, intolerance, other medical reasons)</li> <li>Documentation of patient reason(s) for not prescribing ACE inhibitor or ARB therapy (eg, patient declined, other patient reasons)</li> <li>Documentation of system reason(s) for not prescribing ACE inhibitor or ARB therapy (eg, other system reasons)</li> </ul> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">QPP6<a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Coronary Artery Disease (CAD): Antiplatelet Therapy</div> <div class="tb-col3">Effective Clinical Care</div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/ex-grey-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12-month period who were prescribed aspirin or clopidogrel</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>All patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12-month period</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Patients who were prescribed aspirin or clopidogrel</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <p>None</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <ul> <li>Documentation of medical reason(s) for not prescribing aspirin or clopidogrel (e.g., allergy, intolerance, receiving other thienopyridine therapy, receiving warfarin therapy, bleeding coagulation disorders, other medical reasons)</li> <li>Documentation of patient reason(s) for not prescribing aspirin or clopidogrel (e.g., patient declined, other patient reasons)</li> <li>Documentation of system reason(s) for not prescribing aspirin or clopidogrel (e.g., lack of drug availability, other reasons attributable to the health care system)</li> </ul> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">QPP8<a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)</div> <div class="tb-col3">Effective Clinical Care</div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/ex-grey-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>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</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <ul> <li>SUBMISSION CRITERIA 1: All patients with a diagnosis of HF seen in the outpatient setting with a current or prior LVEF < 40%, OR</li> <li>SUBMISSION CRITERIA 2: All patients with a diagnosis of HF and discharged from hospital with a current or prior LVEF < 40%</li> </ul> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <ul> <li>SUBMISSION CRITERIA 1: Patients who were prescribed beta-blocker therapy within a 12 month period when seen in the outpatient setting, OR</li> <li>SUBMISSION CRITERIA 2: Patients who were prescribed beta-blocker therapy at each hospital discharge</li> </ul> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <p>None</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>Beta-Blocker Therapy for LVEF < 40% not prescribed for reasons documented by the clinician (e.g., low blood pressure, fluid overload, asthma, patients recently treated with an intravenous positive inotropic agent, allergy, intolerance, other medical reasons, patient declined, other patient reasons, or other reasons attributable to the healthcare system)</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">QPP47<a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Advance Care Plan</div> <div class="tb-col3">Communication & Care Coordination</div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/check-cedrgrn-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>All patients aged 65 years and older</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Patients who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <p>Hospice services received by patient any time during the measurement period</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>None</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">QPP65<a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Appropriate Treatment for Children with Upper Respiratory Infection (URI)</div> <div class="tb-col3">Efficiency & Cost Reduction</div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/check-cedrgrn-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of patients ≥ 3 months of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>Patients ≥ 3 months of age who had an outpatient or emergency department (ED) visit with a diagnosis of upper respiratory infection (URI) during the measurement period</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Children without a prescription for antibiotic medication on or 3 days after the outpatient or ED visit for an upper respiratory infection</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <ul> <li>URI episodes where the patient had a competing comorbid condition during the 12 months prior to or on the episode date (e.g., tuberculosis, neutropenia, cystic fibrosis, chronic bronchitis, pulmonary edema, respiratory failure, rheumatoid lung disease)</li> <li>URI episodes when the patient had a new or refill prescription of antibiotics in the 30 days prior to or on the episode date</li> <li>URI episodes when the patient had competing diagnoses on or three days after the episode date (e.g., intestinal infection, pertussis, bacterial infection, Lyme disease, otitis media, acute sinusitis, acute pharyngitis, acute tonsillitis, chronic sinusitis, infection of the pharynx/larynx/tonsils/adenoids, prostatitis, cellulitis, mastoiditis, or bone infections, acute lymphadenitis, impetigo, skin staph infections, pneumonia/gonococcal infections, venereal disease (syphilis, chlamydia, inflammatory diseases [female reproductive organs]), infections of the kidney, cystitis or UTI, and acne)</li> <li>Patients who use hospice services any time during the measurement period</li> </ul> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>None</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">QPP66<a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Appropriate Testing for Children with Pharyngitis</div> <div class="tb-col3">Efficiency & Cost Reduction</div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/check-cedrgrn-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>The percentage of episodes for patients ≥ 3 years old with a diagnosis of pharyngitis that resulted in an antibiotic dispensing event and a group A streptococcus (strep) test</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>Patients ≥ 3 years old who had an outpatient or emergency department (ED) visit with a diagnosis of pharyngitis during the measurement period and an antibiotic prescribed or dispensed</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Children with a group A streptococcus test in the 7-day period from 3 days prior through 3 days after the diagnosis of pharyngitis</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <ul> <li>Episodes where the patient is taking antibiotics (Table 1) in the 30 days prior to the episode date</li> <li>Episodes where the patient had a competing comorbid condition during the 12 months prior to or on the episode date (e.g., tuberculosis, neutropenia, cystic fibrosis, chronic bronchitis, pulmonary edema, respiratory failure, rheumatoid lung disease)</li> <li>Episodes where the patient had a competing diagnosis within three days after the episode date (e.g., intestinal infection, pertussis, bacterial infection, Lyme disease, otitis media, acute sinusitis, chronic sinusitis, infection of the adenoids, prostatitis, cellulitis, mastoiditis, or bone infections, acute lymphadenitis, impetigo, skin staph infections, pneumonia/gonococcal infections, venereal disease (syphilis, chlamydia, inflammatory diseases [female reproductive organs]), infections of the kidney, cystitis or UTI)</li> <li>Patients who use hospice services any time during the measurement period</li> </ul> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>None</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">QPP116<a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis</div> <div class="tb-col3">Efficiency & Cost Reduction</div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/check-cedrgrn-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>The percentage of episodes for patients ≥ 3 months of age with a diagnosis of acute bronchitis/bronchiolitis that did not result in an antibiotic dispensing event.</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>All patients aged patients ≥ 3 months with an outpatient, observation or emergency department (ED) visit with a diagnosis of acute bronchitis/bronchiolitis during the measurement period</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Patients who were not prescribed or dispensed antibiotics on or within 3 days of the initial date of service</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <ul> <li>Observation or ED visits that result in an inpatient admission</li> <li>Documentation of medical reason(s) for prescribing or dispensing antibiotic (e.g., intestinal infection, pertussis, bacterial infection, Lyme disease, otitis media, acute sinusitis, acute pharyngitis, acute tonsillitis, chronic sinusitis, infection of the pharynx/larynx/tonsils/adenoids, prostatitis, cellulitis/ mastoiditis/bone infections, acute lymphadenitis, impetigo, skin staph infections, pneumonia, gonococcal infections/venereal disease (syphilis, chlamydia, inflammatory diseases [female reproductive organs]), infections of the kidney, cystitis/UTI, acne, HIV disease/asymptomatic HIV, cystic fibrosis, disorders of the immune system, malignancy neoplasms, chronic bronchitis, emphysema, bronchiectasis, extrinsic allergic alveolitis, chronic airway obstruction, chronic obstructive asthma, pneumoconiosis and other lung disease due to external agents, other diseases of the respiratory system, and tuberculosis.</li> <li>Patients who use hospice services any time during the measurement period.</li> </ul> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>Documentation of medical reason(s) for prescribing systemic antimicrobial therapy.</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">QPP118<a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)</div> <div class="tb-col3">Effective Clinical Care</div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/ex-grey-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <ul> <li>SUBMISSION CRITERIA 1: All patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have a current or prior LVEF < 40%, OR</li> <li>SUBMISSION CRITERIA 2: All patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes</li> </ul> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Patients who were prescribed ACE inhibitor or ARB therapy</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <p>None</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <ul> <li>SUBMISSION CRITERIA 1: Clinician documented that patient was not an eligible candidate for angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy (e.g., allergy, intolerance, pregnancy, renal failure due to ACE inhibitor, diseases of the aortic or mitral valve, other medical reasons) or (e.g., patient declined, other patient reasons) or (e.g., lack of drug availability, other reasons attributable to the health care system), OR</li> <li>SUBMISSION CRITERIA 2: Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy not prescribed for reasons documented by the clinician (e.g., allergy, intolerance, pregnancy, renal failure due to ACE inhibitor, diseases of the aortic or mitral valve, other medical reasons) or (e.g., patient declined, other patient reasons) or (e.g., lack of drug availability, other reasons attributable to the health care system)</li> </ul> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">QPP130<a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Documentation of Current Medications in the Medical Record</div> <div class="tb-col3">Patient Safety</div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/check-cedrgrn-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of visits for patients aged 18 years and older for which the MIPS eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>All visits occurring during the 12 month measurement period for patients aged 18 years and older</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>MIPS eligible clinician attests to documenting, updating or reviewing a patient’s current medications using all immediate resources available on the date of encounter. This list must include ALL known prescriptions, over-the counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosages, frequency and route of administration</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <p>None</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>Eligible clinician attests to documenting in the medical record the patient is not eligible for a current list of medications being obtained, updated, or reviewed by the eligible clinician</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">QPP134<a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Preventive Care and Screening: Screening for Depression and Follow-Up Plan</div> <div class="tb-col3"> </div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/check-cedrgrn-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>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 or up to two days after the date of the qualifying encounter.</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>All patients aged 12 years and older at the beginning of the performance period with at least one qualifying encounter during the performance period.</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Patients 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 tool AND if positive, a follow-up plan is documented on the date of or up to two days after the date of the qualifying encounter.</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <p>Documentation stating the patient has had a diagnosis of bipolar disorder.</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>Patient refuses to participate in or complete the depression screening OR Documentation of medical reason for not screening patient for depression (e.g., cognitive, functional, or motivational limitations that may impact accuracy of results; patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status)</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">QPP187<a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Stroke and Stroke Rehabilitation: Thrombolytic Therapy (tPA)</div> <div class="tb-col3">Effective Clinical Care</div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/ex-grey-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who arrive at the hospital within two hours of time last known well and for whom IV alteplase was initiated within three hours of time last known well</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>All patients aged 18 years and older with a diagnosis of acute ischemic stroke whose time of arrival is within two hours (≤ 120 minutes) of time last known well</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Patients for whom IV thrombolytic therapy was initiated at the hospital within three hours (≤ 180 minutes) of time last known well</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <p>None</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>IV alteplase not initiated within three hours (≤ 180 minutes) of time last known well for reasons documented by clinician (e.g. patient enrolled in clinical trial for stroke, patient admitted for elective carotid intervention).</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">QPP226<a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Preventive Care and Screening: Tobacco Use: Screening and Cessation</div> <div class="tb-col3">Effective Clinical Care</div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/ex-grey-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within the measurement period AND who received tobacco cessation intervention on the date of the encounter or within the previous 12 months if identified as a tobacco user.</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period.</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Patients who were screened for tobacco use at least once within the measurement period AND who received tobacco cessation intervention if identified as a tobacco user on the date of the encounter or within the previous 12 months</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <p>None</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>Documentation of medical reason(s) for not screening for tobacco use (e.g., limited life expectancy, other medical reason) OR Documentation of medical reason(s) for not providing tobacco cessation intervention on the date of the encounter or within the previous 12 months if identified as a tobacco user (e.g., limited life expectancy, other medical reason)</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">QPP254<a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain</div> <div class="tb-col3">Effective Clinical Care</div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/ex-grey-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of pregnant female patients aged 14 to 50 who present to the emergency department (ED) with a chief complaint of abdominal pain or vaginal bleeding who receive a trans-abdominal or trans-vaginal ultrasound to determine pregnancy location.</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>All pregnant female patients aged 14 to 50 who present to the ED with a chief complaint of abdominal pain or vaginal bleeding along with diagnosis of other current condition in the mother classifiable elsewhere but complicating Pregnancy, Childbirth, or the Puerperium.</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Patients who receive a trans-abdominal or trans-vaginal ultrasound with documentation of pregnancy location in medical record.</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <p>None</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>Trans-abdominal or trans-vaginal ultrasound not performed for reasons documented by clinician (e.g., patient has visited the ED multiple times within 72 hours, patient has a documented Intrauterine Pregnancy [IUP]).</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">QPP317<a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented</div> <div class="tb-col3">Community - Population Health</div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/ex-grey-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of patients aged 18 years and older seen during the submitting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>All patients aged 18 years and older at the beginning of the measurement period with at least one eligible encounter during the measurement period.</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Patients who were screened for high blood pressure AND have a recommended follow-up plan documented, as indicated if the blood pressure is pre-hypertensive or hypertensive</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <p>Patient not eligible due to active diagnosis of hypertension</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <ul> <li>Patient refuses to participate (either BP measurement or follow-up)</li> <li>Patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient's health status. This may include but is not limited to severely elevated BP when immediate medical treatment is indicated.</li> <li>Documented reason for not screening or recommending a follow-up for high blood pressure</li> </ul> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">QPP326<a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy</div> <div class="tb-col3">Effective Clinical Care</div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/ex-grey-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of patients aged 18 years and older with nonvalvular atrial fibrillation (AF) or atrial flutter who were prescribed warfarin OR another FDA-approved oral anticoagulant drug for the prevention of thromboembolism during the measurement period</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>All patients aged 18 years and older with a diagnosis of nonvalvular AF or atrial flutter who do not have a documented CHA2DS2-VASc risk score of 0 or 1</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Patients with nonvalvular AF or atrial flutter for whom warfarin or another FDA-approved oral anticoagulant was prescribed</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <ul> <li>Patient with transient or reversible cause of AF (e.g., pneumonia, hyperthyroidism, pregnancy, cardiac surgery)</li> <li>Patients who are receiving comfort care only OR Documentation of CHA2DS2-VASc risk score of 0 or 1</li> </ul> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <ul> <li>Documentation of medical reason(s) for not prescribing warfarin OR another FDA-approved anticoagulant (e.g., atrial appendage device in place)</li> <li>Documentation of patient reason(s) for not prescribing warfarin OR another FDA-approved oral anticoagulant that is FDA-approved for the prevention of thromboembolism (e.g., patient choice of having atrial appendage device placed)</li> <li>Documentation of system reason(s) for not prescribing warfarin OR another FDA-approved anticoagulation due to patient being currently enrolled in a clinical trial related to AF/atrial flutter treatment</li> </ul> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">QPP331<a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse)</div> <div class="tb-col3">Efficiency and Cost Reduction</div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/check-cedrgrn-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of patients, aged 18 years and older, with a diagnosis of acute viral sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>All patients aged 18 years and older with a diagnosis of acute sinusitis</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Patients prescribed any antibiotic within 10 days after onset of symptoms</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <p>None</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>Antibiotic regimen prescribed within 10 days after onset of symptoms for documented medical reason</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">QPP332<a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patient with Acute Bacterial Sinusitis (Appropriate Use)</div> <div class="tb-col3">Efficiency and Cost Reduction</div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/check-cedrgrn-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosis.</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>All patients aged 18 years and older with a diagnosis of acute bacterial sinusitis who are prescribed an antibiotic.</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Patients who were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosis.</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <p>None</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>Amoxicillin, with or without clavulanate, not prescribed as first line antibiotic at the time of diagnosis for documented reason</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">QPP415<a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older</div> <div class="tb-col3">Efficiency and Cost Reduction</div> <div class="tb-col4">Efficiency</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/check-cedrgrn-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of emergency department visits for patients aged 18 years and older who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>All emergency department visits for patients aged 18 years and older who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider.</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Emergency department visits for patients who have an indication for a head CT</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <p>Patient has documentation of ventricular shunt, brain tumor, multisystem trauma, or is currently taking an antiplatelet medication including: abciximab, anagrelide, cangrelor, cilostazol, clopidogrel, dipyridamole, eptifibatide, prasugrel, ticlopidine, ticagrelor, tirofiban, or vorapaxar</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>None</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">QPP416<a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years</div> <div class="tb-col3">Efficiency and Cost Reduction</div> <div class="tb-col4">Efficiency</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/check-cedrgrn-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of emergency department visits for patients aged 2 through 17 years who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the Pediatric Emergency Care Applied Research Network (PECARN) prediction rules for traumatic brain injury</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>All emergency department visits for patients aged 2 through 17 years who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Emergency department visits for patients who are classified as low risk according to the PECARN prediction rules for traumatic brain injury</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <p>Patient has documentation of ventricular shunt, brain tumor, or coagulopathy</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>None</p> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">QPP419<a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Overuse Of Neuroimaging For Patients With Primary Headache</div> <div class="tb-col3">Efficiency and Cost Reduction</div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/check-cedrgrn-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>Percentage of patients for whom imaging of the head (CT or MRI) is obtained for the evaluation of primary headache when clinical indications are not present</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <p>All patients seen for evaluation of primary headache</p> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <p>Patients for whom imaging of the head (Computed Tomography (CT) or Magnetic Resonance Imaging (MRI)) is obtained for the evaluation of primary headache when clinical indications are not present</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <p>None</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <ul> <li>Documentation of patients with primary headache diagnosis and imaging other than CT or MRI obtained</li> <li>Documentation of System reason(s) for obtaining imaging of the head (CT or MRI) (i.e., needed as part of a clinical trial; other clinician ordered the study)</li> </ul> </div> </div> </div> </div> </div> <div class="tb-row"> <div class="tb-col1">QPP431<a class="measuresTool tb-info-link"><em class="fa fa-angle-down" aria-hidden="true"> </em></a></div> <div class="tb-col2">Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling</div> <div class="tb-col3"> </div> <div class="tb-col4">Process</div> <div class="tb-col5"><img src="/static/globalassets/resources/images/icon_images/svg/check-cedrgrn-icon.svg" alt=""></div> <div class="tb-info"> <div class="measuresToolopen"> <div class="colWrap"> <div class="colWrap-col"> <p><strong>Measure Description</strong></p> <p>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 12 months AND who received brief counseling if identified as an unhealthy alcohol user.</p> </div> <div class="colWrap-col"> <p><strong>Denominator</strong></p> <ul> <li>1. All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period.</li> <li>2. All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period who were screened for unhealthy alcohol use and identified as an unhealthy alcohol user.</li> <li>3. All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period.</li> </ul> </div> <div class="colWrap-col"> <p><strong>Numerator</strong></p> <ul> <li>1. Patients who were screened for unhealthy alcohol use using a systematic screening method at least once within thelast 12 months.</li> <li>2. Patients who received brief counseling.</li> <li>3. Patients who were screened for unhealthy alcohol use using a systematic screening method at least once within 12 months AND who received brief counseling if identified as an unhealthy alcohol user.</li> </ul> </div> <div class="colWrap-col"> <p><strong>Denominator Exclusions</strong></p> <p>1. Patients with dementia any time during the patient’s history through the end of the measurement period OR Patients who use hospice services any time during the measurement period.</p> </div> <div class="colWrap-col"> <p><strong>Denominator Exceptions</strong></p> <p>None</p> </div> </div> </div> </div> </div> </div> </div> <div class="measures-cta"><a class="btn" href="https://qpp.cms.gov/mips/quality-requirements?py=2023" target="_blank" rel="noopener">CMS QPP Measures Website </a></div> </div></div><div class="block richtextblock col-lg-12 col-md-12 col-sm-12 col-xs-12"><div id="contactus-wrap"> <p>For more information <a href="https://forms.monday.com/forms/f22f0b60f23f6c22c02d3b8c4f972d99?r=use1" title="EMDI Interest Form">contact us today</a>.</p> </div></div></div> </div> </section> </main>  <footer role="footer-info">  <section id="top-footer" class="footer-corp">  <div class="product-logo"> <a href="/cedr/" aria-label="Back to CEDR home">CEDR</a> </div>  <div class="footer-links"> <a href="/cedr/about-us/">About Us</a><a href="https://webapps.acep.org/membership/account/#messageus?c=true&url=https://www.acep.org/cedr/&app=CEDR&to=U2FsdGVkX18ws8mNv3WgjkppwH8koQH32hvHJ7pQsdk=" target="_blank">Contact Us</a><a href="/who-we-are/about-us/about-us/contact/privacy-policy-and-copyright-notice/#terms" target="_blank">Terms of Use</a><a href="https://www.acep.org/who-we-are/about-us/about-us/contact/privacy-policy-and-copyright-notice/" target="_blank">Privacy Policy</a> </div>  <div class="footer-social"> <a href="http://www.facebook.com/ACEPFan" target="_blank" title="Visit us on Facebook" aria-label="Visit us on Facebook"><i class="fab fa-facebook-f"></i></a> <a href="https://twitter.com/acepnow" target="_blank" title="Follow us on Twitter" aria-label="Follow us on Twitter"><i class="fab fa-twitter"></i></a> <a href="https://www.linkedin.com/groups?home=&gid=51765" target="_blank" title="Visit us on LinkedIn" aria-label="Visit us on LinkedIn"><i class="fab fa-linkedin-in"></i></a> <a href="https://www.youtube.com/channel/UCXJmNBwfRY-qyj0CIpVH-WA" target="_blank" title="Visit us on YouTube" aria-label="Visit us on YouTube"><i class="fab fa-youtube"></i></a> </div>  <div class="corp-logo"> <a href="https://www.acep.org" aria-label="ACEP.org home page" target="_blank">American College of Emergency Physicians</a> </div> </section> </footer> </div>  <button class="material-scrolltop" type="button"></button> <script type="text/javascript" src="https://dl.episerver.net/13.5.10/epi-util/find.js"></script> <script type="text/javascript"> if(typeof FindApi === 'function'){var api = new FindApi();api.setApplicationUrl('/');api.setServiceApiBaseUrl('/find_v2/');api.processEventFromCurrentUri();api.bindWindowEvents();api.bindAClickEvent();api.sendBufferedEvents();} </script> <script src="/static/globalassets/resources/js/ddaccordion.js"></script> <script src="/static/globalassets/resources/js/material-scrolltop.js"></script> <script src="/_Multisites/ACEP/Areas/CEDR/Static/resources/js/main.js"></script><style> .stickHeader { width: 100%; padding: 0px; margin: 0; position: relative; z-index: 50; background-color: #2569af } .stickHeader .stickHeader-wrap { padding: 20px; margin: auto; width: 100%; max-width: 1560px } .stickHeader h1 { color: #fff; font-size: 1.1rem; line-height: 135%; font-weight: 700; text-align: left; padding: 0 0 10px; margin: 0 } .stickHeader p { color: #fff; text-align: left; font-size: 0.85rem; font-weight: 300; line-height: 135%; letter-spacing: 0.054rem; padding: 0 0 10px; margin: 0 } .sticky-chat { display:none; } </style><script type="text/javascript" src="https://analytics.clickdimensions.com/ts.js" > </script> <script type="text/javascript"> var cdAnalytics = new clickdimensions.Analytics('analytics.clickdimensions.com'); cdAnalytics.setAccountKey('awlqdAuo3nUKQAGcbxQ9OI'); cdAnalytics.setDomain('acep.org'); cdAnalytics.setScore(typeof(cdScore) == "undefined" ? 0 : (cdScore == 0 ? null : cdScore)); cdAnalytics.trackPage(); </script> <input type="hidden" id="meta_acepid" /> <input type="hidden" id="meta_contactid" /> <input type="hidden" value="" id="meta_isacepmember" /> <input type="hidden" value="https://ws.acep.org/" id="meta_wspath" /> <input type="hidden" value="https://webapps.acep.org/" id="meta_webappspath" /> <input type="hidden" value="YWRtaW46MTJuYWljbWVkcGEwNg==" id="meta_auth" /> <input type="hidden" value="https://www.acep.org/" id="meta_siteUrl" /> <script type="text/javascript"> function isWebview() { if (typeof window === undefined) { return false }; let navigator = window.navigator; const standalone = navigator.standalone; const userAgent = navigator.userAgent.toLowerCase(); const safari = /safari/.test(userAgent); //const ios = /iphone|ipod|ipad/macintosh.test(userAgent); const ios = /ipad|iphone|ipod/.test(userAgent) && !window.MSStream; const ios_ipad_webview = ios && !safari; return ios ? 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