EP Measure Specifications Overview

Quality Measure Wiki	Measure Set	Submission Date	Measure Files	Developer	Title	Description
0001 - wiki page	MU	Phase II	0001	AMA	Asthma Assessment	Percentage of patients aged 5 through 40 years with a diagnosis of asthma and who have been seen for at least 2 office visits, who were evaluated during at least one office visit within 12 months for the frequency (numeric) of daytime and nocturnal asthma symptoms.
0002 - wiki page	MU	Phase II	0002	NCQA	Appropriate Testing for Children with Pharyngitis	The percentage of children 2–18 years of age who were diagnosed with Pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test for the episode.
0004 - wiki page	PQRI/MU	1-Nov-10	0004	NCQA	Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: (a) Initiation, (b) Engagement	The percentage of adolescent and adult patients with a new episode of alcohol and other drug (AOD) dependence who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis and who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit.
0012 - wiki page	MU	Phase II	0012	AMA	Prenatal Care: Screening for Human Immunodeficiency Virus (HIV)	Percentage of patients, regardless of age, who gave birth during a 12-month period who were screened for HIV infection during the first or second prenatal visit.
0013 - wiki page	PQRI/MU	1-Nov-10	0013	AMA	Hypertension: Blood Pressure Measurement	Percentage of patient visits for patients aged 18 years and older with a diagnosis of hypertension who have been seen for at least 2 office visits, with blood pressure (BP) Recorded.
0014 - wiki page	MU	Phase II	0014	AMA	Prenatal Care: Anti-D Immune Globulin	Percentage of D (Rh) negative, unsensitized patients, regardless of age, who gave birth during a 12-month period who received anti-D immune globulin at 26-30 weeks gestation.
0018 - wiki page	MU	Phase II	0018	NCQA	Controlling High Blood Pressure	The percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose BP was adequately controlled during the measurement year.
[http://vistapedia.net/index.php?title=2011_EHR_Quality_Measure_Spec_0022 0022 - wiki page]	PQRI	1-Nov-10	[https://docs.google.com/fileview?id=0B7xIkIV4NePEYzNjNDQ3MDctMGZkYS00YzcwLTg5NjctY2ExMGMxY2MwZjM2&hl=en 2011 EHR Measure Specifications July2010-070110.pdf] (page 69-70)	DEV	NQF Measure #0022: Drugs to be Avoided in the Elderly	Percentage of patients ages 65 years and older who received at least one drug to be avoided in the elderly and/or two different drugs to be avoided in the elderly in the measurement period.
0024 - wiki page	PQRI/MU	1-Nov-10	0024	NCQA	Weight Assessment and Counseling for Children and Adolescents	The percentage of patients 2-17 years of age who had an outpatient visit with a PCP or OB/GYN and who had evidence of BMI percentile documentation, counseling for nutrition and counseling for physical activity during the measurement year.
0027 - wiki page	PQRI/MU	1-Nov-10	0027	NCQA	Smoking and Tobacco Use Cessation, Medical assistance: a. Advising Smokers and Tobacco Users to Quit, b. Discussing Smoking and Tobacco Use Cessation Medications, c. Discussing Smoking and Tobacco Use Cessation Strategies	The percentage of patients 18 years of age and older who were current smokers or tobacco users, who were seen by a practitioner during the measurement year and who received advice to quit smoking or tobacco use or whose practitioner recommended or discussed smoking or tobacco use cessation medications, methods or strategies.
0028a - wiki page	PQRI/MU	1-Nov-10	0028a	AMA	Preventive Care and Screening Measure Pair: a.Tobacco Use Assessment	Percentage of patients aged 18 years or older who have been seen for at least 2 office visits, who were queried about tobacco use one or more times within 24 months.
0028b - wiki page	PQRI/MU	1-Nov-10	0028b	AMA	Preventive Care and Screening Measure Pair: b.Tobacco Cessation Intervention	Percentage of patients aged 18 years and older identified as tobacco users within the past 24 months who received cessation intervention.
0031 - wiki page	PQRI/MU	1-Nov-10	0031	NCQA	Breast Cancer Screening	The percentage of women 40–69 years of age who had a mammogram to screen for breast cancer.
0032 - wiki page	MU	Phase II	0032	NCQA	Cervical Cancer Screening	The percentage of women 21-64 years of age who received one or more Pap tests to screen for cervical cancer.
0033 - wiki page	MU	Phase II	0033	NCQA	Chlamydia Screening for Women	The percentage of women 15-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year.
0034 - wiki page	PQRI/MU	1-Nov-10	0034	NCQA	Colorectal Cancer Screening	The percentage of adults 50–75 years of age who had appropriate screening for colorectal cancer.
0036 - wiki page	MU	Phase II	0036	NCQA	Use of Appropriate Medications for Asthma	The percentage of patients 5-50 years of age during the measurement year who were identified as having persistent asthma and were appropriately prescribed medication during the measurement year. Report three age stratifications (5-11 years, 12-50 years, and total).
0038 - wiki page	PQRI/MU	1-Nov-10	0038	NCQA	Childhood immunization Status	The percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV); one measles, mumps and rubella (MMR); two H influenza type B (HiB); three hepatitis B (Hep B), one chicken pox (VZV); four pneumococcal conjugate (PCV); two hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday. The measure calculates a rate for each vaccine and two separate combination rates.
0041 - wiki page	PQRI/MU	1-Nov-10	0041	AMA	Preventive Care and Screening: Influenza Immunization for Patients ≥ 50 Years Old	Percentage of patients aged 50 years and older who received an influenza immunization during the flu season (September through February).
0043 - wiki page	PQRI/MU	1-Nov-10	0043	NCQA	Pneumonia Vaccination Status for Older Adults	The percentage of patients 65 years of age and older as of January 1 of the measurement year who have ever received a pneumococcal vaccine.
0047 - wiki page	MU	Phase II	0047	AMA	Asthma Pharmacologic Therapy	Percentage of patients aged 5 through 40 years with a diagnosis of mild, moderate, or severe persistent asthma who were prescribed either the preferred long-term control medication (inhaled corticosteroid) or an acceptable alternative treatment.
0052 - wiki page	MU	Phase II	0052	NCQA	Low Back Pain: Use of Imaging Studies	The percentage of patients with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of diagnosis.
0055 - wiki page	MU	Phase II	0055	NCQA	Diabetes: Eye Exam	The percentage of patients 18–75 years of age with diabetes (type 1 or type 2) who had a retinal or dilated eye exam or a negative retinal exam (no evidence of retinopathy) by an eye care professional .
0056 - wiki page	MU	Phase II	0056	NCQA	Diabetes: Foot Exam	The percentage of patients aged 18-75 years with diabetes (type 1 or type 2) who had a foot exam (visual inspection, sensory exam with monofilament, or pulse exam).
0059 - wiki page	PQRI/MU	1-Nov-10	0059	NCQA	Diabetes: HbA1c Poor Control	The percentage of patients 18–75 years of age with diabetes (type 1 or type 2) who had HbA1c >9.0%.
0061 - wiki page	MU	Phase II	0061	NCQA	Diabetes: Blood Pressure Management	The percentage of patients 18–75 years of age with diabetes (type 1 or type 2) who had BP <140/90 mmHg.
0062 - wiki page	MU	Phase II	0062	NCQA	Diabetes: Urine Screening	The percentage of patients 18–75 years of age with diabetes (type 1 or type 2) who had a nephropathy screening test or evidence of nephropathy .
0064 - wiki page	PQRI/MU	1-Nov-10	0064	NCQA	Diabetes: LDL Management & Control	The percentage of patients 18–75 years of age with diabetes (type 1 or type 2) who had LDL-C <100mg/dL.
0067 - wiki page	MU	Phase II	0067	AMA	Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients with CAD	Percentage of patients aged 18 years and older with a diagnosis of CAD who were prescribed oral antiplatelet therapy.
0068 - wiki page	MU	Phase II	0068	NCQA	Ischemic Vascular Disease (IVD): Use of Aspirin or another Antithrombotic	The percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA) from January 1–November 1 of the year prior to the measurement year, or who had a diagnosis of ischemic vascular disease (IVD) during the measurement year and the year prior to the measurement year and who had documentation of use of aspirin or another antithrombotic during the measurement year.
0070 - wiki page	PQRI/MU	1-Nov-10	0070	AMA	Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI)	Percentage of patients aged 18 years and older with a diagnosis of CAD and prior MI who were prescribed beta-blocker therapy.
0073 - wiki page	MU	Phase II	0073	NCQA	Ischemic Vascular Disease (IVD): Blood Pressure Management	The percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA) from January 1–November 1 of the year prior to the measurement year, or who had a diagnosis of ischemic vascular disease (IVD) during the measurement year and the year prior to the measurement year and whose most recent blood pressure is in control (<140/90 mmHg).
0074 - wiki page	MU	Phase II	0074	AMA	Coronary Artery Disease (CAD): Drug Therapy for Lowering LDL-Cholesterol	Percentage of patients aged 18 years and older with a diagnosis of CAD who were prescribed a lipid-lowering therapy (based on current ACC/AHA guidelines).
0075 - wiki page	MU	Phase II	0075	NCQA	Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control	The percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA) from January 1–November 1 of the year prior to the measurement year, or who had a diagnosis of ischemic vascular disease (IVD) during the measurement year and the year prior to the measurement year and who had a complete lipid profile performed during the measurement year and whose LDL-C was <100 mg/dL.
0081 - wiki page	PQRI/MU	1-Nov-10	0081	AMA	Heart Failure (HF) : Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)	Percentage of patients aged 18 years and older with a diagnosis of heart failure and LVSD (LVEF < 40%) who were prescribed ACE inhibitor or ARB therapy.
0083 - wiki page	MU	Phase II	0083	AMA	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)	Percentage of patients aged 18 years and older with a diagnosis of heart failure who also have LVSD (LVEF < 40%) and who were prescribed beta-blocker therapy.
0084 - wiki page	MU	Phase II	0084	AMA	Heart Failure (HF) : Warfarin Therapy Patients with Atrial Fibrillation	Percentage of all patients aged 18 and older with a diagnosis of heart failure and paroxysmal or chronic atrial fibrillation who were prescribed warfarin therapy.
0086 - wiki page	MU	Phase II	0086	AMA	Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation	Percentage of patients aged 18 years and older with a diagnosis of POAG who have been seen for at least 2 office visits, who have an optic nerve head evaluation during one or more office visits within 12 months.
0088 - wiki page	MU	Phase II	0088	AMA	Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy	Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy and the presence or absence of macular edema during one or more office visits within 12 months.
0089 - wiki page	MU	Phase II	0089	AMA	Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care	Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the on-going care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months.
0105 - wiki page	MU	Phase II	0105	NCQA	Anti‐depressant medication management: (a) Effective Acute Phase Treatment, (b)Effective Continuation Phase Treatment	The percentage of patients 18 years of age and older who were diagnosed with a new episode of major depression, treated with antidepressant medication, and who remained on an antidepressant medication treatment.
0385 - wiki page	MU	Phase II	0385	AMA	Oncology Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients	Percentage of patients aged 18 years and older with Stage IIIA through IIIC colon cancer who are referred for adjuvant chemotherapy, prescribed adjuvant chemotherapy, or have previously received adjuvant chemotherapy within the 12-month reporting period.
0387 - wiki page	MU	Phase II	0387	AMA	Oncology Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer	Percentage of female patients aged 18 years and older with Stage IC through IIIC, ER or PR positive breast cancer who were prescribed tamoxifen or aromatase inhibitor (AI) during the 12-month reporting period.
0389 - wiki page	MU	Phase II	0389	AMA	Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients	Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer
0421 - wiki page	PQRI/MU	1-Nov-10	0421	QIP	Adult Weight Screening and Follow-Up	Percentage of patients aged 18 years and older with a calculated BMI in the past six months or during the current visit documented in the medical Record AND if the most recent BMI is outside parameters, a follow-up plan is documented.
0575 - wiki page	MU	Phase II	0575	NCQA	Diabetes: HbA1c Control (<8%)	The percentage of patients 18–75 years of age with diabetes (type 1 or type 2) who had HbA1c <8.0%.
39 - wiki page	PQRI	1-Nov-10	[https://docs.google.com/fileview?id=0B7xIkIV4NePEYzNjNDQ3MDctMGZkYS00YzcwLTg5NjctY2ExMGMxY2MwZjM2&hl=en 2011 EHR Measure Specifications July2010-070110.pdf] (page 27-29)	DEV	Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older	Percentage of female patients aged 65 years and older who have a central dual-energy X-ray absorptiometry (DXA) measurement ordered or performed at least once since age 60 or pharmacologic therapy prescribed within 12 months .
47 - wiki page	PQRI	1-Nov-10	2011 EHR Measure Specifications July2010-070110.pdf (page 30-31)	DEV	Advance Care Plan	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.
48 - wiki page	PQRI	1-Nov-10	[https://docs.google.com/fileview?id=0B7xIkIV4NePEYzNjNDQ3MDctMGZkYS00YzcwLTg5NjctY2ExMGMxY2MwZjM2&hl=en 2011 EHR Measure Specifications July2010-070110.pdf] (page 32-34)	DEV	Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older	Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months.
124 - wiki page	PQRI	1-Nov-10	[https://docs.google.com/fileview?id=0B7xIkIV4NePEYzNjNDQ3MDctMGZkYS00YzcwLTg5NjctY2ExMGMxY2MwZjM2&hl=en 2011 EHR Measure Specifications July2010-070110.pdf] (page 50-52)	DEV	Health Information Technology (HIT): Adoption/Use of Electronic Health Records (EHR)	Documents whether provider has adopted and is using health information technology. To qualify, the provider must have adopted and be using a certified/qualified electronic health Record (EHR).

SOURCES

Quality Measures / Electronic Specifications
https://www.cms.gov/QualityMeasures/03_ElectronicSpecifications.asp

EP Measure Specifications [ZIP, 6.35 MB] - (Measure Overview/Description, Measure Logic, Measure Code Lists and QDS Elements)

https://www.cms.gov/QualityMeasures/Downloads/EP_MeasureSpecifications.zip

Eligible Professional Clinical Quality Measures [PDF 52 KB] - (Instructions for Reporting Numerators, Denominators & Exclusions)
https://www.cms.gov/QualityMeasures/Downloads/QMEligibleProfessionalCQM.pdf

Physician Quality Reporting Initiative / Alternative Reporting Mechanisms
https://www.cms.gov/PQRI/20_AlternativeReportingMechanisms.asp

2011 EHR Documents for Eligible Professionals [ZIP 2MB] - (2011 EHR Measure Specifications)

https://www.cms.gov/PQRI/Downloads/EHR_Docs_for_Vendors_080610.zip