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Excludes benchmarks that are below the minimum unique entity submission threshold." + ], + "submissionMethod" : "registry" + }, + { + "benchmarkYear" : 2024, + "measureId" : "VHE6", + "performanceYear" : 2026, + "reasonCodes" : [ + "BR-009" + ], + "reasonDescriptions" : [ + "Excludes measurements that do not meet case count or reporting rate minimums. Excludes benchmarks that are below the minimum unique entity submission threshold." + ], + "submissionMethod" : "registry" + } +] diff --git a/staging/2026/benchmarks/benchmarks.csv b/staging/2026/benchmarks/benchmarks.csv new file mode 100644 index 00000000..e0cd0233 --- /dev/null +++ b/staging/2026/benchmarks/benchmarks.csv @@ -0,0 +1,247 @@ +measureName,measureId,submissionMethod,measureType,standardDeviation,averagePerformanceRate,isToppedOut,isToppedOutByProgram,percentile1,percentile10,percentile20,percentile30,percentile40,percentile50,percentile60,percentile70,percentile80,percentile90,percentile99,isHighPriority,isInverse,metricType +Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention,226,MIPS CQM,Process,25.709760122745568,85.77,Yes,Yes,4.17,41.67,75.0,90.77,98.65,100.0,100.0,100.0,100.0,100.0,100.0,N,N,multiPerformanceRate +Initiation and Engagement of Substance Use Disorder Treatment,305,eCQM,Process,8.085166020709718,7.86,No,No,0.4,1.79,2.85,3.82,4.64,5.56,6.63,8.0,10.5,16.2,41.67,Y,N,multiPerformanceRate +Lung Cancer Reporting (Resection Specimens),396,MIPS CQM,Process,0.8672101287446828,99.85,Yes,No,84.0,86.0,88.0,90.0,92.0,94.0,96.0,98.0,99.0,100.0,100.0,Y,N,singlePerformanceRate +Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care,019,eCQM,Process,20.02913930347261,86.65,No,No,6.56,60.47,81.27,88.52,92.24,94.3,96.23,97.75,99.01,100.0,100.0,Y,N,singlePerformanceRate +Elder Maltreatment Screen and Follow-Up Plan,181,Medicare Part B Claims,Process,18.056638709720808,95.30,Yes,Yes,0.71,98.51,99.83,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate +Functional Status Change for Patients with Knee Impairments,217,MIPS CQM,Patient-Reported Outcome-Based Performance Measure (PRO-PM),22.349068796791986,78.83,No,No,6.67,44.07,61.9,67.66,76.74,83.5,93.94,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate +Avoidance of Opioid therapy for dental pain.,ACEP62,QCDR Measure,Process,7.956221888301932,85.13,No,No,65.79,75.93,80.29,81.72,83.17,85.045,87.5,88.89,92.02,96.09,99.39,Y,N,registrySinglePerformanceRate +Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%),007,MIPS CQM,Process,6.100647019485561,97.61,Yes,Yes,75.0,90.82,98.15,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,N,N,singlePerformanceRate +Appropriate Treatment for Upper Respiratory Infection (URI),065,eCQM,Process,14.253378610128015,88.61,No,No,33.33,70.92,82.26,87.5,90.71,93.165,95.35,97.16,99.02,100.0,100.0,Y,N,singlePerformanceRate +Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity,177,MIPS CQM,Process,14.275237381955264,93.41,Yes,Yes,24.33,81.585,90.65,96.34,98.52,99.62,100.0,100.0,100.0,100.0,100.0,N,N,singlePerformanceRate +Melanoma Reporting,397,MIPS CQM,Process,13.478862305370125,97.14,Yes,No,84.0,86.0,88.0,90.0,92.0,94.0,96.0,98.0,99.0,100.0,100.0,Y,N,singlePerformanceRate +Functional Status After Primary Total Knee Replacement,470,MIPS CQM,Patient-Reported Outcome-Based Performance Measure (PRO-PM),24.99887423267097,28.10,No,No,0.15,3.57,6.75,11.54,15.425,19.57,28.78,34.81,44.92,60.66,100.0,Y,N,singlePerformanceRate +Appropriate Screening and Plan of Care for Elevated Intraocular Pressure Following Intravitreal or Periocular Steroid Therapy,499,MIPS CQM,Process,21.993334989430295,71.11,No,No,4.39,42.86,53.16,63.89,70.45,76.27,80.65,84.85,89.66,94.94,100.0,N,N,singlePerformanceRate +Patients Suffering From a Lower Extremity Injury who Improve Pain,MSK9,QCDR Measure,Patient-Reported Outcome-Based Performance Measure (PRO-PM),7.051190931033896,55.13,No,No,40.0,46.67,50.0,51.32,53.33,54.89,56.61,58.85,61.54,64.29,69.88,Y,N,registrySinglePerformanceRate +Tunneled Hemodialysis Catheter Clinical Success Rate,RCOIR12,QCDR Measure,Outcome,7.706761687352553,87.11,Yes,No,69.14,73.48,82.78,85.99,88.27,89.85,90.04,91.75,93.19,93.73,98.74,Y,N,registrySinglePerformanceRate +Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older,024,Medicare Part B Claims,Process,0.0,100.00,Yes,No,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate +Unplanned Reoperation within the 30-Day Postoperative Period,355,MIPS CQM,Outcome,2.7429999265337406,0.35,No,No,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0.4,5.0,Y,Y,singlePerformanceRate +Melanoma Reporting,397,Medicare Part B Claims,Process,1.383542948529438,99.53,Yes,No,84.0,86.0,88.0,90.0,92.0,94.0,96.0,98.0,99.0,100.0,100.0,Y,N,singlePerformanceRate +Tobacco Use: Screening and Cessation Intervention for Patients with Asthma and COPD,ACEP25,QCDR Measure,Process,14.208665653869877,88.06,No,No,21.62,76.64,80.945,86.75,89.58,92.53,94.495,96.81,97.975,98.88,99.48,N,N,registrySinglePerformanceRate +Patients Suffering From an Upper Extremity Injury who Improve Physical Function,MSK2,QCDR Measure,Patient-Reported Outcome-Based Performance Measure (PRO-PM),10.128198251116418,54.51,No,No,38.71,45.37,48.37,50.0,52.05,53.37,54.72,56.25,58.12,60.71,96.79,Y,N,registrySinglePerformanceRate +Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%),007,eCQM,Process,9.345787304551427,87.44,No,No,55.56,78.46,82.7,85.48,87.5,89.25,90.49,91.91,93.55,95.97,100.0,N,N,singlePerformanceRate +Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention,226,Medicare Part B Claims,Process,17.25916427498292,93.70,Yes,Yes,8.51,80.0,95.65,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,N,N,multiPerformanceRate +Optimizing Patient Exposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines,364,MIPS CQM,Process,19.114571363747046,90.84,Yes,No,84.0,86.0,88.0,90.0,92.0,94.0,96.0,98.0,99.0,100.0,100.0,Y,N,singlePerformanceRate +Psoriasis: Clinical Response to Systemic Medications,410,MIPS CQM,Intermediate Outcome,21.304774956545725,88.39,No,No,6.67,59.26,80.25,90.91,97.37,100.0,100.0,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate +Urinary Bladder Cancer: Complete Analysis and Timely Reporting,CAP30,QCDR Measure,Process,12.657724388180835,91.12,Yes,No,32.56,72.32,80.09,92.11,95.12,95.81,98.31,100.0,100.0,100.0,100.0,Y,N,registrySinglePerformanceRate +Use of Breast Cancer Risk Score on Mammography,QMM18,QCDR Measure,Process,28.095013684175143,87.21,Yes,Yes,0.03,36.68,86.3,97.71,99.9,100.0,100.0,100.0,100.0,100.0,100.0,Y,N,registrySinglePerformanceRate +Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents,239,eCQM,Process,18.96565295215909,39.37,No,No,2.94,22.69,26.91,29.53,31.79,33.33,36.51,42.3,53.545,68.395,95.38,N,N,multiPerformanceRate +Sleep Apnea: Assessment of Adherence to Obstructive Sleep Apnea (OSA) Therapy.,279,MIPS CQM,Process,8.190730163294521,98.17,Yes,Yes,45.97,99.63,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,N,N,singlePerformanceRate +Dysphonia: Laryngeal Examination,AAO37,QCDR Measure,Process,22.805914060702417,74.31,No,No,3.67,42.31,58.895,66.94,72.075,80.77,88.56,90.0,92.59,95.42,100.0,Y,N,registrySinglePerformanceRate +Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients,406,Medicare Part B Claims,Process,18.342965428356518,9.16,Yes,No,0.0,0.0,1.0,2.0,4.0,6.0,8.0,10.0,12.0,14.0,16.0,Y,Y,singlePerformanceRate +Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients,320,MIPS CQM,Process,17.6908065296427,93.54,Yes,Yes,5.73,88.74,95.3,97.73,99.15,100.0,100.0,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate +Avoidance of Acute High-Risk Prescriptions in geriatric patients at discharge,ACEP63,QCDR Measure,Process,2.087040665862262,4.68,Yes,No,0.03,1.89,3.25,3.75,4.24,4.68,5.2,5.52,6.22,6.68,11.59,Y,Y,registrySinglePerformanceRate +Hammer Toe Outcome,MEX5,QCDR Measure,Patient-Reported Outcome-Based Performance Measure (PRO-PM),27.64469153818769,26.49,No,No,0.89,2.13,4.72,6.3,12.43,15.59,20.75,32.0,50.0,74.01,100.0,Y,N,registrySinglePerformanceRate +Avoidance of Cerebral Hyperthermia for Procedures Involving Cardiopulmonary Bypass,AQI65,QCDR Measure,Outcome,13.444159992157816,93.52,No,No,48.08,75.875,88.355,96.91,100.0,100.0,100.0,100.0,100.0,100.0,100.0,Y,N,registrySinglePerformanceRate +Diabetes: Glycemic Status Assessment Greater Than 9%,001SSP,MIPS CQM,Intermediate Outcome,17.775245366066276,25.78,No,No,3.87,7.03,10.14,14.33,18.93,22.27,25.93,29.76,38.28,49.19,80.94,Y,Y,singlePerformanceRate +Screening for Osteoporosis for Women Aged 65-85 Years of Age,039,Medicare Part B Claims,Process,27.46747259417232,76.84,No,No,0.68,32.35,57.28,67.44,79.01,87.255,94.63,98.68,100.0,100.0,100.0,N,N,singlePerformanceRate +Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan,128,eCQM,Process,28.163258162410486,71.71,No,No,4.5,31.26,38.65,61.6,77.91,85.71,90.17,91.5,94.76,96.69,99.49,N,N,singlePerformanceRate +Avoidance of Post-operative Systemic Antibiotics for Office-based Closures and Reconstruction After Skin Cancer Procedures,AAD16,QCDR Measure,Process,12.42949584564677,4.51,Yes,Yes,0.0,0.0,0.0,0.0,0.0,0.305,1.69,3.06,5.02,11.76,83.33,Y,Y,registryMultiPerformanceRate +Patient-Reported Experience with Anesthesia,AQI48,QCDR Measure,Patient-Reported Outcome-Based Performance Measure (PRO-PM),3.1598832196336755,94.73,No,No,83.33,89.72,92.84,94.2,94.75,95.68,95.97,96.47,97.14,97.78,98.75,Y,N,registryMultiPerformanceRate +Glaucoma – Intraocular Pressure Reduction,IRIS2,QCDR Measure,Intermediate Outcome,4.639099989557022,92.40,No,No,77.78,87.01,89.5,90.83,91.93,92.98,93.98,94.91,96.04,97.47,100.0,Y,N,registrySinglePerformanceRate +Screening Abdominal Aortic Aneurysm Reporting with Recommendations,QMM26,QCDR Measure,Process,38.359504354371026,71.69,Yes,No,1.11,6.25,21.27,49.01,90.33,100.0,100.0,100.0,100.0,100.0,100.0,Y,N,registrySinglePerformanceRate +Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery,191,eCQM,Outcome,10.072927267356294,95.45,No,No,41.31,92.02,94.99,96.415,97.405,98.07,98.68,99.135,99.705,100.0,100.0,Y,N,singlePerformanceRate +Functional Status Change for Patients with Hip Impairments,218,MIPS CQM,Patient-Reported Outcome-Based Performance Measure (PRO-PM),22.32255981775237,78.38,No,No,19.35,47.37,58.33,67.5,75.0,81.6,93.75,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate +Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented,317,MIPS CQM,Process,34.198384811466354,73.53,Yes,No,0.13,18.855,32.485,54.275,82.65,97.655,100.0,100.0,100.0,100.0,100.0,N,N,singlePerformanceRate +Closing the Referral Loop: Receipt of Specialist Report,374,eCQM,Process,30.987920736882845,46.43,No,No,0.57,5.77,15.69,24.96,33.79,42.86,52.175,62.5,79.54,95.76,100.0,Y,N,singlePerformanceRate +Optimal Asthma Control,398,MIPS CQM,Outcome,25.354995057498055,80.16,No,No,14.81,33.33,59.42,73.42,82.96,95.38,98.54,100.0,100.0,100.0,100.0,Y,N,multiPerformanceRate +Appropriate Treatment for Patients with Stage I (T1c) - III HER2 Positive Breast Cancer,450,MIPS CQM,Process,10.62781261233303,92.89,Yes,No,42.86,80.43,85.16,90.0,95.45,98.8,100.0,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate +Patients Suffering From a Back Injury who Improve Pain,MSK8,QCDR Measure,Patient-Reported Outcome-Based Performance Measure (PRO-PM),7.753100222525978,54.48,No,No,37.14,44.0,47.62,50.0,52.74,55.0,57.14,59.09,61.22,64.29,70.0,Y,N,registrySinglePerformanceRate +Heel Pain Treatment Outcomes for Adults,REGCLR1,QCDR Measure,Patient-Reported Outcome-Based Performance Measure (PRO-PM),25.913429529878904,44.91,No,No,1.09,13.39,21.03,28.81,34.045,41.82,51.715,57.14,67.63,82.81,100.0,Y,N,registrySinglePerformanceRate +Oncology: Medical and Radiation - Pain Intensity Quantified,143,MIPS CQM,Process,17.047463392671887,92.71,Yes,No,84.0,86.0,88.0,90.0,92.0,94.0,96.0,98.0,99.0,100.0,100.0,Y,N,singlePerformanceRate +Total Knee or Hip Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy,350,MIPS CQM,Process,32.83227225578175,82.49,Yes,No,84.0,86.0,88.0,90.0,92.0,94.0,96.0,98.0,99.0,100.0,100.0,Y,N,singlePerformanceRate +Unplanned Hospital Readmission within 30 Days of Principal Procedure,356,MIPS CQM,Outcome,1.602228008491603,0.79,No,No,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0.0,1.45,3.03,6.73,Y,Y,singlePerformanceRate +Psoriasis - Improvement in Patient-Reported Itch Severity,485,MIPS CQM,Patient-Reported Outcome-Based Performance Measure (PRO-PM),24.927472244119777,52.11,No,No,4.44,22.58,32.09,38.22,43.1,48.0,53.85,61.67,71.64,96.97,100.0,Y,N,singlePerformanceRate +Stones: Repeat Shock Wave Lithotripsy (SWL) Within 6 Months of Initial Treatment,AQUA14,QCDR Measure,Outcome,4.72661797274938,4.20,No,No,0.0,0.0,0.62,1.52,2.33,2.685,3.45,4.5,8.27,10.28,21.54,Y,Y,registrySinglePerformanceRate +Low dose cancer screening recommendation for computed tomography (CT) and computed tomography angiography (CTA) of chest with diagnosis of Emphysema.,QMM23,QCDR Measure,Process,36.033120594356554,77.96,Yes,No,0.65,5.94,40.44,83.78,97.78,100.0,100.0,100.0,100.0,100.0,100.0,Y,N,registrySinglePerformanceRate +Appropriate Emergency Department Utilization of CT for Pulmonary Embolism,ACEP22,QCDR Measure,Process,17.332456359859233,69.53,No,No,27.91,48.87,55.27,60.08,63.54,66.45,74.41,79.9,82.71,97.9,100.0,Y,N,registrySinglePerformanceRate +Repeat screening or surveillance colonoscopy recommended within one year due to inadequate bowel preparation,NHCR4,QCDR Measure,Process,16.201294470160867,89.71,Yes,No,29.79,61.9,84.38,92.49,95.0,96.265,97.73,99.28,100.0,100.0,100.0,Y,N,registrySinglePerformanceRate +Documentation of Current Medications in the Medical Record,130,MIPS CQM,Process,21.33896057028402,92.26,Yes,Yes,3.65,78.38,96.34,99.49,100.0,100.0,100.0,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate +Oncology: Medical and Radiation - Pain Intensity Quantified,143,eCQM,Process,32.449031378442804,77.99,Yes,No,84.0,86.0,88.0,90.0,92.0,94.0,96.0,98.0,99.0,100.0,100.0,Y,N,singlePerformanceRate +Controlling High Blood Pressure,236SSP,MIPS CQM,Intermediate Outcome,15.193681731858517,67.87,No,No,13.68,44.87,62.33,68.17,70.15,72.54,74.09,74.7,76.42,82.81,90.53,Y,N,singlePerformanceRate +Rehabilitative Therapy Referral for Patients with Parkinson's Disease,293,MIPS CQM,Process,16.799256060326055,95.08,Yes,Yes,9.09,91.3,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate +Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD),008,MIPS CQM,Process,5.6286018490838545,98.50,Yes,Yes,69.05,95.79,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,N,N,singlePerformanceRate +Follow-Up Care for Children Prescribed ADHD Medication,366,eCQM,Process,18.20720259957118,44.14,No,No,11.89,23.91,29.74,33.33,37.195,40.68,46.605,51.35,56.645,65.62,100.0,N,N,multiPerformanceRate +Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery,384,MIPS CQM,Outcome,6.577519490050889,94.65,Yes,Yes,71.43,87.1,91.95,93.33,94.67,96.67,97.14,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate +Standard Benign Positional Paroxysmal Vertigo (BPPV) Management,AAO32,QCDR Measure,Process,0.0,0.00,Yes,Yes,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0.0,Y,Y,registrySinglePerformanceRate +Chronic Skin Conditions: Patient Reported Quality-of-Life,AAD8,QCDR Measure,Process,33.57856002471418,36.45,No,No,0.76,3.78,5.43,11.48,15.86,21.4,28.17,58.97,74.94,83.46,95.57,Y,N,registrySinglePerformanceRate +Coronary Artery Disease (CAD): Antiplatelet Therapy,006,MIPS CQM,Process,14.729578245813192,91.60,Yes,Yes,38.16,70.14,80.57,92.16,99.38,100.0,100.0,100.0,100.0,100.0,100.0,N,N,singlePerformanceRate +Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 20% OR Documentation of a Plan of Care.,141,Medicare Part B Claims,Outcome,19.402245099577954,93.64,No,No,84.0,86.0,88.0,90.0,92.0,94.0,96.0,98.0,99.0,100.0,100.0,Y,N,singlePerformanceRate +Complications After Cataract Surgery,IRIS54,QCDR Measure,Outcome,0.9821940682744031,0.45,No,No,0.0,0.0,0.0,0.0,0.0,0.19,0.325,0.49,0.705,1.13,3.32,Y,Y,registrySinglePerformanceRate +Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD),008,eCQM,Process,7.982139385136781,91.56,No,No,57.14,83.33,87.93,90.32,92.19,93.645,94.74,95.65,96.67,98.15,100.0,N,N,singlePerformanceRate +Radiology: Exposure Dose Indices Reported for Procedures Using Fluoroscopy,145,MIPS CQM,Process,22.217177563954074,91.31,Yes,Yes,1.83,68.31,95.04,99.28,100.0,100.0,100.0,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate +Rheumatoid Arthritis (RA): Functional Status Assessment,178,MIPS CQM,Process,19.668234667116163,91.32,Yes,Yes,0.11,64.73,90.91,97.53,99.4,99.89,100.0,100.0,100.0,100.0,100.0,N,N,singlePerformanceRate +Screening for Osteoporosis for Women Aged 65-85 Years of Age,039,MIPS CQM,Process,30.977154395879335,59.10,No,No,0.31,6.37,28.87,45.5,55.71,63.96,72.03,80.65,88.955,99.0,100.0,N,N,singlePerformanceRate +Appropriate Treatment for Upper Respiratory Infection (URI),065,MIPS CQM,Process,9.97005496712184,96.20,Yes,Yes,38.75,91.8,95.71,97.68,98.89,99.51,100.0,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate +Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia,286,MIPS CQM,Process,15.190000172267569,96.57,Yes,Yes,3.7,97.21,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate +Total Knee or Hip Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation,351,MIPS CQM,Process,19.959740793639206,92.60,Yes,No,84.0,86.0,88.0,90.0,92.0,94.0,96.0,98.0,99.0,100.0,100.0,Y,N,singlePerformanceRate +Lung Cancer Reporting (Biopsy/Cytology Specimens),395,Medicare Part B Claims,Process,13.225895631067953,95.96,Yes,No,84.0,86.0,88.0,90.0,92.0,94.0,96.0,98.0,99.0,100.0,100.0,Y,N,singlePerformanceRate +Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status,491,MIPS CQM,Process,14.458141188790423,92.70,Yes,No,20.29,75.76,88.75,95.31,97.87,99.675,100.0,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate +Psoriasis – Appropriate Assessment & Treatment of Severe Psoriasis,AAD15,QCDR Measure,Process,25.622223637774773,75.89,No,No,6.45,34.32,54.035,69.57,76.25,86.42,91.67,95.0,97.855,100.0,100.0,N,N,registrySinglePerformanceRate +Radical Prostatectomy Pathology Reporting,250,MIPS CQM,Process,0.7212934077569166,99.90,Yes,No,84.0,86.0,88.0,90.0,92.0,94.0,96.0,98.0,99.0,100.0,100.0,N,N,singlePerformanceRate +Appropriate Follow-up Imaging for Incidental Thyroid Nodules in Patients,406,MIPS CQM,Process,14.739936879128779,5.44,Yes,No,0.0,0.0,1.0,2.0,4.0,6.0,8.0,10.0,12.0,14.0,16.0,Y,Y,singlePerformanceRate +Use of Anxiety Severity Measure,MBHR1,QCDR Measure,Process,16.28032449659053,92.39,Yes,No,25.2,86.11,89.19,93.24,95.87,98.28,99.23,100.0,100.0,100.0,100.0,N,N,registrySinglePerformanceRate +Oncology: Hepatitis B Serology Testing and Prophylactic Treatment Prior to Receiving Anti-CD20 Targeting Drugs,PIMSH10,QCDR Measure,Process,27.048828886740072,62.24,No,No,1.9,16.0,43.1,54.8,61.5,68.3,71.7,74.6,86.4,93.5,100.0,Y,N,registrySinglePerformanceRate +"Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy - Neurological Evaluation",126,MIPS CQM,Process,30.9578988988768,80.25,Yes,Yes,0.32,21.28,57.4,79.84,94.06,99.46,100.0,100.0,100.0,100.0,100.0,N,N,singlePerformanceRate +Falls: Screening for Future Fall Risk,318,eCQM,Process,34.3443897701942,67.34,No,No,0.15,7.93,29.04,50.47,67.97,81.565,90.86,96.67,99.05,99.86,100.0,Y,N,singlePerformanceRate +Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse),331,MIPS CQM,Process,29.73740237974978,24.51,No,No,0.0,0.0,0.0,0.0,3.45,8.33,18.75,38.6,59.17,74.35,91.67,Y,Y,singlePerformanceRate +Closing the Referral Loop: Receipt of Specialist Report,374,MIPS CQM,Process,23.65242326549335,89.54,Yes,Yes,1.54,56.72,90.0,97.37,100.0,100.0,100.0,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate +Functional Status Change for Patients with Shoulder Impairments,221,MIPS CQM,Patient-Reported Outcome-Based Performance Measure (PRO-PM),22.37687845579282,78.26,No,No,18.18,42.7,59.84,70.83,77.17,84.53,91.3,96.72,100.0,100.0,100.0,Y,N,singlePerformanceRate +Controlling High Blood Pressure,236,Medicare Part B Claims,Intermediate Outcome,17.22710097149586,79.68,No,No,1.0,10.0,20.0,30.0,40.0,50.0,60.0,70.0,80.0,90.0,99.0,Y,N,singlePerformanceRate +Controlling High Blood Pressure,236,MIPS CQM,Intermediate Outcome,20.175867050495135,68.71,No,No,1.0,10.0,20.0,30.0,40.0,50.0,60.0,70.0,80.0,90.0,99.0,Y,N,singlePerformanceRate +Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older,415,MIPS CQM,Efficiency,6.516523541459056,97.14,Yes,Yes,63.39,93.9,96.69,97.76,98.5,99.44,100.0,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate +Syncope – Avoidance of admission for adult patients with low-risk syncope,ACEP60,QCDR Measure,Outcome,5.690618741156286,90.84,No,No,71.89,83.67,86.3,88.35,90.36,91.57,92.84,93.94,95.78,97.99,100.0,Y,N,registrySinglePerformanceRate +Avoidance of admission for adult patients in Emergency Department with low-risk Deep Vein Thrombosis (DVT).,ACEP64,QCDR Measure,Outcome,21.461711470545076,72.28,No,No,27.11,44.44,52.03,57.56,63.72,69.74,79.72,91.89,97.37,100.0,100.0,Y,N,registrySinglePerformanceRate +Avoidance of Long-Acting (LA) or Extended-Release (ER) Opiate Prescriptions and Opiate Prescriptions for Greater Than 3 Days Duration for Acute Pain,ECPR55,QCDR Measure,Process,7.5436064859077305,90.82,No,No,77.06,80.5,83.03,85.26,88.59,91.83,93.94,97.16,100.0,100.0,100.0,Y,N,registrySinglePerformanceRate +Functional Status Assessments for Heart Failure,377,eCQM,Process,5.168611373051859,3.95,No,No,0.04,0.17,0.285,0.7,0.83,1.09,2.71,4.465,6.655,12.305,22.59,Y,N,singlePerformanceRate +Diabetes: Glycemic Status Assessment Greater Than 9%,001,MIPS CQM,Intermediate Outcome,21.914788843548823,23.12,No,No,1.0,10.0,20.0,30.0,40.0,50.0,60.0,70.0,80.0,90.0,99.0,Y,Y,singlePerformanceRate +Radiology: Exposure Dose Indices Reported for Procedures Using Fluoroscopy,145,Medicare Part B Claims,Process,27.159563365989193,86.28,Yes,Yes,1.44,35.0,80.3,95.345,100.0,100.0,100.0,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate +"Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments",219,MIPS CQM,Patient-Reported Outcome-Based Performance Measure (PRO-PM),22.49745847775994,78.79,No,No,11.76,45.37,59.18,68.64,78.26,83.33,92.31,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate +Barrett's Esophagus,249,Medicare Part B Claims,Process,0.0,100.00,Yes,No,84.0,86.0,88.0,90.0,92.0,94.0,96.0,98.0,99.0,100.0,100.0,N,N,singlePerformanceRate +Assessment of Cognitive Impairment or Dysfunction for Patients with Parkinson's Disease,291,MIPS CQM,Process,14.760640812722434,94.04,Yes,Yes,23.06,78.68,92.31,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,N,N,singlePerformanceRate +Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented,317,Medicare Part B Claims,Process,28.24985452515902,87.15,Yes,Yes,0.27,34.76,89.99,98.33,99.68,100.0,100.0,100.0,100.0,100.0,100.0,N,N,singlePerformanceRate +Lung Cancer Reporting (Biopsy/Cytology Specimens),395,MIPS CQM,Process,2.1805417363566586,99.62,Yes,No,84.0,86.0,88.0,90.0,92.0,94.0,96.0,98.0,99.0,100.0,100.0,Y,N,singlePerformanceRate +"Multi-strata weighted average for 3 CT Exam Types: Overall Percent of CT exams for which Dose Length Product is at or below the size-specific diagnostic reference level (for CT Abdomen-pelvis with contrast/single phase scan, CT Chest without contrast/single phase scan and CT Head/Brain without contrast/single phase scan)",ACRAD34,QCDR Measure,Outcome,12.2153851116027,86.30,No,No,37.32,70.38,81.7,82.07,86.9,89.71,91.23,94.32,96.0,96.61,99.93,Y,N,registryMultiPerformanceRate +Hospital Admissions or Infectious Complications Within 30 days of Prostate Biopsy,AQUA8,QCDR Measure,Outcome,3.0973599997827135,2.08,No,No,0.0,0.0,0.0,0.0,0.63,0.98,1.32,2.2,3.41,6.23,14.52,Y,Y,registrySinglePerformanceRate +Patients Suffering From a Knee Injury who Improve Pain,MSK10,QCDR Measure,Patient-Reported Outcome-Based Performance Measure (PRO-PM),5.957021286373333,53.82,No,No,40.0,46.67,48.57,50.0,52.17,53.85,55.56,57.14,59.09,61.29,66.67,Y,N,registrySinglePerformanceRate +"Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention - Evaluation of Footwear",127,MIPS CQM,Process,25.898609224633162,86.80,Yes,Yes,0.54,42.0,80.83,94.62,99.28,100.0,100.0,100.0,100.0,100.0,100.0,N,N,singlePerformanceRate +Childhood Immunization Status,240,eCQM,Process,14.110425274249176,24.80,No,No,1.23,8.0,12.93,16.39,19.51,23.065,27.02,30.67,35.14,43.48,67.49,N,N,singlePerformanceRate +Chlamydia Screening in Women,310,eCQM,Process,19.22478378073111,19.72,No,No,0.27,1.55,2.79,4.35,7.47,13.09,20.0,28.66,35.54,47.81,74.24,N,N,singlePerformanceRate +Patient-Centered Surgical Risk Assessment and Communication,358,MIPS CQM,Process,26.746147098743,88.96,Yes,Yes,0.85,45.71,95.04,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate +Statin Therapy for the Prevention and Treatment of Cardiovascular Disease,438,MIPS CQM,Process,21.068358868120093,75.60,No,No,15.88,42.85,58.74,68.81,73.655,78.03,83.525,89.27,99.775,100.0,100.0,N,N,singlePerformanceRate +Percentage of Patients Who Died from Cancer Receiving Systemic Cancer-Directed Therapy in the Last 14 Days of Life (lower score – better),453,MIPS CQM,Process,7.176918211891407,8.37,No,No,0.0,0.0,0.24,3.61,6.25,7.655,9.52,10.87,14.11,17.95,27.78,Y,Y,singlePerformanceRate +Skin Cancer: Biopsy Reporting Time - Clinician to Patient,AAD6,QCDR Measure,Process,11.691820601868859,96.32,Yes,Yes,29.12,90.56,96.815,98.905,99.475,99.8,100.0,100.0,100.0,100.0,100.0,Y,N,registrySinglePerformanceRate +Squamous Cell Skin Cancer: Complete Reporting,CAP40,QCDR Measure,Process,29.600093804341338,83.77,Yes,No,0.1,35.71,70.91,94.52,100.0,100.0,100.0,100.0,100.0,100.0,100.0,Y,N,registrySinglePerformanceRate +Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation and Long-Acting Inhaled Bronchodilator Therapy,052,MIPS CQM,Process,23.999162252890823,85.98,Yes,No,0.42,45.05,73.64,90.38,95.74,98.76,100.0,100.0,100.0,100.0,100.0,N,N,multiPerformanceRate +Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 20% OR Documentation of a Plan of Care.,141,MIPS CQM,Outcome,9.67055194004787,98.17,Yes,No,34.95,98.45,99.4,99.69,99.87,100.0,100.0,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate +Rheumatoid Arthritis (RA): Glucocorticoid Management,180,MIPS CQM,Process,14.608298422282925,92.89,Yes,Yes,13.67,78.44,90.77,92.96,96.64,99.8,100.0,100.0,100.0,100.0,100.0,N,N,singlePerformanceRate +Cardiac Rehabilitation Patient Referral from an Outpatient Setting,243,MIPS CQM,Process,31.484242512522062,72.12,No,No,2.86,34.78,38.28,40.91,69.68,89.145,97.09,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate +Statin Therapy for the Prevention and Treatment of Cardiovascular Disease,438,eCQM,Process,11.911612010126113,78.25,No,No,24.47,67.86,73.1,76.01,78.2,80.05,81.98,83.95,86.13,89.01,95.06,N,N,singlePerformanceRate +Patients Suffering From an Upper Extremity Injury who Improve Pain,MSK7,QCDR Measure,Patient-Reported Outcome-Based Performance Measure (PRO-PM),6.5763343627031015,53.50,No,No,37.5,45.0,48.28,50.0,52.11,53.57,55.32,57.18,59.26,61.9,66.67,Y,N,registrySinglePerformanceRate +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),005,MIPS CQM,Process,7.137296143049174,97.23,Yes,Yes,73.4,87.69,96.62,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,N,N,singlePerformanceRate +Antidepressant Medication Management,009,eCQM,Process,17.130463645297738,61.23,No,No,18.13,40.94,50.43,55.1,57.55,59.86,62.45,65.38,72.12,86.67,100.0,N,N,multiPerformanceRate +Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older,048,MIPS CQM,Process,21.92505204234516,90.83,Yes,Yes,1.26,64.66,92.02,98.65,99.96,100.0,100.0,100.0,100.0,100.0,100.0,N,N,singlePerformanceRate +Appropriate Follow-up Imaging for Incidental Abdominal Lesions,405,MIPS CQM,Process,33.88209725565545,79.03,Yes,No,84.0,86.0,88.0,90.0,92.0,94.0,96.0,98.0,99.0,100.0,100.0,Y,N,singlePerformanceRate +Appropriate Utilization of Vancomycin for Cellulitis,HCPR24,QCDR Measure,Process,13.736011217477463,88.70,No,No,47.79,73.72,76.24,82.13,86.8,94.93,98.7,100.0,100.0,100.0,100.0,Y,N,registrySinglePerformanceRate +Primary Caries Prevention Intervention as Offered by Dentists,379,eCQM,Process,11.400927814281388,20.86,No,No,3.17,5.05,11.11,13.91,16.05,19.17,23.39,25.53,32.85,36.4,42.22,N,N,singlePerformanceRate +Adherence to Antipsychotic Medications For Individuals with Schizophrenia,383,MIPS CQM,Intermediate Outcome,32.55953327456988,84.19,No,No,1.15,3.66,75.79,97.66,100.0,100.0,100.0,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate +Melanoma: – Appropriate Surgical Margins,AAD12,QCDR Measure,Intermediate Outcome,13.881267927930342,92.15,No,No,38.38,75.27,84.48,93.75,96.7,100.0,100.0,100.0,100.0,100.0,100.0,Y,N,registrySinglePerformanceRate +Radical Prostatectomy Pathology Reporting,250,Medicare Part B Claims,Process,0.0,100.00,Yes,No,84.0,86.0,88.0,90.0,92.0,94.0,96.0,98.0,99.0,100.0,100.0,N,N,singlePerformanceRate +Children Who Have Dental Decay or Cavities,378,eCQM,Outcome,24.88428855716087,26.90,No,No,0.0,3.34,7.45,8.47,12.32,16.3,25.93,43.48,47.94,59.86,97.92,Y,Y,singlePerformanceRate +Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation,012,eCQM,Process,30.192589390370138,76.19,No,No,0.84,20.37,51.72,73.41,83.98,91.3,94.93,97.23,99.09,100.0,100.0,N,N,singlePerformanceRate +Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older,024,MIPS CQM,Process,29.369728376241167,85.30,Yes,Yes,0.84,17.82,83.78,93.49,97.73,100.0,100.0,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate +Diabetes: Eye Exam,117,MIPS CQM,Process,20.994602915820398,91.80,Yes,Yes,1.8,71.07,93.2,99.38,100.0,100.0,100.0,100.0,100.0,100.0,100.0,N,N,singlePerformanceRate +Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy,268,MIPS CQM,Process,29.11330050349662,85.24,Yes,Yes,4.35,27.74,72.67,97.725,100.0,100.0,100.0,100.0,100.0,100.0,100.0,N,N,singlePerformanceRate +Dementia: Cognitive Assessment,281,eCQM,Process,30.758459022670106,40.97,No,No,0.38,3.23,8.04,15.38,25.61,38.95,50.0,58.37,71.35,86.89,100.0,N,N,singlePerformanceRate +Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients,320,Medicare Part B Claims,Process,0.0,100.00,Yes,No,84.0,86.0,88.0,90.0,92.0,94.0,96.0,98.0,99.0,100.0,100.0,Y,N,singlePerformanceRate +Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling,431,MIPS CQM,Process,36.317318927414235,69.11,No,No,1.06,8.33,22.86,50.0,71.43,88.89,99.3,100.0,100.0,100.0,100.0,N,N,multiPerformanceRate +Kidney Health Evaluation,488,MIPS CQM,Process,26.291451391400397,48.67,No,No,1.91,15.87,24.81,33.51,43.36,47.19,51.045,54.65,66.99,96.25,100.0,N,N,singlePerformanceRate +Avoidance of Opiates for Low Back Pain or Migraines,ECPR46,QCDR Measure,Process,3.6336093215840846,96.90,Yes,Yes,86.7,91.31,94.08,95.78,97.32,98.095,98.66,100.0,100.0,100.0,100.0,Y,N,registrySinglePerformanceRate +Patients Suffering From a Lower Extremity Injury who Improve Physical Function,MSK4,QCDR Measure,Patient-Reported Outcome-Based Performance Measure (PRO-PM),7.599697628384084,55.42,No,No,36.67,45.71,49.89,51.79,53.85,55.56,57.14,59.63,62.09,65.0,70.73,Y,N,registrySinglePerformanceRate +Oncology: Patient-Reported Pain Improvement,PIMSH4,QCDR Measure,Patient-Reported Outcome-Based Performance Measure (PRO-PM),14.067039663048144,57.01,No,No,27.4,36.6,44.5,50.8,54.3,56.8,61.3,64.1,69.45,73.7,85.0,Y,N,registrySinglePerformanceRate +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),005,eCQM,Process,10.321672900862078,81.04,No,No,50.0,67.35,74.19,77.34,79.77,81.74,83.82,86.19,89.54,93.33,100.0,N,N,singlePerformanceRate +Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older,050,MIPS CQM,Process,16.50258903894923,93.17,Yes,Yes,1.51,81.97,89.58,96.57,100.0,100.0,100.0,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate +Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%),118,MIPS CQM,Process,11.75472740822677,91.08,Yes,No,47.46,76.485,82.65,86.63,90.78,96.61,100.0,100.0,100.0,100.0,100.0,N,N,singlePerformanceRate +Documentation of Current Medications in the Medical Record,130,eCQM,Process,20.95955076474908,87.08,Yes,Yes,2.94,60.96,80.45,88.9,93.33,95.98,97.76,98.87,99.65,99.96,100.0,Y,N,singlePerformanceRate +Controlling High Blood Pressure,236,eCQM,Intermediate Outcome,17.24471289915835,66.06,No,No,4.76,45.28,55.56,61.54,65.61,68.98,72.0,75.0,78.7,84.04,98.18,Y,N,singlePerformanceRate +Barrett's Esophagus,249,MIPS CQM,Process,6.605617056113943,99.52,Yes,No,84.0,86.0,88.0,90.0,92.0,94.0,96.0,98.0,99.0,100.0,100.0,N,N,singlePerformanceRate +Anesthesiology Smoking Abstinence,404,MIPS CQM,Intermediate Outcome,20.05650456873726,79.89,No,No,12.6,52.94,65.84,75.45,80.37,84.3,87.93,93.13,98.35,100.0,100.0,Y,N,singlePerformanceRate +Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years,416,MIPS CQM,Efficiency,11.251575834070241,4.57,No,No,0.0,0.0,0.0,0.0,0.0,0.0,2.0,3.45,4.35,14.04,61.9,Y,Y,singlePerformanceRate +Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score - better),457,MIPS CQM,Process,11.792746564255154,8.66,Yes,No,0.0,0.0,0.0,0.0,3.45,4.88,6.25,10.26,15.0,24.32,60.0,Y,Y,singlePerformanceRate +Patients Suffering From a Neck Injury who Improve Pain,MSK6,QCDR Measure,Patient-Reported Outcome-Based Performance Measure (PRO-PM),8.348917074308758,53.80,No,No,33.33,42.86,46.67,50.0,52.26,54.17,56.25,59.09,60.87,63.64,71.43,Y,N,registrySinglePerformanceRate +Oncology: Supportive Care Drug Utilization in Last 14 Days of Life,PIMSH9,QCDR Measure,Efficiency,4.373276283811195,5.37,No,No,0.0,0.0,1.4,3.6,3.7,4.7,5.0,6.0,8.3,12.7,18.5,Y,Y,registrySinglePerformanceRate +Arteriovenous Graft Thrombectomy Clinical Success Rate,RPAQIR14,QCDR Measure,Outcome,5.362797166365761,89.45,No,No,75.41,82.86,87.08,87.5,88.89,90.1,90.97,92.54,94.32,95.24,97.87,Y,N,registrySinglePerformanceRate +Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy,326,MIPS CQM,Process,15.121959689292083,92.45,Yes,Yes,30.0,71.43,86.44,95.77,100.0,100.0,100.0,100.0,100.0,100.0,100.0,N,N,singlePerformanceRate +Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment,382,eCQM,Process,32.027393879696746,41.11,No,No,0.4,1.99,5.05,17.78,26.97,37.97,45.33,58.18,72.2,92.65,100.0,Y,N,singlePerformanceRate +Gout: Serum Urate Target,ACR14,QCDR Measure,Intermediate Outcome,16.626304134748207,61.98,No,No,10.59,41.18,50.0,55.0,59.77,62.65,65.9,69.93,75.51,81.16,100.0,Y,N,registrySinglePerformanceRate +Visual Acuity Improvement Following Cataract Surgery and Minimally Invasive Glaucoma Surgery,IRIS61,QCDR Measure,Outcome,16.235567334147593,82.99,No,No,26.32,61.22,70.73,80.64,85.0,88.28,90.91,93.1,95.77,97.67,100.0,Y,N,registrySinglePerformanceRate +Oncology: Medical and Radiation - Plan of Care for Pain,144,MIPS CQM,Process,24.193456313745237,83.56,Yes,No,84.0,86.0,88.0,90.0,92.0,94.0,96.0,98.0,99.0,100.0,100.0,Y,N,singlePerformanceRate +Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention,226,eCQM,Process,31.180799532273635,66.95,No,No,4.17,19.23,33.33,46.58,61.57,75.97,87.41,94.74,98.82,100.0,100.0,N,N,multiPerformanceRate +Cervical Cancer Screening,309,eCQM,Process,24.535931180575563,42.47,No,No,0.27,5.56,19.05,29.41,36.7,43.295,49.53,55.85,63.64,73.55,99.7,N,N,singlePerformanceRate +Anastomotic Leak Intervention,354,MIPS CQM,Outcome,2.302083120469021,0.96,No,No,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0.62,4.63,8.33,Y,Y,singlePerformanceRate +Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery,385,MIPS CQM,Outcome,8.569196295260557,79.26,No,No,59.09,68.18,71.88,75.0,77.39,80.0,81.82,83.67,85.755,89.8,100.0,Y,N,singlePerformanceRate +Multimodal Pain Management,477,MIPS CQM,Process,7.250348239544614,97.47,Yes,No,84.0,86.0,88.0,90.0,92.0,94.0,96.0,98.0,99.0,100.0,100.0,Y,N,singlePerformanceRate +Low Flow Inhalational General Anesthesia,ABG44,QCDR Measure,Efficiency,11.09032472081532,95.52,No,No,32.19,86.87,96.0,98.58,99.24,99.34,99.6,99.82,100.0,100.0,100.0,Y,N,registrySinglePerformanceRate +Safe Hydroxychloroquine Dosing,ACR15,QCDR Measure,Process,15.082424621657555,75.01,No,No,31.57,56.52,62.95,69.55,71.99,76.36,80.07,85.0,88.68,91.98,99.55,Y,N,registrySinglePerformanceRate +Diabetes: Glycemic Status Assessment Greater Than 9%,001,eCQM,Intermediate Outcome,29.02317313548391,40.91,No,No,0.44,12.5,17.18,20.86,24.85,29.525,36.72,49.53,71.68,93.98,99.49,Y,Y,singlePerformanceRate +Use of High-Risk Medications in Older Adults,238,MIPS CQM,Process,6.84547188961289,0.70,Yes,Yes,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0.02,9.62,Y,Y,multiPerformanceRate +Functional Status Assessment for Total Hip Replacement,376,eCQM,Process,21.053534189485053,27.35,No,No,0.73,3.89,6.27,9.38,16.0,27.43,31.82,38.1,46.72,55.81,85.71,Y,N,singlePerformanceRate +Skin Cancer: Biopsy Reporting Time - Pathologist to Clinician,440,MIPS CQM,Process,3.3881460926321427,99.31,Yes,No,84.0,86.0,88.0,90.0,92.0,94.0,96.0,98.0,99.0,100.0,100.0,Y,N,singlePerformanceRate +Tympanostomy Tubes: Comprehensive Audiometric Evaluation,AAO20,QCDR Measure,Process,32.08112737181248,67.61,No,No,3.65,19.33,25.64,41.96,68.89,81.565,93.07,95.05,95.58,97.07,100.0,N,N,registrySinglePerformanceRate +Stroke and Stroke Rehabilitation: Thrombolytic Therapy,187,MIPS CQM,Process,9.139281712025147,97.61,Yes,Yes,51.72,95.45,98.9,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,N,N,singlePerformanceRate +HIV Viral Suppression,338,MIPS CQM,Outcome,5.813803876943919,95.49,Yes,No,76.6,89.19,90.93,93.16,95.12,98.72,99.48,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate +Prostate Cancer: Active Surveillance/Watchful Waiting for Newly Diagnosed Low Risk Prostate Cancer Patients,MUSIC4,QCDR Measure,Process,11.185514645814825,76.66,No,No,55.0,61.54,64.71,69.16,76.36,79.28,80.95,81.08,85.71,91.67,100.0,Y,N,registrySinglePerformanceRate +Depression Remission at Twelve Months,370,eCQM,Outcome,13.182405517552878,13.93,No,No,0.83,2.36,4.46,6.06,7.86,10.0,12.5,15.7,20.0,28.69,66.67,Y,N,multiPerformanceRate +Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control),441,MIPS CQM,Intermediate Outcome,21.23171371720264,53.21,No,No,1.72,28.41,35.0,43.92,49.23,51.82,56.02,61.11,68.17,79.21,100.0,Y,N,singlePerformanceRate +ED Median Time from ED arrival to ED departure for all Pediatric ED Patients,ACEP51,QCDR Measure,Outcome,27.512929693320512,121.03,No,No,68.0,90.0,99.0,105.0,113.0,119.0,125.0,133.0,140.0,164.0,184.0,Y,Y,nonProportion +Appropriate Utilization of Imaging in rAAA (ruptured Abdominal Aortic Aneurysm) patients in Emergency Department,ACEP65,QCDR Measure,Process,26.44349671817648,57.78,No,No,1.68,13.395,33.065,48.855,60.6,62.5,69.805,78.98,82.38,84.31,86.11,Y,N,registrySinglePerformanceRate +Vitamin D level: Effective Control of Low Bone Mass/Osteopenia and Osteoporosis: Therapeutic Level Of 25 OH Vitamin D Level Achieved,UREQA8,QCDR Measure,Outcome,24.46200916646704,62.23,No,No,7.12,18.23,44.15,54.59,62.28,65.53,71.21,80.07,86.91,89.06,93.14,Y,N,registrySinglePerformanceRate +Appropriate Classification and Follow-up Imaging for Incidental Pancreatic Cysts,QMM27,QCDR Measure,Process,35.41235675550041,76.23,Yes,No,8.7,13.79,28.24,69.29,100.0,100.0,100.0,100.0,100.0,100.0,100.0,Y,N,registrySinglePerformanceRate +Screening for Osteoporosis for Men Aged 70 Years and Older,UREQA9,QCDR Measure,Process,16.507263382154417,34.69,No,No,9.64,13.84,18.99,22.47,32.19,35.44,37.305,42.97,46.955,52.335,84.0,N,N,registrySinglePerformanceRate +Diabetes: Glycemic Status Assessment Greater Than 9%,001,Medicare Part B Claims,Intermediate Outcome,6.389577272019828,1.68,No,No,1.0,10.0,20.0,30.0,40.0,50.0,60.0,70.0,80.0,90.0,99.0,Y,Y,singlePerformanceRate +Preventive Care and Screening: Screening for Depression and Follow-Up Plan,134,eCQM,Process,32.20029952016803,45.55,No,No,0.07,2.7,11.42,21.65,31.79,42.685,53.935,67.48,80.72,93.44,100.0,N,N,singlePerformanceRate +Dementia: Functional Status Assessment,282,MIPS CQM,Process,15.097479355935864,96.36,Yes,Yes,4.09,98.59,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,N,N,singlePerformanceRate +Surgical Site Infection (SSI),357,MIPS CQM,Outcome,0.7155847601816656,0.18,No,No,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0.0,0.51,4.55,Y,Y,singlePerformanceRate +Osteoporosis Management in Women Who Had a Fracture,418,MIPS CQM,Process,21.670124688343243,23.18,No,No,1.56,6.23,9.23,11.89,14.01,16.36,19.28,23.08,30.34,47.73,100.0,N,N,singlePerformanceRate +Dermatitis – Improvement in Patient-Reported Itch Severity,486,MIPS CQM,Patient-Reported Outcome-Based Performance Measure (PRO-PM),25.558164654832865,48.20,No,No,6.45,19.23,26.42,32.26,37.83,42.6,49.47,56.32,70.0,95.12,100.0,Y,N,singlePerformanceRate +Bunion Outcome - Adult and Adolescent,REGCLR3,QCDR Measure,Patient-Reported Outcome-Based Performance Measure (PRO-PM),26.421355022049898,24.83,No,No,1.71,2.65,4.12,6.82,9.09,11.69,25.0,31.48,39.58,72.78,100.0,Y,N,registrySinglePerformanceRate +Appropriate Follow-up Recommendations for Ovarian-Adnexal Lesions using the Ovarian-Adnexal Reporting and Data System (O-RADS),QMM17,QCDR Measure,Process,44.41254835786103,55.13,No,No,0.06,0.61,1.99,5.56,17.78,76.215,93.19,100.0,100.0,100.0,100.0,Y,N,registrySinglePerformanceRate +Preventive Care and Screening: Screening for Depression and Follow-Up Plan,134SSP,MIPS CQM,Process,22.047734575180137,62.87,No,No,11.44,32.51,45.67,54.49,59.27,65.56,70.55,76.11,82.17,92.34,99.78,N,N,singlePerformanceRate +Falls: Plan of Care,155,MIPS CQM,Process,14.148728639300767,96.30,Yes,Yes,16.19,95.38,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate +Hepatitis B Safety Screening,ACR10,QCDR Measure,Process,20.21376503917129,62.13,No,No,9.74,33.82,43.88,52.62,58.41,65.64,68.85,71.91,83.08,86.84,98.0,Y,N,registrySinglePerformanceRate +Tympanostomy Tubes: Resolution of Otitis Media with Effusion (OME) in Adults and Children,AAO36,QCDR Measure,Outcome,30.246313829703286,23.71,No,No,0.56,1.08,2.33,3.23,3.64,8.62,15.31,19.62,52.71,82.86,89.66,Y,N,registrySinglePerformanceRate +Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use,464,MIPS CQM,Process,4.7880355145163085,97.01,Yes,Yes,82.19,91.61,94.02,97.66,98.25,98.89,99.5,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate +Appropriate Testing for Pharyngitis,066,eCQM,Process,26.636064232293062,71.29,No,No,2.0,21.04,53.25,67.42,75.63,81.03,86.04,89.42,92.09,94.95,98.96,Y,N,singlePerformanceRate +Appropriate Testing for Pharyngitis,066,MIPS CQM,Process,10.196871636257937,96.54,Yes,Yes,27.08,89.13,95.45,98.87,100.0,100.0,100.0,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate +Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery,191,MIPS CQM,Outcome,8.384839149144167,97.81,Yes,Yes,68.18,96.17,99.18,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate +Sleep Apnea: Severity Assessment at Initial Diagnosis,277,MIPS CQM,Process,36.810229725967794,71.11,Yes,Yes,0.44,6.82,27.68,55.69,77.38,95.6,100.0,100.0,100.0,100.0,100.0,N,N,singlePerformanceRate +Dementia: Education and Support of Caregivers for Patients with Dementia,288,MIPS CQM,Process,14.090237067802143,96.98,Yes,Yes,12.86,99.07,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate +Immunizations for Adolescents,394,MIPS CQM,Process,25.563697318289343,47.42,No,No,1.75,18.42,24.32,30.63,36.65,43.33,51.72,60.0,71.43,85.19,100.0,N,N,multiPerformanceRate +"Avoidance of Chest X-ray in pediatric patients with Asthma, Bronchiolitis or Croup",ACEP61,QCDR Measure,Process,13.043124766297005,33.89,No,No,0.91,19.87,24.75,27.72,30.77,33.875,37.78,40.3,43.35,51.5,63.16,Y,Y,registrySinglePerformanceRate +Refractive Surgery: Patients with a postoperative uncorrected visual acuity (UCVA) of 20/20 or better within 30 days,IRIS23,QCDR Measure,Outcome,12.822540476275924,87.77,No,No,14.81,75.86,81.48,84.61,88.71,90.58,93.33,94.64,96.67,98.3,100.0,Y,N,registrySinglePerformanceRate +Improved Visual Acuity after Vitrectomy for Complications of Diabetic Retinopathy within 120 Days,IRIS58,QCDR Measure,Outcome,5.64146498655201,86.38,No,No,70.0,80.77,81.82,83.78,84.61,85.71,87.04,89.65,91.04,94.54,100.0,Y,N,registrySinglePerformanceRate +Advance Care Plan,047,Medicare Part B Claims,Process,0.0,100.00,Yes,Yes,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate +Functional Status Change for Patients with Low Back Impairments,220,MIPS CQM,Patient-Reported Outcome-Based Performance Measure (PRO-PM),22.40874609197322,78.90,No,No,15.79,41.18,60.0,69.57,78.38,85.11,93.75,97.9,100.0,100.0,100.0,Y,N,singlePerformanceRate +Prevention of Post-Operative Nausea and Vomiting (PONV) - Combination Therapy,430,MIPS CQM,Process,1.5783773731536113,99.34,Yes,No,84.0,86.0,88.0,90.0,92.0,94.0,96.0,98.0,99.0,100.0,100.0,Y,N,singlePerformanceRate +Oncology: Advance Care Planning in Metastatic Cancer Patients,PIMSH1,QCDR Measure,Patient Engagement/Experience,25.47371814054909,53.16,No,No,0.9,9.2,33.3,44.6,49.0,55.5,60.3,67.8,77.3,87.7,94.4,Y,N,registrySinglePerformanceRate +"Functional Status Change for Patients with Elbow, Wrist or Hand Impairments",222,MIPS CQM,Patient-Reported Outcome-Based Performance Measure (PRO-PM),20.63223709927701,80.76,No,No,30.0,52.27,63.64,66.67,73.42,86.125,98.39,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate +Intraocular Pressure Reduction Following Trabeculectomy or an Aqueous Shunt Procedure,IRIS39,QCDR Measure,Outcome,21.771204242160014,49.45,No,No,17.78,26.11,31.82,34.92,40.0,44.325,54.9,59.37,60.46,85.29,100.0,Y,N,registrySinglePerformanceRate +Arteriovenous Fistulae Thrombectomy Clinical Success Rate,RPAQIR15,QCDR Measure,Outcome,7.492519747982856,88.90,Yes,No,72.73,77.14,81.25,86.49,89.17,90.2,92.0,93.75,96.43,96.55,97.3,Y,N,registrySinglePerformanceRate +Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis,116,MIPS CQM,Process,15.920954970215076,91.71,Yes,Yes,21.05,80.73,90.77,93.83,95.7,97.395,98.27,99.53,100.0,100.0,100.0,Y,N,singlePerformanceRate +Diabetes: Eye Exam,117,eCQM,Process,39.56689493960212,62.05,No,No,0.45,5.88,15.38,26.78,43.01,80.365,98.93,99.63,100.0,100.0,100.0,N,N,singlePerformanceRate +Preventive Care and Screening: Screening for Depression and Follow-Up Plan,134,Medicare Part B Claims,Process,14.20869242820514,95.64,Yes,Yes,24.03,87.86,99.55,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,N,N,singlePerformanceRate +Elder Maltreatment Screen and Follow-Up Plan,181,MIPS CQM,Process,18.690452044472487,94.05,Yes,Yes,0.71,79.4,99.3,100.0,100.0,100.0,100.0,100.0,100.0,100.0,100.0,Y,N,singlePerformanceRate +HIV Screening,475,eCQM,Process,19.2341064221688,20.91,No,No,0.1,0.88,2.6,4.795,9.09,16.97,23.69,30.36,37.595,47.715,79.02,N,N,singlePerformanceRate +Adult Kidney Disease: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy,489,MIPS CQM,Process,19.212630054223823,87.14,Yes,No,25.0,60.93,70.41,77.81,95.09,100.0,100.0,100.0,100.0,100.0,100.0,N,N,singlePerformanceRate +Neck Mass Evaluation,AAO39,QCDR Measure,Process,8.683601852777807,10.83,No,No,1.37,1.6,2.27,3.77,9.09,10.64,11.61,14.75,16.9,21.43,39.13,Y,N,registrySinglePerformanceRate +Screening Colonoscopy Adenoma Detection Rate,GIQIC26,QCDR Measure,Outcome,9.060305465412426,40.19,No,No,19.91,27.425,31.76,36.11,38.085,39.61,42.66,45.11,47.535,52.05,60.8,Y,N,registryMultiPerformanceRate +Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan,128,MIPS CQM,Process,38.31578498379918,58.11,No,No,0.17,7.38,17.24,20.56,49.56,70.54,86.21,93.48,96.69,100.0,100.0,N,N,singlePerformanceRate +Tuberculosis Screening Prior to First Course of Biologic and/or Immune Response Modifier Therapy,176,MIPS CQM,Process,29.98032049368899,80.36,Yes,Yes,4.0,25.0,52.94,79.53,94.44,99.17,100.0,100.0,100.0,100.0,100.0,N,N,singlePerformanceRate +Use of High-Risk Medications in Older Adults,238,eCQM,Process,7.54011343639384,4.79,Yes,Yes,0.0,0.0,0.0,0.0,0.14,0.66,2.02,5.23,10.16,15.85,30.71,Y,Y,multiPerformanceRate +Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented,317,eCQM,Process,19.525908012871515,28.13,No,No,0.05,5.05,15.11,19.845,23.195,26.24,29.12,32.26,36.555,45.84,100.0,N,N,singlePerformanceRate +Appropriate Follow-up Imaging for Incidental Abdominal Lesions,405,Medicare Part B 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