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2015 Physician Quality Reporting System (PQRS)Measure Specifications Manual for Claims andRegistry Reporting of Individual MeasuresUtilized by Individual Eligible Professionals for Claims and Registry Reporting andClinical Practices Participating in Group Practice Reporting Option (GPRO) forRegistry Reporting12/23/2014Version 9.112/23/2014CPT only copyright 2014 American Medical Association. All rights reserved.Page 1 of 593
Table of ContentsMeasure #1 (NQF 0059): Diabetes: Hemoglobin A1c Poor Control – National Quality Strategy Domain:Effective Clinical Care .30Measure #5 (NQF 0081): Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor orAngiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) – NationalQuality Strategy Domain: Effective Clinical Care.33Measure #6 (NQF 0067): Coronary Artery Disease (CAD): Antiplatelet Therapy – National Quality StrategyDomain: Effective Clinical Care .38Measure #7 (NQF 0070): Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior MyocardialInfarction (MI) or Left Ventricular Systolic Dysfunction (LVEF 40%) – National Quality Strategy Domain:Effective Clinical Care .40Measure #8 (NQF 0083): Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction(LVSD) – National Quality Strategy Domain: Effective Clinical Care.45Measure #12 (NQF 0086): Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation – National QualityStrategy Domain: Effective Clinical Care .49Measure #14 (NQF 0087): Age-Related Macular Degeneration (AMD): Dilated Macular Examination –National Quality Strategy Domain: Effective Clinical Care .51Measure #19 (NQF 0089): Diabetic Retinopathy: Communication with the Physician Managing OngoingDiabetes Care – National Quality Strategy Domain: Effective Clinical Care.53Measure #21 (NQF 0268): Perioperative Care: Selection of Prophylactic Antibiotic – First OR SecondGeneration Cephalosporin – National Quality Strategy Domain: Patient Safety .56Measure #22 (NQF 0271): Perioperative Care: Discontinuation of Prophylactic Parenteral Antibiotics (NonCardiac Procedures) – National Quality Strategy Domain: Patient Safety .61Measure #23 (NQF 0239): Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (WhenIndicated in ALL Patients) – National Quality Strategy Domain: Patient Safety .66Measure #24 (NQF 0045): Osteoporosis: Communication with the Physician Managing On-going Care PostFracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older – National QualityStrategy Domain: Communication and Care Coordination .73Measure #32 (NQF 0325): Stroke and Stroke Rehabilitation: Discharged on Antithrombotic Therapy –National Quality Strategy Domain: Effective Clinical Care .79Measure #33 (NQF 0241): Stroke and Stroke Rehabilitation: Anticoagulant Therapy Prescribed for AtrialFibrillation (AF) at Discharge – National Quality Strategy Domain: Effective Clinical Care.82Measure #39 (NQF 0046): Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older –National Quality Strategy Domain: Effective Clinical Care .84Measure #40 (NQF 0048): Osteoporosis: Management Following Fracture of Hip, Spine or Distal Radius forMen and Women Aged 50 Years and Older – National Quality Strategy Domain: Effective Clinical Care .87Measure #41 (NQF 0049): Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years andOlder – National Quality Strategy Domain: Effective Clinical Care .94Measure #43 (NQF 0134): Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) inPatients with Isolated CABG Surgery – National Quality Strategy Domain: Effective Clinical Care .97Measure #44 (NQF 0236): Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patientswith Isolated CABG Surgery – National Quality Strategy Domain: Effective Clinical Care .99Version 9.112/23/2014CPT only copyright 2014 American Medical Association. All rights reserved.Page 2 of 593
Measure #46 (NQF 0097): Medication Reconciliation – National Quality Strategy Domain: Communicationand Care Coordination . 102Measure #47 (NQF 0326): Care Plan – National Quality Strategy Domain: Communication and CareCoordination . 106Measure #48: Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in WomenAged 65 Years and Older – National Quality Strategy Domain: Effective Clinical Care . 109Measure #50: Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years andOlder – National Quality Strategy Domain: Person and Caregiver-Centered Experience and Outcomes . 111Measure #51 (NQF 0091): Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation –National Quality Domain: Effective Clinical Care . 113Measure #52 (NQF 0102): Chronic Obstructive Pulmonary Disease (COPD): Inhaled BronchodilatorTherapy – National Quality Domain: Effective Clinical Care . 115Measure #53 (NQF 0047): Asthma: Pharmacologic Therapy for Persistent Asthma - Ambulatory CareSetting – National Quality Strategy Domain: Effective Clinical Care . 118Measure #54 (NQF 0090): Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed for NonTraumatic Chest Pain – National Quality Strategy Domain: Effective Clinical Care . 120Measure #65 (NQF 0069): Appropriate Treatment for Children with Upper Respiratory Infection (URI) –National Quality Strategy Domain: Efficiency and Cost Reduction . 122Measure #66 (NQF 0002): Appropriate Testing for Children with Pharyngitis – National Quality StrategyDomain: Efficiency and Cost Reduction . 125Measure #67 (NQF 0377): Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemias: BaselineCytogenetic Testing Performed on Bone Marrow – National Quality Strategy Domain: Effective Clinical Care. 128Measure #68 (NQF 0378): Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Storesin Patients Receiving Erythropoietin Therapy – National Quality Strategy Domain: Effective Clincial Care . 130Measure #69 (NQF 0380): Hematology: Multiple Myeloma: Treatment with Bisphosphonates – NationalQuality Strategy Domain: Effective Clinical Care. 132Measure #70 (NQF 0379): Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry –National Quality Strategy Domain: Effective Clinical Care . 134Measure #71 (NQF 0387): Breast Cancer: Hormonal Therapy for Stage IC - IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer – National Quality Domain: Effective Clinical Care 136Measure #72 (NQF 0385): Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients –National Quality Domain: Effective Clinical Care . 140Measure #76 (NQF 0464): Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections –National Quality Strategy Domain: Patient Safety . 143Measure #81 (NQF 0323): Adult Kidney Disease: Hemodialysis Adequacy: Solute – National QualityStrategy Domain: Communication and Care Coordination . 145Measure #82 (NQF 0321): Adult Kidney Disease: Peritoneal Dialysis Adequacy: Solute – National QualityStrategy Domain: Effective Clinical Care . 147Measure #91 (NQF 0653): Acute Otitis Externa (AOE): Topical Therapy – National Quality StrategyDomain: Effective Clinical Care . 149Version 9.112/23/2014CPT only copyright 2014 American Medical Association. All rights reserved.Page 3 of 593
Measure #93 (NQF 0654): Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance ofInappropriate Use – National Quality Strategy Domain: Efficiency and Cost Reduction . 151Measure #99 (NQF 0391): Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor)and pN Category (Regional Lymph Nodes) with Histologic Grade – National Quality Clinical Strategy:Effective Clinical Care . 153Measure #100 (NQF 0392): Colorectal Cancer Resection Pathology Reporting: pT Category (PrimaryTumor) and pN Category (Regional Lymph Nodes) with Histologic Grade – National Quality Strategy Domain:Effective Clinical Care . 156Measure #102 (NQF 0389): Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low RiskProstate Cancer Patients – National Quality Strategy Domain: Efficiency and Cost Reduction . 159Measure #104 (NQF 0390): Prostate Cancer: Adjuvant Hormonal Therapy for High Risk Prostate CancerPatients – National Quality Strategy Domain: Effective Clinical Care. 161Measure #109: Osteoarthritis (OA): Function and Pain Assessment – National Quality Strategy Domain:Person and Caregiver-Centered Experience and Outcomes . 164Measure #110 (NQF 0041): Preventive Care and Screening: Influenza Immunization – National QualityStrategy Domain: Community/Population Health . 166Measure #111 (NQF 0043): Pneumonia Vaccination Status for Older Adults – National Quality StrategyDomain: Effective Clinical Care . 168Measure #112: Breast Cancer Screening – National Quality Strategy Domain: Effective Clinical Care . 170Measure #113 (NQF 0034): Colorectal Cancer Screening – National Quality Strategy Domain: EffectiveClinical Care . 173Measure #116 (NQF 0058): Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis –NationalQuality Strategy Domain: Efficiency and Cost Reduction . 176Measure #117 (NQF 0055): Diabetes: Eye Exam – National Quality Strategy Domain: Effective Clinical Care. 179Measure #118 (NQF 0066): Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE)Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic Dysfunction(LVEF 40%) – National Quality Strategy Domain: Effective Clinical Care . 182Measure #119 (NQF 0062): Diabetes: Medical Attention for Nephropathy – National Quality StrategyDomain: Effective Clinical Care . 186Measure #121 (NQF 1668): Adult Kidney Disease: Laboratory Testing (Lipid Profile) – National QualityStrategy Domain: Effective Clinical Care . 189Measure #122: Adult Kidney Disease: Blood Pressure Management – National Quality Strategy Domain:Effective Clinical Care . 191Measure #126 (NQF 0417): Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy –Neurological Evaluation – National Quality Strategy Domain: Effective Clinical Care . 194Measure #127 (NQF 0416): Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluationof Footwear – National Quality Strategy Domain: Effective Clinical Care . 196Measure #128 (NQF 0421): Preventive Care and Screening: Body Mass Index (BMI) Screening and FollowUp Plan – National Quality Strategy Domain: Community/Population Health. 198Version 9.112/23/2014CPT only copyright 2014 American Medical Association. All rights reserved.Page 4 of 593
Measure #130 (NQF 0419): Documentation of Current Medications in the Medical Record – NationalQuality Strategy Domain: Patient Safety. 203Measure #131 (NQF 0420): Pain Assessment and Follow-Up – National Quality Strategy Domain:Community/Population Health* . 207Measure #134 (NQF 0418): Preventive Care and Screening: Screening for Clinical Depression and FollowUp Plan – National Quality Strategy Domain: Community/Population Health. 212Measure #137 (NQF 0650): Melanoma: Continuity of Care – Recall System – National Quality StrategyDomain: Communication and Care Coordination . 216Measure #138: Melanoma: Coordination of Care – National Quality Strategy Domain: Communication andCare Coordination . 218Measure #140 (NQF 0566): Age-Related Macular Degeneration (AMD): Counseling on AntioxidantSupplement – National Quality Strategy Domain: Effective Clinical Care . 222Measure #141 (NQF 0563): Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure(IOP) by 15% OR Documentation of a Plan of Care – National Quality Strategy Domain: Communication andCare Coordination . 225Measure #143 (NQF0384): Oncology: Medical and Radiation – Pain Intensity Quantified – National QualityStrategy Domain: Person and Caregiver-Centered Experience and Outcomes. 228Measure #144 (NQF 0383): Oncology: Medical and Radiation – Plan of Care for Pain – National QualityStrategy Domain: Person and Caregiver-Centered Experience and Outcomes. 233Measure #145 (NQF 0510): Radiology: Exposure Time Reported for Procedures Using Fluoroscopy –National Quality Strategy Domain: Patient Safety . 238Measure #146 (NQF 0508): Radiology: Inappropriate Use of “Probably Benign” Assessment Category inScreening Mammograms – National Quality Strategy Domain: Efficiency and Cost Reduction . 240Measure #147: Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients UndergoingBone Scintigraphy – National Quality Strategy Domain: Communication and Care Coordination . 243Measure #154 (NQF: 0101): Falls: Risk Assessment – National Quality Strategy Domain: Patient Safety . 246Measure #155 (NQF: 0101): Falls: Plan of Care – National Quality Strategy Domain: Communication andCare Coordination . 250Measure #156 (NQF 0382): Oncology: Radiation Dose Limits to Normal Tissues – National QualityStrategy Domain: Patient Safety. 253Measure #163 (NQF 0056): Diabetes: Foot Exam – National Quality Strategy Domain: Effective ClinicalCare . 256Measure #164 (NQF 0129): Coronary Artery Bypass Graft (CABG): Prolonged Intubation – NationalQuality Strategy Domain: Effective Clinical Care. 258Measure #165 (NQF 0130): Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate –National Quality Strategy Domain: Effective Clinical Care . 260Measure #166 (NQF 0131): Coronary Artery Bypass Graft (CABG): Stroke – National Quality StrategyDomain: Effective Clinical Care . 262Measure #167 (NQF 0114): Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure – NationalQuality Strategy Domain: Effective Clinical Care. 264Version 9.112/23/2014CPT only copyright 2014 American Medical Association. All rights reserved.Page 5 of 593
Measure #168 (NQF 0115): Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration – NationalQuality Strategy Domain: Effective Clinical Care. 266Measure #172 (NQF 0259): Hemodialysis Vascular Access Decision-Making by Surgeon to MaximizePlacement of Autogenous Arterial Venous (AV) Fistula – National Quality Strategy Domain: Effective ClinicalCare . 268Measure #173: Preventive Care and Screening: Unhealthy Alcohol Use – Screening – National QualityStrategy Domain: Community/Population Health . 270Measure #178: Rheumatoid Arthritis (RA): Functional Status Assessment – National Quality StrategyDomain: Effective Clinical Care . 272Measure #181: Elder Maltreatment Screen and Follow-Up Plan – National Quality Strategy Domain: PatientSafety . 275Measure #182: Functional Outcome Assessment – National Quality Strategy Domain: Communication andCare Coordination . 279Measure #185 (NQF 0659): Colonoscopy Interval for Patients with a History of Adenomatous Polyps –Avoidance of Inappropriate Use – National Quality Strategy Domain: Communication and Care Coordination. 285Measure #187: Stroke and Stroke Rehabilitation: Thrombolytic Therapy – National Quality StrategyDomain: Effective Clinical Care . 288Measure #191 (NQF 0565): Cataracts: 20/40 or Better Visual Acuity within 90 Days Following CataractSurgery – National Quality Strategy Domain: Effective Clinical Care . 290Measure #192 (NQF 0564): Cataracts: Complications within 30 Days Following Cataract Surgery RequiringAdditional Surgical Procedures – National Quality Strategy Domain: Patient Safety . 298Measure #193 (NQF 0454): Perioperative Temperature Management – National Quality Strategy Domain:Patient Safety . 304Measure #194 (NQF 0386): Oncology: Cancer Stage Documented – National Quality Strategy Domain:Effective Clinical Care . 308Measure #195 (NQF 0507): Radiology: Stenosis Measurement in Carotid Imaging Reports – NationalQuality Strategy Domain: Effective Clinical Care. 312Measure #204 (NQF 0068): Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic –National Quality Strategy Domain: Effective Clinical Care . 315Measure #205 (NQF 0409): HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia, Gonorrhea,and Syphilis – National Quality Strategy Domain: Effective Clinical Care . 318Measure #217 (NQF 0422): Functional Deficit: Change in Risk-Adjusted Functional Status for Patients withKnee Impairments – National Quality Strategy Domain: Communication and Care Coordination . 320Measure #218 (NQF 0423): Functional Deficit: Change in Risk-Adjusted Functional Status for Patients withHip Impairments – National Quality Strategy Domain: Communication and Care Coordination . 324Measure #219 (NQF 0424): Functional Deficit: Change in Risk-Adjusted Functional Status for Patients withLower Leg, Foot or Ankle Impairments – National Quality Strategy Domain: Communication and CareCoordination . 327Measure #220 (NQF 0425): Functional Deficit: Change in Risk-Adjusted Functional Status for Patients withLumbar Spine Impairments – National Quality Stratgy Domain: Communication and Care Coordination . 331Version 9.112/23/2014CPT only copyright 2014 American Medical Association. All rights reserved.Page 6 of 593
Measure #221 (NQF 0426): Functional Deficit: Change in Risk-Adjusted Functional Status for Patients withShoulder Impairments – National Quality Strategy Domain: Communication and Care Coordination . 335Measure #222 (NQF 0427): Functional Deficit: Change in Risk-Adjusted Functional Status for Patients withElbow, Wrist or Hand Impairments – National Quality Strategy Domain: Communication and CareCoordination . 339Measure #223 (NQF 0428): Functional Deficit: Change in Risk-Adjusted Functional Status for Patients withNeck, Cranium, Mandible, Thoracic Spine, Ribs, or Other General Orthopedic Impairments – National QualityStrategy Domain: Communication and Care Coordination . 343Measure #224 (NQF 0562): Melanoma: Overutilization of Imaging Studies in Melanoma – National QualityStrategy Domain: Efficiency and Cost Reduction. 347Measure #225 (NQF 0509): Radiology: Reminder System for Screening Mammograms – National QualityStrategy Domain: Communication and Care Coordination . 351Measure #226 (NQF 0028): Preventive Care and Screening: Tobacco Use: Screening and CessationIntervention – National Quality Strategy Domain: Community / Population Health. 353Measure #236 (NQF 0018): Controlling High Blood Pressure – National Quality Strategy Domain: EffectiveClinical Care . 356Measure #238 (NQF 0022): Use of High-Risk Medications in the Elderly – National Quality StrategyDomain: Patient Safety . 359Measure #242: Coronary Artery Disease (CAD): Symptom Management – National Quality StrategyDomain: Effective Clincial Care . 365Measure #243 (NQF 0643): Cardiac Rehabilitation Patient Referral from an Outpatient Setting – NationalQuality Strategy Domain: Effective Clinical Care. 369Measure #249: Barrett’s Esophagus – National Quality Strategy Domain: Effective Clinical Care . 373Measure #250: Radical Prostatectomy Pathology Reporting – National Quality Strategy Domain: EffectiveClincial Care . 375Measure #251: Quantitative Immunohistochemical (IHC) Evaluation of Human Epidermal Growth FactorReceptor 2 Testing (HER2) for Breast Cancer Patients – National Quality Strategy Domain: Effective ClinicalCare . 378Measure #254 (NQF 0651): Ultrasound Determination of Pregnancy Location for Pregnant Patients withAbdominal Pain – National Quality Strategy Domain: Effective Clinical Care . 381Measure #255: Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal BloodExposure – National Quality Strategy Domain: Effective Clinical Care . 384Measure #257: Statin Therapy at Discharge after Lower Extremity Bypass (LEB) – National QualityStrategy Domain: Effective Clinical Care . 386Measure #258: Rate of Open Repair of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms(AAA) without Major Complications (Discharged to Home by Post-Operative Day #7) – National QualityStrategy Domain: Patient Safety. 389Measure #259: Rate of Endovascular Aneurysm Repa
Measure #14 (NQF 0087): Age-Related Macular Degeneration (AMD): Dilated Macular Examination - National Quality Strategy Domain: Effective Clinical Care .51 Measure #19 (NQF 0089): Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care -
