This measure set was for 2018 MIPS Quality reporting. View 2019 version ->
CMS specialty measure sets may be reported as an alternative to reporting 6 separate quality measures. If a measure set has less than 6 measures, eligible groups and clinicians must report all measures in the set. However, if a set has more than 6 measures, participants may choose the 6 measures that best fit their practice. Remember, at least one outcome measure must be reported, regardless of whether or not an outcome measure is included in a measure set.
| Quality Id | Measure Name | High Priority | Measure Type | Measure Description | Full Specifications |
|---|---|---|---|---|---|
| 076 | Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections | Yes | Process | Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed | Read More |
| 145 | Radiology: Exposure Dose or Time Reported for Procedures Using Fluoroscopy | No | Process | Final reports for procedures using fluoroscopy that document radiation exposure indices, or exposure time and number of fluorographic images (if radiation exposure indices are not available) | Read More |
| 374 | Closing the Referral Loop: Receipt of Specialist Report | Yes | Process | Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred | Read More |
| 409 | Clinical Outcome Post Endovascular Stroke Treatment | Yes | Outcome | Percentage of patients with a mRs score of 0 to 2 at 90 days following endovascular stroke intervention | Read More |
| 413 | Door to Puncture Time for Endovascular Stroke Treatment | Yes | Intermediate Outcome | Percentage of patients undergoing endovascular stroke treatment who have a door to puncture time of less than two hours | Read More |
| 420 | Varicose Vein Treatment with Saphenous Ablation: Outcome Survey | No | Outcome | Percentage of patients treated for varicose veins (CEAP C2-S) who are treated with saphenous ablation (with or without adjunctive tributary treatment) that report an improvement on a disease specific patient reported outcome survey instrument after treatment | Read More |
| 421 | Appropriate Assessment of Retrievable Inferior Vena Cava (IVC) Filters for Removal | No | Process | Percentage of patients in whom a retrievable IVC filter is placed who, within 3 months post-placement, have a documented assessment for the appropriateness of continued filtration, device removal or the inability to contact the patient with at least two attempts | Read More |
| 437 | Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure | Yes | Outcome | Inpatients assigned to endovascular treatment for obstructive arterial disease, the percent of patients who undergo unplanned major amputation or surgical bypass within 48 hours of the index procedure | Read More |
| 465 | Uterine Artery Embolization Technique: Documentation of Angiographic Endpoints and Interrogation of Ovarian Arteries | Yes | Process | The percentage of patients with documentation of angiographic endpoints of embolization AND the documentation of embolization strategies in the presence of unilateral or bilateral absent uterine arteries | Read More |