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 |
|---|---|---|---|---|---|
| 023 | Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) | Yes | Process | Percentage of surgical patients aged 18 years and older undergoing procedures for which venous thromboembolism (VTE) prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low- Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time | Read More |
| 043 | Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery | No | Process | Percentage of patients aged 18 years and older undergoing isolated CABG surgery who received an IMA graft | Read More |
| 047 | Care Plan | Yes | Process | Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented 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 | Read More |
| 021 | Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin | No | Process | Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic, who had an order for a first OR second generation cephalosporin for antimicrobial prophylaxis | Read More |
| 130 | Documentation of Current Medications in the Medical Record | Yes | Process | Percentage of visits for patients aged 18 years and older for which the eligible professional or 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 | Read More |
| 168 | Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration | Yes | Outcome | Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require a return to the operating room (OR) during the current hospitalization for mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction, or other cardiac reason | Read More |
| 167 | Coronary Artery Bypass Graft (CABG): Postoperative Renal Failure | Yes | Outcome | Percentage of patients aged 18 years and older undergoing isolated CABG surgery (without pre-existing renal failure) who develop postoperative renal failure or require dialysis | Read More |
| 166 | Coronary Artery Bypass Graft (CABG): Stroke | Yes | Outcome | Percentage of patients aged 18 years and older undergoing isolated CABG surgery who have a postoperative stroke (i.e., any confirmed neurological deficit of abrupt onset caused by a disturbance in blood supply to the brain) that did not resolve within 24 hours | Read More |
| 165 | Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate | Yes | Outcome | Percentage of patients aged 18 years and older undergoing isolated CABG surgery who, within 30 days postoperatively, develop deep sternal wound infection involving muscle, bone, and/or mediastinum requiring operative intervention | Read More |
| 164 | Coronary Artery Bypass Graft (CABG): Prolonged Intubation | Yes | Outcome | Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require postoperative intubation > 24 hours | Read More |
| 226 | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | No | Process | Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user | Read More |
| 236 | Controlling High Blood Pressure | Yes | Intermediate Outcome | Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period | Read More |
| 317 | Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | No | Process | 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 | Read More |
| 358 | Patient-Centered Surgical Risk Assessment and Communication | Yes | Process | Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon | 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 |
| 402 | Tobacco Use and Help with Quitting Among Adolescents | No | Process | The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user | Read More |
| 441 | Ischemic Vascular Disease (IVD) All or None Outcome Measure (Optimal Control) | Yes | Intermediate Outcome | The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization's total IVD denominator. All-or-None Outcome Measure (Optimal Control) - Using the IVD denominator optimal results include: +G254 · Most recent blood pressure (BP) measurement is less than 140/90 mm Hg -- And · Most recent tobacco status is Tobacco Free -- And · Daily Aspirin or Other Antiplatelet Unless Contraindicated -- And · Statin Use Unless Contraindicated | Read More |
| 445 | Risk-Adjusted Operative Mortality for Coronary Artery Bypass Graft (CABG) | Yes | Outcome | Percent of patients aged 18 years and older undergoing isolated CABG who die, including both all deaths occurring during the hospitalization in which the CABG was performed, even if after 30 days, and those deaths occurring after discharge from the hospital, but within 30 days of the procedure | Read More |