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 |
|---|---|---|---|---|---|
| 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 |
| 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 |
| 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 |
| 187 | Stroke and Stroke Rehabilitation: Thrombolytic Therapy | No | Process | Percentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who arrive at the hospital within two hours of time last known well and for whom IV t-PA was initiated within three hours of time last known well | 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 |
| 345 | Rate of Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS) Who Are Stroke Free or Discharged Alive | Yes | Outcome | Percent of asymptomatic patients undergoing CAS who are stroke free while in the hospital or discharged alive following surgery | Read More |
| 346 | Rate of Asymptomatic Patients Undergoing Carotid Endarterectomy (CEA) Who Are Stroke Free or Discharged Alive | Yes | Outcome | Percent of asymptomatic patients undergoing CEA who are stroke free or discharged alive following surgery | 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 |
| 459 | Average Change in Back Pain following Lumbar Discectomy / Laminotomy | Yes | Outcome | The average change (preoperative to three months postoperative) in back pain for patients 18 years of age or older who had lumbar discectomy/laminotomy procedure | Read More |
| 460 | Average Change in Back Pain following Lumbar Fusion | Yes | Outcome | The average change (preoperative to one year postoperative) in back pain for patients 18 years of age or older who had lumbar spine fusion procedure | Read More |
| 461 | Average Change in Leg Pain following Lumbar Discectomy and/or Laminotomy | Yes | Outcome | The average change (preoperative to three months postoperative) in leg pain for patients 18 years of age or older who had lumbar discectomy/laminotomy procedure | Read More |