Merge pull request #858 from CMSgov/QPPA-9539

QPPA-9539: Initial CQM measures update for PY25

updates/measures/2025/MedicareCQM_Quality_QCDR_PY25_20241106.csv

@@ -0,0 +1,27 @@
+Category ,Measure Title,CMS eCQM ID,eCQM NQF,NQF,*** Quality Number (#) / QCDR #,Primary Measure Steward,Allowed QCDR Vendor ID,Measure Description,*** Measure Type  ,High Priority,First Performance Year,Year Removed,*** Collection Type(s) for Submission,Specialty Measure Sets,*** Inverse,*** Metric Type,*** Calculation Type,Collection Type(s) where Historic Benchmark Removed,Collection Type(s) where Suppressed,Collection Type(s) where Truncated,*** Collection Type(s) where 7-point Cap Removed,Collection Type(s) where Historic Benchmark Removed ** Special Rules **,Is Risk Adjusted 
+"Values:  Quality, QCDR ",,,,,,,** Comma delimited list  **,,"
+
+Values:  Efficiency, Intermediate Outcome, Outcome, Patient Engagement/Experience, Patient Reported Outcome, Patient-Reported Outcome-Based Performance Measure, Process, Structure","Values: Y, N",,Enter current PY if measure is to be removed,"** Comma delimited list  **
+
+Values:  Part B Claims, CSV, eCQM, CMS WI, Admin Claims, MIPS CQM, QCDR","** Comma delimited list  **
+
+Values: Allergy/ Immunology, Anesthesiology, Audiology, Cardiology, Certified Nurse Midwife, Chiropractic Medicine, Clinical Social Work, Dentistry, Dermatology, Diagnostic Radiology, Electro-physiology Cardiac Specialist, Emergency Medicine, Endocrinology, Family Medicine, Gastro-enterology, General Surgery, Geriatrics, Hospitalists, Infectious Disease, Internal Medicine, Interventional Radiology, Mental/Behavioral Health and Psychiatry, Nephrology, Neurology, Neurosurgical, Nutrition/ Dietician, Obstetrics/
+Gynecology, Oncology/ Hematology, Ophthalmology/Optometry, Orthopedic Surgery, Otolaryngology, Pathology, Pediatrics, Physical Medicine, Physical Therapy/ Occupational Therapy, Plastic 
+Surgery, Podiatry, Preventive Medicine, Pulmonology, Radiation Oncology, Rheumatology, Skilled Nursing Facility, Speech Language Pathology, Thoracic Surgery, Urgent Care, Urology, Vascular Surgery","Values: Y, N","Values: singlePerformanceRate, multiPerformanceRate, nonProportion, costScore","Values: weightedAverage, simpleAverage, overallStratumOnly, split
+
+Complete only when Metric Type is multiPerformanceRate","** Comma delimited list  **
+
+Values:  Part B Claims, CSV, eCQM, CMS WI, Admin Claims, MIPS CQM, QCDR","** Comma delimited list  **
+
+Values:  Part B Claims, CSV, eCQM, CMS WI, Admin Claims, MIPS CQM, QCDR","** Comma delimited list  **
+
+Values:  Part B Claims, CSV, eCQM, CMS WI, Admin Claims, MIPS CQM, QCDR","** Comma delimited list  **
+
+Values:  Part B Claims, CSV, eCQM, CMS WI, Admin Claims, MIPS CQM, QCDR","This is for Historic Benchmark Removal items that require special handling by scoring.
+Not to be confused with Column S for typical HB removal due to substantive changes to the measure.
+
+** Comma delimited list  **
+
+Values:  Part B Claims, CSV, eCQM, CMS WI, Admin Claims, MIPS CQM, QCDR","Values:  Y, N"
+Quality,Breast Cancer Screening,null,null,null,112SSP,National Committee for Quality Assurance,,Percentage of women 40 - 74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the measurement period.,process,N,2017,,MIPS CQM,NULL,N,singlePerformanceRate,,,,,,,N
+,,,,,,,,,,,,,,,,,,,,,,,

updates/measures/2025/Quality_PY2025_AnalyticBMCollectType Updates_CR_11182024.csv

@@ -0,0 +1,20 @@
+Category ,Measure Title,CMS eCQM ID,eCQM NQF,NQF,*** Quality Number (#) / QCDR #,Primary Measure Steward,Allowed QCDR Vendor ID,Measure Description,*** Measure Type  ,High Priority,First Performance Year,Year Removed,*** Collection Type(s) for Submission,Specialty Measure Sets,*** Inverse,*** Metric Type,*** Calculation Type,Collection Type(s) where Historic Benchmark Removed,Collection Type(s) where Suppressed,Collection Type(s) where Truncated,*** Collection Type(s) where 7-point Cap Removed,Collection Type(s) where Historic Benchmark Removed ** Special Rules **,Is Risk Adjusted 
+Quality,HIV Annual Retention in Care,CMS1157v1,,,340,,,"Percentage of patients, regardless of age, with a diagnosis of Human Immunodeficiency Virus (HIV) before or during the first 240 days of the performance period who had at least two eligible encounters or at least one eligible encounter and one HIV viral load test that were at least 90 days apart within the performance period",,,,,"eCQM, MIPS CQM",,,,,MIPS CQM,,,,,
+Quality,"Rate of Carotid Endarterectomy (CEA) or Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2)",,,,344,,,Percent of asymptomatic patients undergoing Carotid Endarterectomy (CEA) or Carotid Artery Stenting (CAS) without major complication who are discharged to home no later than post-operative day #2.,,,,,,,,,,MIPS CQM,,,,,
+Quality,Proportion of Patients Sustaining a Bladder or Bowel Injury at the time of any Pelvic Organ Prolapse Repair,,,,432,,,Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by a bladder or bowel injury at the time of index surgery that is recognized intraoperatively or within 30 days after surgery.,,,,,,,,multiPerformanceRate,simpleAverage,MIPS CQM,,,,,
+Quality,,CMS157v13,,,143,,,,,,,,,,,,,,,,"eCQM, MIPS CQM",,
+Quality,,,,,249,,,,,,,,,,,,,,,,"Part B Claims, MIPS CQM",,
+Quality,,,,,250,,,,,,,,,,,,,,,,"Part B Claims, MIPS CQM",,
+Quality,,,,,360,,,"Percentage of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion or infarct avid imaging) reports for all patients, regardless of age, that document a count of known previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion or infarct avid imaging) studies that the patient has received in the 12-month period prior to the current study.",,,,,,,,,,,,,MIPS CQM,,
+Quality,,,,,364,,,,,,,,,,,,,,,,MIPS CQM,,
+Quality,,,,,395,,,,,,,,,,,,,,,,"Part B Claims, MIPS CQM",,
+Quality,,,,,396,,,,,,,,,,,,,,,,MIPS CQM,,
+Quality,,,,,397,,,,,,,,,,,,,,,,"Part B Claims, MIPS CQM",,
+Quality,,,,,405,,,,,,,,,,,,,,,,MIPS CQM,,
+Quality,,,,,406,,,,,,,,,,,,,,,,MIPS CQM,,
+Quality,,,,,424,,,,,,,,,,,,,,,,MIPS CQM,,
+Quality,,,,,430,,,,,,,,,,,,,,,,MIPS CQM,,
+Quality,,,,,440,,,,,,,,,,,,,,,,MIPS CQM,,
+Quality,,,,,463,,,,,,,,,,,,,,,,MIPS CQM,,
+Quality,,,,,477,,,,,,,,,,,,,,,,MIPS CQM,,
+Quality,,,,,155,,,Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months.,,,,,MIPS CQM,,,,,,,,,,

updates/measures/2025/Quality_PY2025_Annual Revisions_CR_11182024.csv

@@ -0,0 +1,67 @@
+Category ,Measure Title,CMS eCQM ID,eCQM NQF,NQF,*** Quality Number (#) / QCDR #,Primary Measure Steward,Allowed QCDR Vendor ID,Measure Description,*** Measure Type  ,High Priority,First Performance Year,Year Removed,*** Collection Type(s) for Submission,Specialty Measure Sets,*** Inverse,*** Metric Type,*** Calculation Type,Collection Type(s) where Historic Benchmark Removed,Collection Type(s) where Suppressed,Collection Type(s) where Truncated,*** Collection Type(s) where 7-point Cap Removed,Collection Type(s) where Historic Benchmark Removed ** Special Rules **,Is Risk Adjusted 
+Quality,Diabetes: Glycemic Status Assessment Greater Than 9%,CMS122v13,,,001,,,Percentage of patients 18-75 years of age with diabetes who had a glycemic status assessment (hemoglobin A1c [HbA1c] or glucose management indicator [GMI]) > 9.0% during the measurement period.,,,,,,,,,,,,,,,
+Quality,Antidepressant Medication Management,CMS128v13,,,009,,,,,,,,,,,,,,,,,,
+Quality,Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing  Status ,,,,491,,,,,,,,,,,,,,,,,,
+Quality,,CMS135v13,,,005,,,,,,,,,,,,,,,,,,
+Quality,,CMS145v13,,,007,,,,,,,,,,,,,,,,,,
+Quality,,CMS144v13,,,008,,,,,,,,,,,,,,,,,,
+Quality,,CMS143v13,,,012,,,,,,,,,,,,,,,,,,
+Quality,,CMS142v13,,,019,,,,,,,,eCQM,"Ophthalmology/Optometry",,,,,,,,,
+Quality,,CMS154v13,,,065,,,,,,,,,,,,,,,,,,
+Quality,,CMS146v13,,,066,,,,,,,,,,,,,,,,,,
+Quality,,CMS129v14,,,102,,,,,,,,,,,,,,,,,,
+Quality,,CMS125v13,,,112,,,,,,,,,,,,,,,,,,
+Quality,,CMS130v13,,,113,,,,,,,,,,,,,,,,,,
+Quality,,CMS131v13,,,117,,,,,,,,,"Endocrinology, Family Medicine, Internal Medicine, Ophthalmology/Optometry",,,,,,,,,
+Quality,,CMS69v13,,,128,,,,,,,,,,,,,,,,,,
+Quality,,CMS68v14,,,130,,,Percentage of visits for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter.,,,,,,"Allergy/ Immunology, Audiology, Cardiology, Certified Nurse Midwife, Clinical Social Work, Dermatology, Endocrinology, Family Medicine, Gastro-enterology, General Surgery, Geriatrics, Hospitalists, Infectious Disease, Internal Medicine, Mental/ Behavioral Health and  Psychiatry, Nephrology, Neurology, Neurosurgical, Nutrition/ Dietician, Obstetrics/Gynecology, Oncology/ Hematology, Ophthalmology/Optometry,Orthopedic Surgery, Otolaryngology, Physical Medicine, Physical Therapy/Occupational Therapy, Plastic Surgery, Preventive Medicine, Pulmonology, Rheumatology, Speech Language Pathology, Thoracic Surgery, Urgent Care, Urology, Vascular Surgery",,,,,,,,,
+Quality,,CMS2v14,,,134,,,,,,,,,,,,,,,,,,
+Quality,,CMS133v13,,,191,,,,,,,,,,,,,,,,,,
+Quality,,CMS1188v2,3755e,,205,,,,,,,,,,,,,,,,,,
+Quality,,CMS138v13,,,226,,,,,,,,,"Allergy/ Immunology, Audiology, Cardiology, Certified Nurse Midwife, Clinical Social Work, Dermatology, Endocrinology, Gastro-enterology, General Surgery, Infectious Disease, Mental/ Behavioral Health and  Psychiatry, Nephrology, Neurology, Neurosurgical, Nutrition/ Dietician, Oncology/ Hematology, Ophthalmology/Optometry,Orthopedic Surgery, Otolaryngology, Pediatrics, Physical Medicine, Physical Therapy/Occupational Therapy, Plastic Surgery, Podiatry, Pulmonology, Radiation Oncology, Rheumatology, Speech Language Pathology, Thoracic Surgery, Urgent Care, Urology, Vascular Surgery",,,,,,,,,
+Quality,,CMS165v13,,,236,,,,,,,,,,,,,,,,,,
+Quality,,CMS156v13,,,238,,,,,,,,,"Allergy/ Immunology, Cardiology, Family Medicine, Geriatrics, Internal Medicine, Oncology/ Hematology, Ophthalmology/Optometry,Otolaryngology, Pulmonology, Rheumatology, Skilled Nursing Facility, Urology",,,,,,,,,
+Quality,,CMS155v13,,,239,,,,,,,,,,,,,,,,,,
+Quality,,CMS117v13,,,240,,,"Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three or four H influenza type B (HiB); three hepatitis B (HepB); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (HepA); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday.",,,,,,,,,,,,,,,
+Quality,,CMS149v13,,,281,,,,,,,,,,,,,,,,,,
+Quality,,CMS137v13,,,305,,,"Percentage of patients 13 years of age and older with a new substance use disorder (SUD) episode who received the following (Two rates are reported):
+a. Percentage of patients who initiated treatment, including either an intervention or medication for the treatment of SUD, within 14 days of the new SUD episode. 
+b. Percentage of patients who engaged in ongoing treatment, including two additional interventions or medication treatment events for SUD, or one long-acting medication event for the treatment of SUD, within 34 days of the initiation.",,,,,,,,,,,,,,,
+Quality,,CMS124v13,,,309,,,,,,,,,,,,,,,,,,
+Quality,,CMS153v13,,,310,,,,,,,,,,,,,,,,,,
+Quality,,CMS22v13,,,317,,,,,,,,,,,,,,,,,,
+Quality,,CMS139v13,,,318,,,,,,,,,,,,,,,,,,
+Quality,,CMS314v2,,,338,,,,,,,,,,,,,,,,,,
+Quality,,CMS136v14,,,366,,,,,,,,,,,,,,,,,,
+Quality,,CMS159v13,,,370,,,,,,,,,,,,,,,,,,
+Quality,,CMS50v13,,,374,,,,,,,,,"Allergy/ Immunology, Cardiology, Dermatology, Endocrinology, Family Medicine, Gastro-enterology, General Surgery, Internal Medicine, Interventional Radiology, Neurology, Obstetrics/Gynecology, Oncology/ Hematology, Ophthalmology/Optometry,Orthopedic Surgery, Otolaryngology, Physical Medicine, Preventive Medicine, Pulmonology, Rheumatology, Thoracic Surgery, Urology, Vascular Surgery",,,,,,,,,
+Quality,,CMS56v13,,,376,,,,,,,,,,,,,,,,,,
+Quality,,CMS90v14,,,377,,,,,,,,,,,,,,,,,,
+Quality,,CMS75v13,,,378,,,,,,,,,,,,,,,,,,
+Quality,,CMS74v14,,,379,,,,,,,,,,,,,,,,,,
+Quality,,CMS177v13,,,382,,,,,,,,,,,,,,,,,,
+Quality,,CMS347v8,,,438,,,,,,,,,,,,,,,,,,
+Quality,,CMS645v8,,,462,,,,,,,,,,,,,,,,,,
+Quality,,CMS349v7,,,475,,,,,,,,,,,,,,,,,,
+Quality,,CMS771v6,,,476,,,,,,,,,,,,,,,,,,
+Quality,,CMS646v5,,,481,,,,,,,,,,,,,,,,,,
+Quality,,CMS951v3,,,488,,,Percentage of patients aged 18--85 years with a diagnosis of diabetes who received a kidney health evaluation defined by an Estimated Glomerular Filtration Rate (eGFR) AND Urine Albumin-Creatinine Ratio (uACR) within the measurement period.,,,,,,"Endocrinology, Family Medicine, Geriatrics, Internal Medicine, Nephrology, Preventive Medicine, Urgent Care, Urology",,,,,,,,,
+Quality,,,,,039,,,Percentage of women aged 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) test to check for osteoporosis.,,,,,,,,,,,,,,,
+Quality,,,,,168,,,"Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require a return to the operating room (OR) for mediastinal bleeding with or without tamponade, unplanned coronary artery intervention (native vessel, graft or both), valve dysfunction, aortic reintervention or other cardiac reason during the current hospitalization. ",,,,,,,,,,,,,,,
+Quality,,,,,177,,,Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment of disease activity using an ACR-preferred RA disease activity assessment tool at ≥50% of encounters for RA for each patient during the performance period.,,,,,,,,,,,,,,,
+Quality,,,,,178,,,Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) for whom a functional status assessment was performed during the performance period.,,,,,,,,,,,,,,,
+Quality,,,,,180,,,"Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone > 5 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan during the performance period.",,,,,,,,,,,,,,,
+Quality,,,,,277,,,"Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI), a respiratory disturbance index (RDI), or a respiratory event index (REI) documented or measured within 2 months after initial evaluation for suspected obstructive sleep apnea.",,,,,,,,,,,,,,,
+Quality,,,,,320,,,Percentage of patients aged 45 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of 10 years for repeat colonoscopy documented in their colonoscopy report.,,,,,,,,,,,,,,,
+Quality,,,,,322,,,"Percentage of stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), stress echocardiogram (ECHO), multigated acquisition scan (MUGA), cardiac computed tomography angiography (CCTA), or cardiac magnetic resonance (CMR) performed in low-risk surgery patients 18 years or older for preoperative evaluation during the 12-month submission period.",,,,,,,,,,,,,,,
+Quality,,,,,336,,,"Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for postpartum care before or at 12 weeks of giving birth and received the following at a postpartum visit: breastfeeding evaluation and education, postpartum depression screening, intimate partner violence screening, postpartum glucose screening for gestational diabetes patients, family and contraceptive planning counseling, tobacco use screening and cessation education, healthy lifestyle behavioral advice, and an immunization review and update. ",,,,,,,,,,,,,,,
+Quality,,,,,418,,,The percentage of women 50-85 years of age who suffered a fracture and who had either a bone mineral density (BMD) test or prescription for a drug to treat osteoporosis in the 180 days after the fracture.,,,,,,,,,,,,,,,
+Quality,,,,,450,,,Percentage of patients aged 18 to 70 with stage I (T1c) – III HER2 positive breast cancer for whom appropriate treatment is initiated.,,,,,,,,,,,,,,,
+Quality,,,,,504,,,"Percentage of patients aged 12 years and older with suicidal ideation or behavior symptoms (based on results of a standardized assessment tool or screening tool) or increased suicide risk (based on the clinician's evaluation or clinician-rating tool) for whom a suicide safety plan is initiated, reviewed, and/or updated in collaboration between the patient and their clinician",,,,,,,,,,,,,,,
+Quality,,,,,181,,,,,,,,,"Audiology, Clinical Social Work, Emergency Medicine, Family Medicine, Geriatrics, Internal Medicine, Mental/ Behavioral Health and  Psychiatry, Neurology, Nutrition/ Dietician, Physical Therapy/Occupational Therapy, Skilled Nursing Facility, Speech Language Pathology",,,,,,,,,
+Quality,,,,,495,,,,,,,,,"Cardiology, Family Medicine, Geriatrics, Internal Medicine, Oncology/ Hematology",,,,,,,,,
+Quality,,,,,503,,,,,,,,,"Allergy/ Immunology, Cardiology, Certified Nurse Midwife, Clinical Social Work, Dermatology, Endocrinology, Family Medicine, Gastro-enterology, Geriatrics, Infectious Disease, Internal Medicine, Nephrology, Neurology, Obstetrics/Gynecology, Oncology/ Hematology, Physical Therapy/Occupational Therapy, Podiatry, Preventive Medicine, Pulmonology, Rheumatology, Urology",,,,,,,,,
+Quality,,,,,282,,,,,,,,,"Clinical Social Work, Geriatrics, Mental/ Behavioral Health and  Psychiatry, Neurology, Speech Language Pathology",,,,,,,,,
+Quality,,,,,286,,,,,,,,,"Clinical Social Work, Geriatrics, Mental/ Behavioral Health and  Psychiatry, Neurology, Physical Therapy/Occupational Therapy, Speech Language Pathology",,,,,,,,,
+Quality,,,,,288,,,,,,,,,"Clinical Social Work, Geriatrics, Mental/ Behavioral Health and  Psychiatry, Neurology, Physical Therapy/Occupational Therapy, Speech Language Pathology",,,,,,,,,
+Quality,,,,,396,,,,,,,,,"Neurology, Speech Language Pathology",,,,,,,,,