CMS Measures - Fiscal Year 2019
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1 ID Me asure Name NQF # Value- (VBP) - (HACRP) (HRRP) ID Me asure Name NQF # Value- (VBP) - (HACRP) (HRRP) CMS s - Fiscal Year 2019 ID Name NQF # The Centers for Medicare & Medicaid Services (CMS) Improvement s for Acute Care s - Fiscal Year (FY) 2019 Payment Update IQR IQR Value- (VBP) VBP VBP - Compare Clinical Process of Care s (via Chart-Abstraction) ED-1 ED-2 IMM-2 PC-01 Sepsis for Admitted ED Patients Admit Decision Time to ED Departure Time for Admitted Patients Influenza Immunization Note The IMM-2 measure is collected for all 4 quarters; however, only discharges included in 1st and 4th quarters will be included in the measure calculation. The IMM-2 measure is reported by flu season on CMS's Compare site. Elective Delivery Prior to 39 Completed Weeks Gestation Severe Sepsis and Septic Shock Management Bundle (Composite ) No No No No No No No No Flu Season December Flu Season December 2018 No No No No Baseline Performance December 2018 No No No No No VTE-6 Incidence of Potentially Preventable Venous Thromboembolism Clinical Process of Care s (via Clinical s) No No No No AMI-8a Primary PCI Received Within 90 Minutes of Arrival 0163 * Q3, or Q4) TBD No ** CAC-3 Home Management Plan of Care Document Given to Patient/Caregiver * Q3, or Q4) TBD No ** ED-1 for Admitted ED Patients 0495 * Q3, or Q4) TBD No ** ED-2 Admit Decision Time to ED Departure Time for Admitted Patients 0497 * Q3, or Q4) TBD No ** ED-3 for Discharged ED Patients 0496 No NA No ** EHDI-1a Hearing Screening Prior to Discharge 1354 * Q3, or Q4) TBD No ** PC-01 Elective Delivery (Collected in aggregate) 0469 * Q3, or Q4) TBD No ** Attestation and QRDA PC-05 Exclusive Breast Milk Feeding and the Subset PC-05a Exclusive Breast Milk Feeding Considering Mother s Choice 0480 * Q3, or Q4) TBD No ** November 1
2 CMS s - Fiscal Year 2019 ID Name NQF # IQR IQR Value- (VBP) VBP VBP - Compare STK-02 Discharged on Antithrombotic Therapy 0435 * Q3, or Q4) TBD No ** STK-03 Anticoagulation Therapy for Atrial Fibrillation/Flutter 0436 * Q3, or Q4) TBD No ** STK-05 Antithrombotic Therapy by the End of Day Two 0438 * Q3, or Q4) TBD No ** STK-06 Discharged on Statin Medication 0439 * Q3, or Q4) TBD No ** STK-08 Stroke Education * Q3, or Q4) TBD No ** STK-10 Assessed for Rehabilitation 0441 * Q3, or Q4) TBD No ** VTE-1 Venous Thromboembolism Prophylaxis 0371 * Report 1 self-selected Q3, or Q4) TBD No ** VTE-2 Intensive Care Unit Venous Thromboembolism Prophylaxis 0372 * Report 1 self-selected Q3, or Q4) TBD No ** November 2
3 ID Me asure Name NQF # Value- (VBP) - (HACRP) (HRRP) ID Me asure Name NQF # Value- (VBP) - (HACRP) (HRRP) CMS s - Fiscal Year 2019 ID Name NQF # IQR IQR Value- (VBP) VBP VBP - Compare Healthcare-Associated Infection and Patient Safety s CLABSI CAUTI Central Line-Associated Bloodstream Infection (CLABSI) Outcome Catheter-associated Urinary Tract Infection (CAUTI) Outcome Baseline Performance Baseline Performance December 2018 No December 2018 No December 2018 No December 2018 No Colon and Abdominal Hysterectomy SSI American College of Surgeons Centers for Disease Control and Prevention (ACS-CDC) Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome Colon Procedures Hysterectomy Procedures 0753 Baseline Performance December 2018 No January 1, December 31, December 2018 No MRSA Bacteremia Facility-wide -onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome 1716 Baseline Performance December 2018 No January 1, December 31, December 2018 No CDI Facility-wide -onset Clostridium difficile Infection (CDI) Outcome 1717 Baseline Performance December 2018 No December 2018 No HCP Influenza Vaccination Coverage Among Healthcare Personnel 0431 October 1, March 31, October No No No No PSI 4 (PSI/NSI) Death among Surgical s with Serious, Treatable Complications 0351 October 1, June 30, No No No No PSI 90 Patient Safety and Adverse Events Composite 0531 October 1, June 30, No No October 1, December 2018 No Outcome s MORT-30-AMI MORT-30-HF MORT-30-PN 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Acute Myocardial Infarction (AMI) ization 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Heart Failure (HF) ization 30-Day, All-Cause, Risk-Standardized Mortality Rate Following Pneumonia ization Baseline Performance July 1, Baseline Performance July 1, Baseline Performance July 1, December 2018 No No No December 2018 No No No December 2018 No No No MORT-30-COPD 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Chronic Obstructive Pulmonary Disease (COPD) ization 1893 No No No No MORT-30-STK 30-Day, All-Cause, Risk-Standardized Mortality Rate Following Acute Ischemic Stroke No No No No MORT-30-CABG 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Coronary Artery Bypass Graft (CABG) Surgery 2558 No No No No Hip/Knee Complications -Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) 1550 April 1, March 31, Baseline July 1, June 30, 2013 Performance January 1, December 2018 No No No November 3
4 ID Me asure Name NQF # Value- (VBP) - (HACRP) (HRRP) ID Me asure Name NQF # Value- (VBP) - (HACRP) (HRRP) CMS s - Fiscal Year 2019 ID Name NQF # IQR IQR Value- (VBP) VBP VBP - Compare Coordination of Care s READM-30-AMI 30-Day All-Cause Risk-Standardized Readmission Rate (RSRR) Following Acute Myocardial Infarction (AMI) ization 0505 No No No December 2018 READM-30-PN 30-Day, All-Cause, Risk-Standardized Readmission Rate (RSRR) Following Pneumonia ization 0506 No No No December 2018 READM-30-THA/TKA READM-30-HWR -Level 30-Day, All-Cause Risk- Standardized Readmission Rate (RSRR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) -Wide All-Cause Unplanned Readmission (HWR) July 1, No No No December 2018 No No No No READM-30-COPD 30-Day, All-Cause, Risk-Standardized Readmission Rate (RSRR) Following Chronic Obstructive Pulmonary Disease (COPD) ization 1891 No No No December 2018 READM-30-STK 30-Day Risk Standardized Readmission Rate Following Stroke ization No No No No READM-30-CABG 30-Day, All-Cause, Unplanned, Risk- Standardized Readmission Rate (RSRR) Following Coronary Artery Bypass Graft (CABG) Surgery 2515 No No No December 2018 READM-30-HF 30-Day, All-Cause, Risk-Standardized Readmission Rate (RSRR) Following Heart Failure (HF) ization 0330 No No No No December 2018 AMI Excess Days Excess Days in Acute Care after ization for Acute Myocardial Infarction No No No No HF Excess Days PN Excess Days Cost/Payment s Excess Days in Acute Care after ization for Heart Failure Excess Days in Acute Care after ization for Pneumonia No No No No July 1, No No No No MSPB Payment-Standardized Medicare Spending Per Beneficiary (MSPB) 2158 December 31, December 2018 Baseline Performance December 2018 No No No AMI Payment -Level, Risk-Standardized Payment Associated with a 30-Day Episode-of-Care for Acute Myocardial Infarction (AMI) 2431 No No No No HF Payment PN Payment -Level, Risk-Standardized Payment Associated with a 30-Day Episode-of-Care For Heart Failure (HF) -Level, Risk-Standardized Payment Associated with a 30-day Episode-of-Care For Pneumonia No No No No No No No No THA/TKA Payment -Level, Risk-Standardized Payment Associated with an Episode-of-Care for Primary Elective Total Hip Arthroplasty and/or Total Knee Arthroplasty April 1, March 31, No No No No Kidney/UTI Payment Cellulitis Payment GI Payment Kidney/Urinary Tract Infection Clinical Episode- Based Payment Cellulitis Clinical Episode-Based Payment Gastrointestinal Hemorrhage Clinical Episode- Based Payment December 2018 No No No No December 2018 No No No No December 2018 No No No No November 4
5 ID Me asure Name NQF # Value- (VBP) - (HACRP) (HRRP) ID Me asure Name NQF # Value- (VBP) - (HACRP) (HRRP) CMS s - Fiscal Year 2019 ID Name NQF # AA Payment Chole and CDE Payment SFusion Payment Aortic Aneurysm Procedure Clinical Episode- Based Payment Cholecystectomy and Common Duct Exploration Clinical Episode-Based Payment Spinal Fusion Clinical Episode-Based Payment IQR IQR Value- (VBP) VBP VBP - December 2018 No No No No December 2018 No No No No December 2018 No No No No Compare Structural s Patient Safety Culture Survey on Patient Safety Culture Safe Surgery Checklist Safe Surgery Check List Use Patient Experience of Care Survey December 2018 No No No No December 2018 No No No No HCAHPS Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey + Care Transition (CTM-3) December 31, Baseline Performance December 2018 No No No Footnotes (*) A hospital may choose to submit this measure as one of the four self-selected ecqms required for the IQR. (**) For reporting CQMs by attestation, a hospital is required to report on this measure, which is one of the 16 required CQMs under the that is attested to in the CMS Registration and Attestation System. For reporting CQMs electronically, a hospital may choose to report this measure, which is one of the four self-selected required CQMs from the available 16 CQMs required under the Pro (***) Per the FY IPPS final rule, for EHs and CAHs reporting CQMs by attestation and demonstrating meaningful use for the first time in, the reporting period is any continuous 90-day period within CY ; for those that demonstrated meaningful use in any year prior to, the reporting period is one full calendar year. For EHs and CAHs electronically reporting, the reporting period is one self-selected full calend Updates to Document Date of Update Summary of Update November 5
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