Proposed Individual Measures for 2017 under MIPS

Transcription

1 Registry Title 001 Diabetes: Hemoglobin A1c Poor Control 005 Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) 006 Chronic Stable Coronary Artery Disease (CAD): Antiplatelet Therapy: 007 Coronary Artery Disease (CAD): Beta-Blocker Therapy Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF < 40%) 008 Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) 012 Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation 014 Age-Related Macular Degeneration (AMD): Dilated Macular Eamination 019 Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care No Longer 021 Perioperative Care: Selection of Prophylactic Antibiotic First OR Second Generation Cephalosporin 023 Perioperative Care: Venous Thromboembolism (VTE) Prophylais (When Indicated in ALL Patients) 024 Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older 032 Stroke and Stroke Rehabilitation: Discharged on Antithrombotic Therapy 039 Screening for Osteoporosis for Women Aged Years of Age 043 Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery 044 Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery 046 Medication Reconciliation Post-Discharge no longer 047 Care Plan 048 Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older 050 Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older 051 Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation 052 Chronic Obstructive Pulmonary Disease (COPD): Inhaled Bronchodilator Therapy 065 Appropriate Treatment for Children with Upper Respiratory Infection (URI) Updated: 08/01/2016 As outlined in the 2017 Proposed Rule; subject to change. 1 of 11

2 Registry Title 066 Appropriate Testing for Children with Pharyngitis 067 Hematology: Myelodysplastic Syndrome (MDS) and Acute Leukemia: Baseline Cytogenetic Testing Performed on Bone Marrow 068 Hematology: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy 069 Hematology: Multiple Myeloma: Treatment with Bisphosphonates 070 Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry 076 Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections 091 Acute Otitis Eterna (AOE): Topical Therapy 093 Acute Otitis Eterna (AOE): Systemic Antimicrobial Therapy Avoidance of In Use 099 Breast Cancer Resection Pathology Reporting: pt Category (Primary Tumor) and pn Category (Regional Lymph Nodes) with Histologic Grade 100 Colorectal Cancer Resection Pathology Reporting: pt Category (Primary Tumor) and pn Category (Regional Lymph Nodes) with Histologic Grade 102 Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients 104 Prostate Cancer: Adjuvant Hormonal Therapy for High Risk or Very High Risk Prostate Cancer 109 Osteoarthritis (OA): Function and Pain Assessment 110 Preventive Care and Screening: Influenza Immunization no longer 111 Pneumonia Vaccination Status for Older Adults no longer 112 Breast Cancer Screening no longer 113 Colorectal Cancer Screening 116 Antibiotic Treatment for Adults with Acute Bronchitis: Avoidance of In Use 117 Diabetes: Eye Eam 118 Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy -- Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%) 119 Diabetes: Medical Attention for Nephropathy 122 Adult Kidney Disease: Blood Pressure Management Updated: 08/01/2016 As outlined in the 2017 Proposed Rule; subject to change. 2 of 11

3 Registry Title 126 Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy Neurological Evaluation 127 Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention Evaluation of Footwear 128 Preventive Care and Screening: Body Mass Inde (BMI) Screening and Follow-Up Plan Yes 130 Documentation of Current Medications in the Medical Record 131 Pain Assessment and Follow-Up no longer 134 Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan no longer 137 Melanoma: Continuity of Care Recall System 138 Melanoma: Coordination of Care 140 Age-Related Macular Degeneration (AMD): Counseling on Antioidant Supplement 141 Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care 143 Oncology: Medical and Radiation Pain Intensity Quantified 144 Oncology: Medical and Radiation Plan of Care for Pain 145 Radiology: Eposure Time Reported for Procedures Using Fluoroscopy 146 Radiology: In Use of Probably Benign Assessment Category in Mammography Screening 147 Nuclear Medicine: Correlation with Eisting Imaging Studies for All Patients Undergoing Bone Scintigraphy 154 Falls: Risk Assessment no longer 155 Falls: Plan of Care no longer 156 Oncology: Radiation Dose Limits to Normal Tissues 164 Coronary Artery Bypass Graft (CABG): Prolonged Intubation 165 Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate 166 Coronary Artery Bypass Graft (CABG): Stroke: 167 Coronary Artery Bypass Graft (CABG):Postoperative Renal Failure 168 Coronary Artery Bypass Graft (CABG): Surgical Re-Eploration 176 Rheumatoid Arthritis (RA): Tuberculosis Screening 177 Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity 178 Rheumatoid Arthritis (RA): Functional Status Assessment 179 Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis 180 Rheumatoid Arthritis (RA): Glucocorticoid Management Updated: 08/01/2016 As outlined in the 2017 Proposed Rule; subject to change. 3 of 11

4 Registry Title 181 Elder Maltreatment Screen and Follow-Up Plan 182 Functional Assessment no longer 185 Colonoscopy Interval for Patients with a History of Adenomatous Polyps Avoidance of In Use 187 Stroke and Stroke Rehabilitation: Thrombolytic Therapy 191 Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery 192 Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures 195 Radiology: Stenosis ment in Carotid Imaging Reports 204 Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 205 HIV/AIDS: Seually Transmitted Disease Screening for Chlamydia, Gonorrhea, and Syphilis 217 Functional Status Change for Patients with Knee Impairments 218 Functional Status Change for Patients with Hip Impairments 219 Functional Status Change for Patients with Foot and Ankle Impairments 220 Functional Status Change for Patients withlumbar Impairments 221 Functional Status Change for Patients with Shoulder Impairments 222 Functional Status Change for Patients with Elbow, Wrist and Hand Impairments 223 Functional Status Change for Patients with General Orthopedic Impairments: 224 Melanoma: Overutilization of Imaging Studies in Melanoma 225 Radiology: Reminder System for Screening Mammograms 226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 236 Controlling High Blood Pressure 238 Use of High-Risk Medications in the Elderly 243 Cardiac Rehabilitation Patient Referral from an Outpatient Setting 249 Barrett's Esophagus 250 Radical Prostatectomy Pathology Reporting 251 Quantitative Immunohistochemical (IHC) Evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) for Breast Cancer Patients 254 Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain Updated: 08/01/2016 As outlined in the 2017 Proposed Rule; subject to change. 4 of 11

5 Registry Title 255 Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Eposure 257 Statin Therapy at Discharge after Lower Etremity Bypass (LEB) 258 Rate of Open Repair of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7) Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured 259 Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #2) 260 Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2) 261 Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness 262 Image Confirmation of Successful Ecision of Image Localized Breast Lesion 263 Preoperative Diagnosis of Breast Cancer 264 Sentinel Lymph Node Biopsy for Invasive Breast Cancer 265 Biopsy Follow-Up 268 Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy 271 Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid Related Iatrogenic Injury Bone Loss Assessment 275 Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy 276 Sleep Apnea: Assessment of Sleep Symptoms 277 Sleep Apnea: Severity Assessment at Initial Diagnosis 278 Sleep Apnea: Positive Airway Pressure Therapy Prescribed 279 Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy 282 Dementia: Functional Status Assessment 283 Dementia: Neuropsychiatric Symptom Assessment 284 Dementia: Management of Neuropsychiatric Symptoms 286 Dementia: Counseling Regarding Safety Concerns 288 Dementia: Caregiver Education and Support 290 Parkinson s Disease: Psychiatric Disorders or Disturbances Assessment 291 Parkinson s Disease: Cognitive Impairment or Dysfunction Assessment 293 Parkinson s Disease: Rehabilitative Therapy Options Updated: 08/01/2016 As outlined in the 2017 Proposed Rule; subject to change. 5 of 11

6 Registry Title 294 Parkinson s Disease: Parkinson s Disease Medical and Surgical Treatment Options Reviewed 303 Cataracts: Improvement in Patient s Visual Function within 90 Days Following Cataract Surgery 304 Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery 317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 320 Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients 322 Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk Surgery Patients 323 Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous Coronary Intervention (PCI) 324 Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Testing in Asymptomatic, Low- Risk Patients 325 Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions 326 Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy 327 Pediatric Kidney Disease: Adequacy of Volume Management: 328 Pediatric Kidney Disease: ESRD Patients Receiving Dialysis: Hemoglobin Level < 10 g/dl 329 Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis 330 Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days 331 Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse) 332 Adult Sinusitis: Appropriate Choice of Antibiotic: Amoicillin With or Without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis (Appropriate Use) 333 Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse) 334 Adult Sinusitis: More than One Computerized Tomography (CT) Scan Within 90 Days for Chronic Sinusitis (Overuse) 335 Maternity Care: Elective Delivery or Early Induction Without Medical Indication at 37 and < 39 Weeks 336 Maternity Care: Post-Partum Follow-Up and Care Coordination 337 Tuberculosis Prevention for Psoriasis,Psoriatic Arthritis and Rheumatoid Arthritis Patients on a Biological Immune Response Modifier Updated: 08/01/2016 As outlined in the 2017 Proposed Rule; subject to change. 6 of 11

7 Registry Title 338 HIV Viral Load Suppression 340 HIV Medical Visit Frequency 342 Pain Brought Under Control Within 48 Hours 343 Screening Colonoscopy Adenoma Detection Rate 344 Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients, Without Major Complications (Discharged to Home by Post-Operative Day #2) 345 Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Artery Stenting (CAS) 346 Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Endarterectomy (CEA) 347 Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) Who Die While in Hospital 348 HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications Rate 350 Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy 351 Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation 352 Total Knee Replacement: Preoperative Antibiotic Infusion with Proimal Tourniquet 353 Total Knee Replacement: Identification of Implanted Prosthesis in Operative Report 354 Anastomotic Leak Intervention 355 Unplanned Reoperation within the 30 Day Postoperative Period 356 Unplanned Hospital Readmission within 30 Days of Principal Procedure 357 Surgical Site Infection (SSI) 358 Patient-Centered Surgical Risk Assessment and Communication 359 Optimizing Patient Eposure to Ionizing Radiation: Utilization of a Standardized Nomenclature for Computed Tomography (CT) Imaging Description 360 Optimizing Patient Eposure to Ionizing Radiation: Count of Potential High Dose Radiation Imaging Studies: Computed Tomography (CT) and Cardiac Nuclear Medicine Studies Optimizing Patient Eposure to Ionizing Radiation: Reporting to a Radiation Dose Inde Registry Optimizing Patient Eposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison Purposes Updated: 08/01/2016 As outlined in the 2017 Proposed Rule; subject to change. 7 of 11

8 Registry Title 363 Optimizing Patient Eposure to Ionizing Radiation: Search for Prior Computed Tomography (CT) Studies Through a Secure, Authorized, Media-Free, Shared Archive 364 Optimizing Patient Eposure to Ionizing Radiation: Appropriateness: Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules According to Recommended Guidelines 370 Depression Remission at Twelve Months 383 Adherence to Antipsychotic Medications for Individuals with Schizophrenia 384 Adult Primary Rhegmatogenous Retinal Detachment Surgery: No Return to the Operating Room Within 90 Days of Surgery 385 Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual Acuity Improvement Within 90 Days of Surgery 386 Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences 387 Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users 388 Cataract Surgery with Intra-Operative Complications (Unplanned Rupture of Posterior Capsule Requiring Unplanned Vitrectomy 389 Cataract Surgery: Difference Between Planned and Final Refraction 390 Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options 391 Follow-up After Hospitalization for Mental Illness (FUH) 392 HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following Atrial Fibrillation Ablation 393 HRS-9: Infection within 180 Days of Cardiac Implantable Electronic Device (CIED) Implantation, Replacement, or Revision 394 Immunizations for Adolescents 395 Lung Cancer Reporting (Biopsy/Cytology Specimens) 396 Lung Cancer Reporting (Resection Specimens) 397 Melanoma Reporting 398 Optimal Asthma Control 400 One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk no longer 401 Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in Patients with Cirrhosis 402 Tobacco Use and Help with Quitting Among Adolescents Updated: 08/01/2016 As outlined in the 2017 Proposed Rule; subject to change. 8 of 11

9 Registry Title 403 Adult Kidney Disease: Referral to Hospice 404 Anesthesiology Smoking Abstinence 405 Appropriate Follow-up Imaging for Incidental Abdominal Lesions 406 Appropriate Follow-Up Imaging for Incidental Thyroid Nodules in Patients 407 Appropriate Treatment of Meticillin-Sensitive Staphylococcus Aureus (MSSA) Bacteremia 408 Opioid Therapy Follow-up Evaluation 409 Clinical Post-Endovascular Stroke Treatment 410 Psoriasis: Clinical Response to Oral Systemic or Biologic Medications 411 Depression Remission at Si Months 412 Documentation of Signed Opioid Treatment Agreement 413 Door to Puncture Time for Endovascular Stroke Treatment 414 Evaluation or Interview for Risk of Opioid Misuse 415 Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older 416 Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 through 17 Years 417 Rate of Open Repair of Ascending Abdominal Aortic Aneurysms (AAA) Where Patients Are Discharged Alive 418 Osteoporosis Management in Women Who Had a Fracture 419 Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Eamination 420 Varicose Vein Treatment with Saphenous Ablation: Survey 421 Appropriate Assessment of Retrievable Inferior Vena Cava Filters for Removal 422 Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ Prolapse to Detect Lower Urinary Tract Injury 423 Perioperative Anti-platelet Therapy for Patients Undergoing Carotid Endarterectomy 424 Perioperative Temperature Management 426 Post-Anesthetic Transfer of Care : Procedure Room to a Post Anesthesia Care Unit (PACU): Updated: 08/01/2016 As outlined in the 2017 Proposed Rule; subject to change. 9 of 11

10 Registry Title 427 Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU) 428 Pelvic Organ Prolapse: Preoperative Assessment of Occult Stress Urinary Incontinence 429 Pelvic Organ Prolapse: Preoperative Screening for Uterine Malignancy 430 Prevention of Post-Operative Nausea and Vomiting (PONV) Combination Therapy 431 Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling 432 Proportion of Patients Sustaining a Bladder Injury at the Time of any Pelvic Organ Prolapse Repair 433 Proportion of Patients Sustaining a Major Viscus Injury at the Time of Any Pelvic Organ Prolapse Repair 434 Proportion of Patients Sustaining A Ureter Injury at the Time of any Pelvic Organ Prolapse Repair 435 Quality Of Life Assessment For Patients With Primary Headache Disorders 436 Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques 437 Rate of Surgical Conversion from Lower Etremity Endovascular Revasculatization Procedure 438 Statin Therapy for the Prevention and Treatment of Cardiovascular Disease 439 Age Appropriate Screening Colonoscopy new Non-melanoma Skin Cancer (NMSC): Biopsy Reporting Time - Pathologist new Ischemic Vascular Disease All or None (Optimal Control) new Persistent Beta Blocker Treatment After a Heart Attack new Non-recommended Cervical Cancer Screening in Adolescent Females new Medication Management for People with Asthma (MMA) new Risk-Adjusted Operative Mortality for CABG new Operative Mortality Stratified by the Five STS-EACTS Mortality Categories new Chlamydia Screening and Follow-up new Appropriate Work Up Prior to Endometrial Ablation Procedure new Patients with breast cancer and negative or undocumented human epidermal growth factor receptor 2 (HER2) status who are spared treatment with trastuzumab new Trastuzumab administered to patients with AJCC stage I (T1c) III and human epidermal growth factor receptor 2 (HER2) positive breast cancer who receive adjuvant chemotherapy Updated: 08/01/2016 As outlined in the 2017 Proposed Rule; subject to change. 10 of 11

11 Registry Title new KRAS gene mutation testing performed for patients with metastatic colorectal cancer who receive anti-epidermal growth factor receptor monoclonal antibody therapy new Patients with metastatic colorectal cancer and KRAS gene mutation spared treatment with anti-epidermal growth factor receptor monoclonal antibodies new Proportion receiving chemotherapy in the last 14 days of life new Proportion with more than one emergency room visit in the last 30 days of life new Proportion admitted to the ICU in the last 30 days of life new Proportion not admitted to hospice new Proportion admitted to hospice for less than 3 days Updated: 08/01/2016 As outlined in the 2017 Proposed Rule; subject to change. 11 of 11