The first 25 quality measures listed in the “Individual Measures" tab are integrated into PsychPRO, the APA Registry.
Preventative Care and Screening: Screening for Depression and Follow-Up
Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen.
- eMeasure ID: CMS2v6
- Quality ID: 134
- High Priority Measure: No
- Measure Type: Process
Reporting Mechanism
Preventive Care and Screening: Unhealthy Alcohol Use: Screening and Brief Counseling
Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user.
- eMeasure ID: N/A
- Quality ID: 431
- High Priority Measure: No
- Measure Type: Process
Reporting Mechanism
Adult Major Depressive Disorder (MDD) Suicide Risk Assessment
Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified.
- eMeasure ID: CMS161v5
- Quality ID: 107
- High Priority Measure: No
- Measure Type: Process
- Reporting Mechanism: EHR
Reporting Mechanism
Adherence to Antipsychotic Medications for Individuals with Schizophrenia
Percentage of individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months).
- eMeasure ID: N/A
- Quality ID: 383
- High Priority Measure: Yes
- Measure Type: Intermediate Outcome
Reporting Mechanism
Functional Outcome Assessment
Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies.
- eMeasure ID: N/A
- Quality ID: 182
- High Priority Measure: Yes
- Measure Type: Process
Reporting Mechanism
Documentation of Current Medications in the Medical Record
Percentage of visits for patients aged 18 years and older for which the eligible professional 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.
- eMeasure ID: CMS68v6
- Quality ID: 130
- High Priority Measure: Yes
- Measure Type: Process
Reporting Mechanism
Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.
- eMeasure ID: CMS138v5
- Quality ID: 226
- High Priority Measure: No
- Measure Type: Process
Reporting Mechanism
Preventative Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter Normal Parameters: Age 18 years and older BMI greater than or equal to 18.5 and less than 25 kg/m2.
- eMeasure ID: CMS69v5
- Quality ID: 128
- High Priority Measure: No
- Measure Type: Process
Reporting Mechanism
Anti-Depressant Medication Management
Percentage of patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported.
- Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks)
- Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months)
- eMeasure ID: CMS128v5
- Quality ID: 9
- High Priority Measure: No
- Measure Type: Process
Reporting Mechanism
Depression Remission at Six Months
Adult patients age 18 years and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at six months defined as a PHQ-9 score less than 5. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment. This measure additionally promotes ongoing contact between the patient and provider as patients who do not have a follow-up PHQ-9 score at six months (+/- 30 days) are also included in the denominator.
- eMeasure ID: N/A
- Quality ID: 411
- High Priority Measure: Yes
- Measure Type: Outcome
Reporting Mechanism
Depression Remission at Twelve Months
Patients age 18 and older with major depression or dysthymia and an initial Patient Health Questionnaire (PHQ-9) score greater than nine who demonstrate remission at twelve months (+/- 30 days after an index visit) defined as a PHQ-9 score less than five. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment.
- eMeasure ID: CMS159v5
- Quality ID: 370
- High Priority Measure: Yes
- Measure Type: Outcome
Reporting Mechanism
Bipolar Disorder and Major Depression: Appraisal for Alcohol or Chemical Substance
Percentage of patients with depression or bipolar disorder with evidence of an initial assessment that includes an appraisal for alcohol or chemical substance use.
- eMeasure ID: CMS169v5
- Quality ID: 367
- High Priority Measure: No
- Measure Type: Process
Reporting Mechanism
ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication
Percentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported.
- Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase.
- Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.
- eMeasure ID: CMS136v6
- Quality ID: 366
- High Priority Measure: No
- Measure Type: Process
Reporting Mechanism
Tobacco Use and Help with Quitting Among Adolescents
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.
- eMeasure ID: N/A
- Quality ID: 402
- High Priority Measure: No
- Measure Type: Process
Reporting Mechanism
Child and Adolescent Major Depressive Disorder (MDD): Suicide Assessment
Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk.
- eMeasure ID: CMS177v5
- Quality ID: 382
- High Priority Measure: Yes
- Measure Type: Process
Reporting Mechanism
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
Percentage of patients 13 years of age and older with a new episode of alcohol and other drug (AOD) dependence who received the following. Two rates are reported.
- Percentage of patients who initiated treatment within 14 days of the diagnosis.
- Percentage of patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit.
- eMeasure ID: CMS137v5
- Quality ID: 305
- High Priority Measure: No
- Measure Type: Process
Reporting Mechanism
Follow-Up After Hospitalization for Mental Illness (FUH)
The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported:
- The percentage of discharges for which the patient received follow-up within 30 days of discharge
- The percentage of discharges for which the patient received follow-up within 7 days of discharge
- eMeasure ID: N/A
- Quality ID: 391
- High Priority Measure: Yes
- Measure Type: Process
Reporting Mechanism
Evaluation of Interview for Risk of Opioid Misuse
All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical record.
- eMeasure ID: N/A
- Quality ID: 414
- High Priority Measure: No
- Measure Type: Process
Reporting Mechanism
Dementia: Cognitive Assessment
Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12 month period
- eMeasure ID: CMS149v5
- Quality ID: 281
- High Priority Measure: No
- Measure Type: Process
Reporting Mechanism
Dementia: Functional Assessment
Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of functional status is performed and the results reviewed at least once within a 12 month period.
- eMeasure ID: N/A
- Quality ID: 282
- High Priority Measure: No
- Measure Type: Process
Reporting Mechanism
Care Plan
Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation 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.
- eMeasure ID: N/A
- Quality ID: 47
- High Priority Measure: Yes
- Measure Type: Process
Reporting Mechanism
Falls: Risk Assessment
Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months.
- eMeasure ID: N/A
- Quality ID: 154
- High Priority Measure: yes
- Measure Type: Process
Reporting Mechanism
Falls: Plan of Care
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.
- eMeasure ID: N/A
- Quality ID: 155
- High Priority Measure: yes
- Measure Type: Process
Reporting Mechanism
Depression Utilization of the PHQ-9 Tool
Patients age 18 and older with the diagnosis of major depression or dysthymia who have a Patient Health Questionnaire (PHQ-9) tool administered at least once during a 4-month period in which there was a qualifying visit.
- eMeasure ID: CMS160v5
- Quality ID: 371
- High Priority Measure: No
- Measure Type: Process
Reporting Mechanism
Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported. - Percentage of patients with height, weight, and body mass index (BMI) percentile documentation - Percentage of patients with counseling for nutrition - Percentage of patients with counseling for physical activity
- eMeasure ID: CMS155v5
- Quality ID: 239
- High Priority Measure: No
- Measure Type: Process
Reporting Mechanism
Medication Reconciliation Post-Discharge
The percentage of discharges from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years and older of age seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record. This measure is reported as three rates stratified by age group:
- Reporting Criteria 1: 18-64 years of age
- Reporting Criteria 2: 65 years and older
- Total Rate: All patients 18 years of age and older
- eMeasure ID: N/A
- Quality ID: 46
- High Priority Measure: Yes
- Measure Type: Process
Reporting Mechanism
Preventative Care and Screening: Influenza Immunization
Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization.
- eMeasure ID: CMS147v5
- Quality ID: 110
- High Priority Measure: No
- Measure Type: Process
Reporting Mechanism
Pneumonia Vaccination Status for Older Adults
Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine.
- eMeasure ID: CMS127v5
- Quality ID: 111
- High Priority Measure: No
- Measure Type: Process
Reporting Mechanism
Controlling High Blood Pressure
Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (Less than 140/90mmHg) during the measurement period.
- eMeasure ID: CMS165v5
- Quality ID: 236
- High Priority Measure: Yes
- Measure Type: Intermediate Outcomes
Reporting Mechanism
Use of High Risk Medications in the Elderly
Percentage of patients 66 years of age and older who were ordered high-risk medications. Two rates are reported.
- Percentage of patients who were ordered at least one high-risk medication.
- Percentage of patients who were ordered at least two different high-risk medications.
- eMeasure ID: CMS156v5
- Quality ID: 238
- High Priority Measure: Yes
- Measure Type: Process
Reporting Mechanism
Childhood Immunization Status
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 H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday.
- eMeasure ID: CMS117v5
- Quality ID: 240
- High Priority Measure: No
- Measure Type: Process
Reporting Mechanism
Dementia: Counseling Regarding Safety
Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled or referred for counseling regarding safety concerns within a 12 month period.
- eMeasure ID: N/A
- Quality ID: 286
- High Priority Measure: Yes
- Measure Type: Process
Reporting Mechanism
Dementia: Caregiver Education and Support
Percentage of patients, regardless of age, with a diagnosis of dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND referred to additional resources for support within a 12 month period.
- eMeasure ID: N/A
- Quality ID: 288
- High Priority Measure: Yes
- Measure Type: Process
Reporting Mechanism
Dementia: Neuropsychiatric Symptom Assessement
Percentage of patients, regardless of age, with a diagnosis of dementia and for whom an assessment of neuropsychiatric symptoms is performed and results reviewed at least once in a 12 month period.
- eMeasure ID: N/A
- Quality ID: 283
- High Priority Measure: No
- Measure Type: Process
Reporting Mechanism
Dementia: Management of Neuropsychiatric Symptoms
Percentage of patients, regardless of age, with a diagnosis of dementia who have one or more neuropsychiatric symptoms who received or were recommended to receive an intervention for neuropsychiatric symptoms within a 12 month period.
- eMeasure ID: N/A
- Quality ID: 284
- High Priority Measure: No
- Measure Type: Process
Reporting Mechanism
Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Percentage of patients aged 18 years and older seen during the reporting 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.
- eMeasure ID: CMS22v5
- Quality ID: 317
- High Priority Measure: No
- Measure Type: Process
Reporting Mechanism
Falls Screening: Screening for Fall Risk
Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period.
- eMeasure ID: CMS139v5
- Quality ID: 318
- High Priority Measure: Yes
- Measure Type: Process
Reporting Mechanism
CAHPS for MIPS Clinician/Group Survey
- Getting timely care, appointments, and information;
- How well providers Communicate;
- Patient's Rating of Provider;
- Access to Specialists;
- Health Promotion & Education;
- Shared Decision Making;
- Health Status/Functional Status;
- Courteous and Helpful Office Staff;
- Care Coordination;
- Between Visit Communication;
- Helping You to Take Medication as Directed; and
- Stewardship of Patient Resources
- eMeasure ID: N/A
- Quality ID: 321
- High Priority Measure: Yes
- Measure Type: Patient Experience
Reporting Mechanism
CMS Approved Survey Vendor
Adult Major Depressive Disorder (MDD) Coordination of Care of Patients with Specific Comorbid Conditions
Percentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Renal Disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition.
- eMeasure ID: N/A
- Quality ID: 325
- High Priority Measure: Yes
- Measure Type: Process
Reporting Mechanism
Maternal Depression Screening
The percentage of children who turned 6 months of age during the measurement year, who had a face-to-face visit between the clinician and the child during child's first 6 months, and who had a maternal depression screening for the mother at least once between 0 and 6 months of life.
- eMeasure ID: CMS82v4
- Quality ID: 372
- High Priority Measure: No
- Measure Type: Process
Reporting Mechanism
Closing the Referal Loop: Receipt of Specialist Report
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.
- eMeasure ID: CMS50v5
- Quality ID: 374
- High Priority Measure: No
- Measure Type: Process
Reporting Mechanism
Immunizations for Adolescents
The percentage of adolescents 13 years of age who had the recommended immunizations by their 13th birthday.
- eMeasure ID: N/A
- Quality ID: 394
- High Priority Measure: No
- Measure Type: Process
Reporting Mechanism
Documentation of Signed Opioid Treatment Agreement
All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record.
- eMeasure ID: N/A
- Quality ID: 412
- High Priority Measure: No
- Measure Type: Process
Reporting Mechanism