Clinical Quality Measures

Reports > Incentive Programs > Clinical Quality Performance

Clinical Quality Measures, or CQMs, are tools that help measure and track the quality of health care services provided within our health care system. These measures use data associated with providers’ ability to deliver high-quality care or relate to long term goals for quality health care.

CQMs fall under one of six National Quality Strategy (NQS) areas:

1. Clinical Processes and Effectiveness
2. Patient Safety
3. Efficient use of Health Care Resources
4. Care Coordination
5. Patient and Family Engagement
6. Population and Public Health

Measuring and reporting CQMs helps to ensure that our health care system is delivering effective, safe, efficient, patient-centered, equitable, and timely care.

Important Information Regarding Lab/Radiology Orders:

When placing Lab/ Radiology orders for any eCQM criterion, verify that the test/procedure code is linked to a LOINC code from the Settings. This ensures patient eligibility for that particular measure.

To learn how to map LOINC codes, click on the following links:

For LOINC Code Based Labs

For LOINC Code Based Radiology

For CPT Code Based Labs/Radiology

Reporting Requirement:

You need to report at least 9 CQMs that relate to at least 3 National Quality Strategy (NQS) domains.

Clinical Quality Performance Report
In order to generate the CQM report:

Follow the workflow mentioned above to land on the ‘Clinical Quality Performance’ screen.

Select the required provider, Measurement Period, and time frame from the relevant fields.

Enable checkmark to select the required Measure.

Click Report to display the required report.

Clinical Quality Performance

2017

NQS Domain CMS ID NQF ID CQM Title
Community and Population Health CMS2v5 0418 Preventive Care and Screening: Screening for Depression and Follow-Up Plan
Communication and Care Coordination CMS50v6 None Closing the Referral Loop: Receipt of Specialist Report
Effective Clinical Care CMS61v6 None Preventive Care and Screening: Cholesterol – Fasting Low Density Lipoprotein (LDL-C) Test Performed
Effective Clinical Care CMS62v5 None HIV/AIDS: Medical Visit
Effective Clinical Care CMS64v6 None Preventive Care and Screening: Risk-Stratified Cholesterol -Fasting Low Density Lipoprotein (LDL-C)
Effective Clinical Care CMS65v7 None Hypertension: Improvement in Blood Pressure
Communication and Care Coordination CMS50v8 Not Applicable Closing the Referral Loop: Receipt of Specialist Report
Effective Clinical Care CMS68v6 0419 Documentation of Current Medications in the Medical Record
Effective Clinical Care CMS74v6 None Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists
Effective Clinical Care CMS75v5 None Children Who Have Dental Decay or Cavities
Effective Clinical Care CMS77v5 None HIV/AIDS: RNA Control for Patients with HIV
Community/Population Health CMS117v8 0038 Childhood Immunization Status
Effective Clinical Care CMS122v5 0059 Diabetes: Hemoglobin A1c Poor Control
Effective Clinical Care CMS123v5 0056 Diabetes: Foot Exam
Effective Clinical Care CMS124v5 0032 Cervical Cancer Screening
Effective Clinical Care CMS125v5 2372 Breast Cancer Screening
Effective Clinical Care CMS126v5 None Use of Appropriate Medications for Asthma
Effective Clinical Care CMS127v5 0043 Pneumococcal Vaccination Status for Older Adults
Effective Clinical Care CMS130v5 0034 Colorectal Cancer Screening
Effective Clinical Care CMS134v5 0062 Diabetes: Medical Attention for Nephropathy
Effective Clinical Care CMS137v5 0004 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
Patient Safety CMS138v5 0028 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Patient Safety CMS139v5 0101 Falls: Screening for Future Fall Risk
Patient Safety CMS146v5 None Appropriate Testing for Children with Pharyngitis
Patient Safety CMS147v6 0041 Preventive Care and Screening: Influenza Immunization
Patient Safety CMS148v5 None Hemoglobin A1c Test for Pediatric Patients
Patient Safety CMS149v5 None Dementia: Cognitive Assessment
Patient Safety CMS153v5 0033 Chlamydia Screening for Women
Patient Safety CMS155v5 0024 Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
Patient Safety CMS156v5 0022 Use of High-Risk Medications in the Elderly
Patient Safety CMS158v5 None Pregnant Women That had HBsAg Testing
Patient Safety CMS159v5 0710 Depression Remission at Twelve Months
Patient Safety CMS161v5 0104 Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
Effective Clinical Care CMS163v5 None Diabetes: Low Density Lipoprotein (LDL) Management
Effective Clinical Care CMS164v5 0068 Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet
Effective Clinical Care CMS165v5 0018 Controlling High Blood Pressure
Effective Clinical Care CMS166v6 0052 Use of Imaging Studies for Low Back Pain
Effective Clinical Care CMS177v5 1365 Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment
Effective Clinical Care CMS182v6 None Ischemic Vascular Disease (IVD): Complete Lipid Profile and LDL-C Control (<100 mg/dL)

2018

NQS Domain CMS ID NQF ID CQM Title
Community and Population Health CMS2v7 0418 Preventive Care and Screening: Screening for Depression and Follow-Up Plan
Community and Population Health CMS22v6 None Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Communication and Care Coordination CMS50v6 None Closing the Referral Loop: Receipt of Specialist Report
Effective Clinical Care CMS65v7 None  Hypertension: Improvement in Blood Pressure
Effective Clinical Care CMS68v7 0419 Documentation of Current Medications in the Medical Record
Community/Population Health CMS69v6 0421 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Effective Clinical Care CMS74v7 None Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists
Effective Clinical Care CMS75v6 None Children Who Have Dental Decay or Cavities
Effective Clinical Care CMS117v6 0038 Childhood Immunization Status
Effective Clinical Care CMS122v6 0059 Diabetes: Hemoglobin A1c Poor Control
Effective Clinical Care CMS123v6 0056 Diabetes: Foot Exam
Effective Clinical Care CMS124v6 0032 Cervical Cancer Screening
Effective Clinical Care CMS125v6 2372 Breast Cancer Screening
Effective Clinical Care CMS127v6 None  Pneumococcal Vaccination Status for Older Adults
Effective Clinical Care CMS130v6 0034 Colorectal Cancer Screening
Effective Clinical Care CMS131v6 0055 Diabetes: Eye Exam
Effective Clinical Care CMS134v6 0062 Diabetes: Medical Attention for Nephropathy
Effective Clinical Care CMS137v6 0004 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
Patient Safety CMS138v6 0028 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Patient Safety CMS139v6 0101 Falls: Screening for Future Fall Risk
Patient Safety CMS146v6 None Appropriate Testing for Children with Pharyngitis
Patient Safety CMS147v7 0041 Preventive Care and Screening: Influenza Immunization
Patient Safety CMS149v6 None Dementia: Cognitive Assessment
Patient Safety CMS153v6 0033 Chlamydia Screening for Women
Patient Safety CMS155v6 0024 Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
Patient Safety CMS156v6 0022 Use of High-Risk Medications in the Elderly
Patient Safety CMS158v5 None Pregnant Women That had HBsAg Testing
Patient Safety CMS159v6 0710 Depression Remission at Twelve Months
Patient Safety CMS161v6 0104 Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
Effective Clinical Care CMS164v6 0068 Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet
Effective Clinical Care CMS165v6 0018 Controlling High Blood Pressure
Effective Clinical Care CMS166v7 0052 Use of Imaging Studies for Low Back Pain
Effective Clinical Care CMS177v6 1365 Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment

2019

NQS Domain CMS ID NQF ID CQM Title
Community and Population Health CMS2v8 0418 Preventive Care and Screening: Screening for Depression and Follow-Up Plan
Community and Population Health CMS22v7 None Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Communication and Care Coordination CMS50v7 None Closing the Referral Loop: Receipt of Specialist Report
Effective Clinical Care CMS68v8 0419 Documentation of Current Medications in the Medical Record
Community/Population Health CMS69v7 0421 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Effective Clinical Care CMS74v8 None Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists
Effective Clinical Care CMS75v7 None Children Who Have Dental Decay or Cavities
Effective Clinical Care CMS117v7 0038 Childhood Immunization Status
Effective Clinical Care CMS122v7 0059 Diabetes: Hemoglobin A1c Poor Control
Effective Clinical Care CMS124v7 0032 Cervical Cancer Screening
Effective Clinical Care CMS125v7 2372 Breast Cancer Screening
Effective Clinical Care CMS127v7 None Pneumococcal Vaccination Status for Older Adults
Effective Clinical Care CMS130v7 0034 Colorectal Cancer Screening
Effective Clinical Care CMS131v7 0055 Diabetes: Eye Exam
Effective Clinical Care CMS134v7 0062 Diabetes: Medical Attention for Nephropathy
Effective Clinical Care CMS137v7 0004 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
Patient Safety CMS138v7 0028 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Patient Safety CMS139v7 0101 Falls: Screening for Future Fall Risk
Patient Safety CMS146v7 None Appropriate Testing for Children with Pharyngitis
Patient Safety CMS147v8 0041 Preventive Care and Screening: Influenza Immunization
Patient Safety CMS149v7 None Dementia: Cognitive Assessment
Patient Safety CMS153v7 0033 Chlamydia Screening for Women
Patient Safety CMS155v7 0024 Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
Patient Safety CMS156v7 0022 Use of High-Risk Medications in the Elderly
Patient Safety CMS158v6 None Pregnant Women That had HBsAg Testing
Patient Safety CMS159v7 0710 Depression Remission at Twelve Months
Patient Safety CMS161v7 0104 Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
Effective Clinical Care CMS165v7 0018 Controlling High Blood Pressure
Effective Clinical Care CMS177v7 1365 Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment

2020

NQS Domain CMS ID NQF ID CQM Title
Community and Population Health CMS2v9 0418e Preventive Care and Screening: Screening for Depression and Follow-Up Plan
Community and Population Health CMS22v8 Not Applicable Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Communication and Care Coordination CMS50v8 Not Applicable Closing the Referral Loop: Receipt of Specialist Report
Person and Caregiver-Centered Experience and Outcomes CMS56v8 Not Applicable Functional Status Assessment for Total Hip Replacement
Person and Caregiver-Centered Experience and Outcomes CMS66v8 Not Applicable Functional Status Assessment for Total Knee Replacement
Patient Safety CMS68v9 0419e Documentation of Current Medications in the Medical Record
Community/Population Health CMS69v8 0421e Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Effective Clinical Care CMS74v9 Not Applicable Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists
Community/Population Health CMS75v8 Not Applicable Children Who Have Dental Decay or Cavities
Person and Caregiver-Centered Experience and Outcomes CMS90v9 Not Applicable Functional Status Assessments for Congestive Heart Failure
Community/Population Health CMS117v7 Not Applicable Childhood Immunization Status
Effective Clinical Care CMS122v7 001 Diabetes: Hemoglobin A1c Poor Control
Effective Clinical Care CMS124v8 Not Applicable Cervical Cancer Screening
Effective Clinical Care CMS125v7 Not Applicable Breast Cancer Screening
Community/Population Health CMS127v8 Not Applicable Pneumococcal Vaccination Status for Older Adults
Community/Population Health CMS128v8 Not Applicable Anti-depressant Medication Management
Efficiency and Cost Reduction CMS129v9 0389e Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients
Effective Clinical Care CMS130v8 Not Applicable Colorectal Cancer Screening
Effective Clinical Care CMS131v8 Not Applicable Diabetes: Eye Exam
Effective Clinical Care CMS133v8 0565e Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery
Effective Clinical Care CMS134v8 Not Applicable Diabetes: Medical Attention for Nephropathy
Effective Clinical Care CMS135v9 0081e Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Effective Clinical Care CMS136v9 Not Applicable Follow-Up Care for Children Prescribed ADHD Medication (ADD)
Effective Clinical Care CMS137v8 Not Applicable Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
Community/Population Health CMS138v8 0028e Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Patient Safety CMS139v8 Not Applicable Falls: Screening for Future Fall Risk
Effective Clinical Care CMS142v8 0089e Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
Effective Clinical Care CMS143v8 0086e Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation
Effective Clinical Care CMS144v8 0083e Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Effective Clinical Care CMS145v8 0070e Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)
Patient Safety CMS146v8 Not Applicable Appropriate Testing for Children with Pharyngitis
Community/Population Health CMS147v9 0041e Preventive Care and Screening: Influenza Immunization
Effective Clinical Care CMS149v8 2872e Dementia: Cognitive Assessment
Community/Population Health CMS153v8 Not Applicable Chlamydia Screening for Women
Efficiency and Cost Reduction CMS154v8 Not Applicable Appropriate Treatment for Children with Upper Respiratory Infection (URI)
Community/Population Health CMS155v8 Not Applicable Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
Patient Safety CMS156v7 Not Applicable Use of High-Risk Medications in the Elderly
Person and Caregiver-Centered Experience and Outcomes CMS157v8 0384e Oncology: Medical and Radiation – Pain Intensity Quantified
Effective Clinical Care CMS159v8 0710e Depression Remission at Twelve Months
Effective Clinical Care CMS161v8 0104e Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
Effective Clinical Care CMS165v7 Not Applicable Controlling High Blood Pressure
Patient Safety CMS177v8 1365e Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment
Efficiency and Cost Reduction CMS249v2 Not Applicable Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture
Effective Clinical Care CMS347v3 Not Applicable Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
Community/Population Health CMS349v2 Not Applicable HIV Screening
Effective Clinical Care CMS645v3 Not Applicable Bone density evaluation for patients with prostate cancer and receiving androgen deprivation therapy

2021

NQS Domain CMS ID NQF ID CQM Title
Community and Population Health CMS2v10 0418e Preventive Care and Screening: Screening for Depression and Follow-Up Plan
Community and Population Health CMS22v9 Not Applicable Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Communication and Care Coordination CMS50v9 Not Applicable Closing the Referral Loop: Receipt of Specialist Report
Person and Caregiver-Centered Experience and Outcomes CMS56v9 Not Applicable Functional Status Assessment for Total Hip Replacement
Person and Caregiver-Centered Experience and Outcomes CMS66v9 Not Applicable Functional Status Assessment for Total Knee Replacement
Patient Safety CMS68v10 0419e Documentation of Current Medications in the Medical Record
Community and Population Health CMS69v9 Not Applicable Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Effective Clinical Care CMS74v10 Not Applicable Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists
Community/Population Health CMS75v9 Not Applicable Children Who Have Dental Decay or Cavities
Person and Caregiver-Centered Experience and Outcomes CMS90v10 Not Applicable Functional Status Assessments for Congestive Heart Failure
Community/Population Health CMS117v9 Not Applicable Childhood Immunization Status
Effective Clinical Care CMS122v9 Not Applicable Diabetes: Hemoglobin A1c Poor Control
Effective Clinical Care CMS124v9 Not Applicable Cervical Cancer Screening
Effective Clinical Care CMS125v9 Not Applicable Breast Cancer Screening
Community/Population Health CMS127v9 Not Applicable Pneumococcal Vaccination Status for Older Adults
Community/Population Health CMS128v9 Not Applicable Anti-depressant Medication Management
Efficiency and Cost Reduction CMS129v10 0389e Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients
Effective Clinical Care CMS130v9 Not Applicable Colorectal Cancer Screening
Effective Clinical Care CMS131v9 Not Applicable Diabetes: Eye Exam
Effective Clinical Care CMS133v9 0565e Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery
Effective Clinical Care CMS134v9 Not Applicable Diabetes: Medical Attention for Nephropathy
Effective Clinical Care CMS135v9 0081e Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Effective Clinical Care CMS136v10 Not Applicable Follow-Up Care for Children Prescribed ADHD Medication (ADD)
Effective Clinical Care CMS137v9 Not Applicable Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
Community and Population Health CMS138v9 0028e Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Patient Safety CMS139v9 Not Applicable Falls: Screening for Future Fall Risk
Effective Clinical Care CMS142v9 Not Applicable Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
Effective Clinical Care CMS143v9 0086e Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation
Effective Clinical Care CMS144v9 0083e Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Effective Clinical Care CMS145v9 0070e Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)
Patient Safety CMS146v9 Not Applicable Appropriate Testing for Children with Pharyngitis
Community/Population Health CMS147v10 0041e Preventive Care and Screening: Influenza Immunization
Effective Clinical Care CMS149v9 2872e Dementia: Cognitive Assessment
Community/Population Health CMS153v9 Not Applicable Chlamydia Screening for Women
Efficiency and Cost Reduction CMS154v9 Not Applicable Appropriate Treatment for Children with Upper Respiratory Infection (URI)
Community and Population Health CMS155v9 Not Applicable Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
Patient Safety CMS156v9 Not Applicable Use of High-Risk Medications in the Elderly
Person and Caregiver-Centered Experience and Outcomes CMS157v9 0384e Oncology: Medical and Radiation – Pain Intensity Quantified
Effective Clinical Care CMS159v9 0710e Depression Remission at Twelve Months
Effective Clinical Care CMS161v9 0104e Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
Effective Clinical Care CMS164v7 (UDS) 0068 Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet
Effective Clinical Care CMS165v9 Not Applicable Controlling High Blood Pressure
Patient Safety CMS177v9 1365e Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment
Efficiency and Cost Reduction CMS249v3 3475e Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture
Effective Clinical Care CMS347v4 Not Applicable Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
Community and Population Health CMS349v3 Not Applicable HIV Screening
Effective Clinical Care CMS645v4 Not Applicable Bone density evaluation for patients with prostate cancer and receiving androgen deprivation therapy
Effective Clinical Care CMS771v2 Not Applicable Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia

2022

NQS Domain CMS ID NQF ID CQM Title
Community and Population Health CMS2v11 Not Applicable Preventive Care and Screening: Screening for Depression and Follow-Up Plan
Community and Population Health CMS22v10 Not Applicable Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Communication and Care Coordination CMS50v10 Not Applicable Closing the Referral Loop: Receipt of Specialist Report
Person and Caregiver-Centered Experience and Outcomes CMS56v10 Not Applicable Functional Status Assessment for Total Hip Replacement
Person and Caregiver-Centered Experience and Outcomes CMS66v10 Not Applicable Functional Status Assessment for Total Knee Replacement
Patient Safety CMS68v11 0419e Documentation of Current Medications in the Medical Record
Community and Population Health CMS69v10 Not Applicable Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Effective Clinical Care CMS74v11 Not Applicable Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists
Community/Population Health CMS75v10 Not Applicable Children Who Have Dental Decay or Cavities
Person and Caregiver-Centered Experience and Outcomes CMS90v11 Not Applicable Functional Status Assessments for Congestive Heart Failure
Community/Population Health CMS117v10 Not Applicable Childhood Immunization Status
Effective Clinical Care CMS122v10 Not Applicable Diabetes: Hemoglobin A1c Poor Control
Effective Clinical Care CMS124v10 Not Applicable Cervical Cancer Screening
Effective Clinical Care CMS125v10 Not Applicable Breast Cancer Screening
Community/Population Health CMS127v10 Not Applicable Pneumococcal Vaccination Status for Older Adults
Community/Population Health CMS128v10 Not Applicable Anti-depressant Medication Management
Efficiency and Cost Reduction CMS129v11 0389e Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients
Effective Clinical Care CMS130v10 Not Applicable Colorectal Cancer Screening
Effective Clinical Care CMS131v10 Not Applicable Diabetes: Eye Exam
Effective Clinical Care CMS133v10 0565e Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery
Effective Clinical Care CMS134v10 Not Applicable Diabetes: Medical Attention for Nephropathy
Effective Clinical Care CMS135v10 0081e Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Effective Clinical Care CMS136v11 Not Applicable Follow-Up Care for Children Prescribed ADHD Medication (ADD)
Effective Clinical Care CMS137v10 Not Applicable Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
Community and Population Health CMS138v10 0028e Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Patient Safety CMS139v10 Not Applicable Falls: Screening for Future Fall Risk
Effective Clinical Care CMS142v10 Not Applicable Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
Effective Clinical Care CMS143v10 0086e Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation
Effective Clinical Care CMS144v10 0083e Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Effective Clinical Care CMS145v10 0070e Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)
Patient Safety CMS146v10 Not Applicable Appropriate Testing for Pharyngitis
Community/Population Health CMS147v11 0041e Preventive Care and Screening: Influenza Immunization
Effective Clinical Care CMS149v10 2872e Dementia: Cognitive Assessment
Community/Population Health CMS153v10 Not Applicable Chlamydia Screening for Women
Efficiency and Cost Reduction CMS154v10 Not Applicable Appropriate Treatment for Children with Upper Respiratory Infection (URI)
Community and Population Health CMS155v10 Not Applicable Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
Patient Safety CMS156v10 Not Applicable Use of High-Risk Medications in the Elderly
Person and Caregiver-Centered Experience and Outcomes CMS157v10 0384e Oncology: Medical and Radiation – Pain Intensity Quantified
Effective Clinical Care CMS159v10 0710e Depression Remission at Twelve Months
Effective Clinical Care CMS161v10 0104e Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
Effective Clinical Care CMS165v10 Not Applicable Controlling High Blood Pressure
Patient Safety CMS177v10 1365e Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment
Efficiency and Cost Reduction CMS249v4 3475e Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture
Effective Clinical Care CMS347v5 Not Applicable Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
Community/Population Health CMS349v4 Not Applicable HIV Screening
Effective Clinical Care CMS645v5 Not Applicable Bone density evaluation for patients with prostate cancer and receiving androgen deprivation therapy
Effective Clinical Care CMS646v2 Not Applicable Intravesical Bacillus-Calmette-Guerin for Non-Muscle Invasive Bladder Cancer
Effective Clinical Care CMS771v3 Not Applicable Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia

2023

NQS Domain CMS ID NQF ID CQM Title
Community and Population Health CMS2v12 Not Applicable Preventive Care and Screening: Screening for Depression and Follow-Up Plan
Community and Population Health CMS22v11 Not Applicable Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Communication and Care Coordination CMS50v11 Not Applicable Closing the Referral Loop: Receipt of Specialist Report
Person and Caregiver-Centered Experience and Outcomes CMS56v11 Not Applicable Functional Status Assessment for Total Hip Replacement
Patient Safety CMS68v12 0419e Documentation of Current Medications in the Medical Record
Community and Population Health CMS69v11 Not Applicable Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Effective Clinical Care CMS74v12 Not Applicable Primary Caries Prevention Intervention as Offered by Dentists
Community/Population Health CMS75v11 Not Applicable Children Who Have Dental Decay or Cavities
Person and Caregiver-Centered Experience and Outcomes CMS90v12 Not Applicable Functional Status Assessments for Heart Failure
Community/Population Health CMS117v11 Not Applicable Childhood Immunization Status
Effective Clinical Care CMS122v11 Not Applicable Diabetes: Hemoglobin A1c Poor Control
Effective Clinical Care CMS124v11 Not Applicable Cervical Cancer Screening
Effective Clinical Care CMS125v11 Not Applicable Breast Cancer Screening
Community/Population Health CMS127v11 Not Applicable Pneumococcal Vaccination Status for Older Adults
Effective Clinical Care CMS128v11 Not Applicable Anti-depressant Medication Management
Efficiency and Cost Reduction CMS129v12 0389e Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients
Effective Clinical Care CMS130v11 Not Applicable Colorectal Cancer Screening
Effective Clinical Care CMS131v11 Not Applicable Diabetes: Eye Exam
Effective Clinical Care CMS133v11 0565e Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery
Effective Clinical Care CMS135v11 0081e Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Effective Clinical Care CMS136v12 Not Applicable Follow-Up Care for Children Prescribed ADHD Medication (ADD)
Effective Clinical Care CMS137v11 Not Applicable Initiation and Engagement of Substance Use Disorder Treatment
Community/Population Health CMS138v11 0028e Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Patient Safety CMS139v11 Not Applicable Falls: Screening for Future Fall Risk
Communication and Care Coordination CMS142v11 Not Applicable Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
Effective Clinical Care CMS143v11 0086e Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation
Effective Clinical Care CMS144v11 0083e Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LSVD)
Effective Clinical Care CMS145v11 0070e Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <=40%)
Patient Safety CMS146v11 Not Applicable Appropriate Testing for Pharyngitis
Community/Population Health CMS147v12 0041e Preventive Care and Screening: Influenza Immunization
Effective Clinical Care CMS149v11 2872e Dementia: Cognitive Assessment
Community/Population Health CMS153v11 Not Applicable Chlamydia Screening in Women
Efficiency and Cost Reduction CMS154v11 Not Applicable Appropriate Treatment for Upper Respiratory Infection (URI)
Community and Population Health CMS155v11 Not Applicable Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
Patient Safety CMS156v11 Not Applicable Use of High-Risk Medications in Older Adults
Person and Caregiver-Centered Experience and Outcomes CMS157v11 0384e Oncology: Medical and Radiation – Pain Intensity Quantified
Effective Clinical Care CMS159v11 0710e Depression Remission at Twelve Months
Effective Clinical Care CMS161v11 0104e Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
Effective Clinical Care CMS165v11 Not Applicable Controlling High Blood Pressure
Patient Safety CMS177v11 1365e Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment
Efficiency and Cost Reduction CMS249v5 3475e Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture
Effective Clinical Care CMS347v6 Not Applicable Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
Community/ Population Health CMS349v5 Not Applicable HIV Screening
Effective Clinical Care CMS645v6 Not Applicable Bone density evaluation for patients with prostate cancer and receiving androgen deprivation therapy
Effective Clinical Care CMS646v3 Not Applicable Intravesical Bacillus-Calmette-Guerin for non-muscle invasive bladder cancer
Person and Caregiver-Centered Experience and Outcomes CMS771v4 Not Applicable Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia
CMS951v1 Not Applicable Kidney Health Evaluation 

2024

NQS Domain CMS ID NQF ID CQM Title
Community and Population Health CMS2v13 Not Applicable Preventive Care and Screening: Screening for Depression and Follow-Up Plan
Community and Population Health CMS22v12 Not Applicable Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Communication and Care Coordination CMS50v12 Not Applicable Closing the Referral Loop: Receipt of Specialist Report
Person and Caregiver- Centered Experience and Outcomes CMS56v12 Not Applicable Functional Status Assessment for Total Hip Replacement
Patient Safety CMS68v13 0419e Documentation of Current Medications in the Medical Record
Community and Population Health CMS69v12 Not Applicable Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Effective Clinical Care CMS74v13 Not Applicable Primary Caries Prevention Intervention as Offered by Dentists
Community/Population Health CMS75v12 Not Applicable Children Who Have Dental Decay or Cavities
Person and Caregiver-Centered Experience and Outcomes CMS90v13 Not Applicable Functional Status Assessments for Heart Failure
Community/Population Health CMS117v12 Not Applicable Childhood Immunization Status
Effective Clinical Care CMS124v12 Not Applicable Cervical Cancer Screening
Effective Clinical Care CMS125v12 Not Applicable Breast Cancer Screening
Community/Population Health CMS127v12 Not Applicable Pneumococcal Vaccination Status for Older Adults
Effective Clinical Care CMS128v12 Not Applicable Anti-depressant Medication Management
Efficiency and Cost Reduction CMS129v13 0389e Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients
Effective Clinical Care CMS133v12 0565e Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery
Effective Clinical Care CMS135v12 0081e Heart Failure (HF): Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Effective Clinical Care CMS136v13 Not Applicable Follow-Up Care for Children Prescribed ADHD Medication (ADD)
Effective Clinical Care CMS137v12 Not Applicable Initiation and Engagement of Substance Use Disorder Treatment
Community/Population Health CMS138v12 0028e Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Patient Safety CMS139v12 Not Applicable Falls: Screening for Future Fall Risk
Communication and Care Coordination CMS142v12 Not Applicable Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care 
Effective Clinical Care CMS143v12 0086e Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation 
Effective Clinical Care CMS144v12 0083e Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Effective Clinical Care CMS145v12 0070e Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%)
Patient Safety CMS146v12 Not Applicable Appropriate Testing for Pharyngitis
Community/Population Health CMS147v13 0041e Preventive Care and Screening: Influenza Immunization 
Effective Clinical Care CMS149v12 2872e Dementia: Cognitive Assessment
Community/Population Health CMS153v12 Not Applicable Chlamydia Screening for Women 
Efficiency and Cost Reduction CMS154v12 Not Applicable Appropriate Treatment for Upper Respiratory Infection (URI)
Community and Population Health CMS155v12 Not Applicable Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
Patient Safety CMS156v12 Not Applicable Use of High Risk Medications in Older Adults
Person and Caregiver-Centered Experience and Outcomes CMS157v12 0384e Oncology: Medical and Radiation – Pain Intensity Quantified
Effective Clinical Care CMS159v12 0710e Depression Remission at Twelve Months
Effective Clinical Care CMS161v12 0104e Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
Effective Clinical Care CMS165v12 Not Applicable Controlling High Blood Pressure
Patient Safety CMS177v12 1365e Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment
Efficiency and Cost Reduction CMS249v6 3475e Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture
Effective Clinical Care CMS314v1 Not Applicable HIV Viral Suppression
Effective Clinical Care CMS347v7 Not Applicable Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
Community/Population Health CMS349v6 Not Applicable HIV Screening
Effective Clinical Care CMS645v7 Not Applicable Bone density evaluation for patients with prostate cancer and receiving androgen deprivation therapy
Effective Clinical Care CMS646v4 Not Applicable Intravesical Bacillus-Calmette-Guerin for Non-Muscle Invasive Bladder Cancer
Person and Caregiver- Centered Experience and Outcomes CMS771v5 Not Applicable Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia 
Effective Clinical Care CMS951v2 Not Applicable Kidney Health Evaluation 
Effective Clinical Care CMS1188v1 Not Applicable Sexually Transmitted Infection (STI) Testing for People with HIV

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