Column DescriptionsTable 1 Column Descriptions for the MIPS Bench

Column DescriptionsTable 1: Column Descriptions for the MIPS
Benchmark Results worksheetPhysical Column
NameDescriptionMeasure_NameNameTitle of the
MeasureMeasure_IDID of the
MeasureCollection_TypeIdentifies whether the benchmark
applies to Medicare Part B Claims measures, electronic clinical
quality measures (eCQMs), MIPS clinical quality measures
(MIPS CQMs), or QCDR measures.
CMS Web Interface measures use Shared Savings Program
benchmarks. https://www.cms.gov/Medicare/Medicare-Fee-
for-Service-Payment/sharedsavingsprogram/Downloads/2019-
quality-benchmarks-guidance.pdf.Measure_TypeMeasure
TypeBenchmarkIndicates whether or not a measure is included
in the benchmark analysis. Y = Yes, the measure is included in
benchmark analysis
N = No, the measure is not included in benchmark
analysisStandard DeviationStandard Deviation of performance
rate(s)AverageAverage performance rate(s)Decile 3The lower
and upper bound of decile 3 data rangeDecile 4The lower and
upper bound of decile 4 data rangeDecile 5The low er and upper
bound of decile 5 data rangeDecile 6The lower and upper
bound of decile 9 data rangeDecile 10Decile 10 open ended data
rangeTopped_OutIndicates whether or not a measure is topped
out for the 2019 performance period.
Y = Yes, the measure is topped out
N = No, the measure is not topped out
'--' = The measure has no historic benchmark for
2019SevenPointCap_PY19Indicates whether or not a Topped
Out Measure will receive special scoring.
Y=Yes, the measure cannot earn more than 7 points.
N=No, the measure is not capped and can earn up to 10 points.

MIPS Benchmark ResultsTable 2: Historical MIPS Quality
Measure Benchmark Results; created using PY2017 data and
PY2019 Eligibility
RulesMeasure_NameMeasure_IDCollection_TypeMeasure_Type
BenchmarkStandard_DeviationAverageDecile_3Decile_4Decile
_5Decile_6Decile_7Decile_8Decile_9Decile_10TOPPED_OUTS
evenPointCapDiabetes: Hemoglobin A1c (HbA1c) Poor Control
(>9%)1eCQMIntermediate OutcomeY28.246.377.14 -
60.7960.78 - 48.4948.48 - 38.9038.89 - 31.6031.59 - 25.8825.87
- 20.5620.55 - 14.72<= 14.71NoNoDiabetes: Hemoglobin A1c
(HbA1c) Poor Control (>9%)1Medicare Part B
ClaimsIntermediate OutcomeY24.524.644.44 - 29.0429.03 -
19.5219.51 - 14.7214.71 - 11.1211.11 - 8.348.33 - 5.575.56 -
2.79<= 2.78NoNoDiabetes: Hemoglobin A1c (HbA1c) Poor
Control (>9%)1MIPS CQMIntermediate
OutcomeY30.136.568.31 - 50.6350.62 - 37.5137.50 -
28.7028.69 - 20.0120.00 - 13.6013.59 - 9.039.02 - 2.71<=
2.70NoNoHeart Failure (HF): Angiotensin-Converting Enzyme
(ACE) Inhibitor or Angiotensin Receptor Blocker (ARB)
Therapy for Left Ventricular Systolic Dysfunction
(LVSD)5eCQMProcessY13.882.874.19 - 78.5678.57 -
82.1382.14 - 85.1885.19 - 87.9287.93 - 90.9090.91 - 93.7493.75
- 97.72>= 97.73NoNoHeart Failure (HF): Angiotensin-
Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor
Blocker (ARB) Therapy for Left Ventricular Systolic
Dysfunction (LVSD)5MIPS CQMProcessY13.594.193.33 -
96.9696.97 - 98.4098.41 - 99.99--------100YesNoCoronary
Artery Disease (CAD): Antiplatelet Therapy6MIPS
CQMProcessY13.289.684.13 - 87.9988.00 - 90.6690.67 -
92.8592.86 - 95.0995.10 - 97.0897.09 - 99.99--
100NoNoCoronary Artery Disease (CAD): Beta-Blocker
Therapy - Prior Myocardial Infarction (MI) or Left Ventricular
Systolic Dysfunction (LVEF <
40%)7eCQMProcessY13.782.976.74 - 80.3080.31 - 83.1783.18 -
85.2885.29 - 87.1587.16 - 89.7389.74 - 91.9191.92 - 94.86>=
94.87NoNoCoronary Artery Disease (CAD): Beta-Blocker

Therapy - Prior Myocardial Infarction (MI) or Left Ventricular
Systolic Dysfunction (LVEF < 40%)7MIPS
CQMProcessY8.896.396.17 - 98.1198.12 - 99.7699.77 - 99.99---
-----100YesNoHeart Failure (HF): Beta-Blocker Therapy for
Left Ventricular Systolic Dysfunction
(LVSD)8eCQMProcessY11.187.980.49 - 85.6185.62 -
88.9788.98 - 91.2991.30 - 93.0493.05 - 94.7394.74 - 96.3496.35
- 99.99100NoNoHeart Failure (HF): Beta-Blocker Therapy for
Left Ventricular Systolic Dysfunction (LVSD)8MIPS
CQMProcessY10.395.995.45 - 98.0598.06 - 99.2899.29 - 99.99-
-------100YesNoAnti-Depressant Medication
Management9eCQMProcessY32.453.916.67 - 31.0631.07 -
42.1842.19 - 53.1553.16 - 71.7371.74 - 82.7882.79 - 88.8888.89
- 94.43>= 94.44NoNoPrimary Open-Angle Glaucoma (POAG):
Optic Nerve Evaluation12eCQMProcessY2086.279.11 -
86.5786.58 - 90.6190.62 - 93.8793.88 - 96.3196.32 - 98.0198.02
- 99.1099.11 - 99.99100NoNoPrimary Open-Angle Glaucoma
(POAG): Optic Nerve Evaluation12Medicare Part B
ClaimsProcessY9.897.4--------------100YesYes - see "Scoring
Examples" tab of spreadsheetPrimary Open-Angle Glaucoma
(POAG): Optic Nerve Evaluation12MIPS
CQMProcessY9.896.296.47 - 99.1699.17 - 99.99----------
100YesYes - see "Scoring Examples" tab of spreadsheetAge-
Related Macular Degeneration (AMD): Dilated Macular
Examination14Medicare Part B ClaimsProcessY10.297.8---------
-----100YesYes - see "Scoring Examples" tab of
spreadsheetAge-Related Macular Degeneration (AMD): Dilated
Macular Examination14MIPS CQMProcessY24.386.276.54 -
89.8089.81 - 96.5396.54 - 99.7099.71 - 99.99------100YesYes -
see "Scoring Examples" tab of spreadsheetDiabetic Retinopathy:
Communication with the Physician Managing Ongoing Diabetes
Care19eCQMProcessY28.861.733.90 - 47.6147.62 - 57.8857.89
- 67.0267.03 - 75.3675.37 - 82.4882.49 - 90.0290.03 - 95.99>=
96.00NoNoDiabetic Retinopathy: Communication with the
Physician Managing Ongoing Diabetes Care19Medicare Part B

Examples" tab of spreadsheetDiabetic Retinopathy:
Communication with the Physician Managing Ongoing Diabetes
Care19MIPS CQMProcessY26.683.470.29 - 84.4184.42 -
92.7292.73 - 98.5698.57 - 99.99------100YesNoPerioperative
Care: Selection of Prophylactic Antibiotic - First OR Second
Generation Cephalosporin21Medicare Part B
ClaimsProcessY22.69299.17 - 99.99------------100YesYes - see
"Scoring Examples" tab of spreadsheetPerioperative Care:
Selection of Prophylactic Antibiotic - First OR Second
Generation Cephalosporin21MIPS CQMProcessY17.594.698.67
- 99.99------------100YesYes - see "Scoring Examples" tab of
spreadsheetPerioperative Care: Venous Thromboembolism
(VTE) Prophylaxis (When Indicated in ALL
Patients)23Medicare Part B ClaimsProcessY19.994.9-------------
-100YesYes - see "Scoring Examples" tab of
spreadsheetPerioperative Care: Venous Thromboembolism
(VTE) Prophylaxis (When Indicated in ALL Patients)23MIPS
CQMProcessY17.49598.68 - 99.99------------100YesYes - see
"Scoring Examples" tab of spreadsheetCommunication with the
Physician or Other Clinician Managing On-going Care Post-
Fracture for Men and Women Aged 50 Years and
Older24Medicare Part B ClaimsProcessY31.976.332.35 -
63.6363.64 - 92.3092.31 - 96.2096.21 - 97.6197.62 - 99.99----
100YesYes - see "Scoring Examples" tab of
spreadsheetCommunication with the Physician or Other
Clinician Managing On-going Care Post-Fracture for Men and
Women Aged 50 Years and Older24MIPS
CQMProcessY32.459.626.32 - 45.0945.10 - 55.3155.32 -
60.2060.21 - 69.9970.00 - 80.5580.56 - 99.99--
100NoNoScreening for Osteoporosis for Women Aged 65-85
Years of Age39Medicare Part B ClaimsProcessY26.556.232.79 -
42.3642.37 - 49.0049.01 - 55.9055.91 - 62.5462.55 - 70.6870.69
- 82.8882.89 - 95.49>= 95.50NoNoScreening for Osteoporosis
for Women Aged 65-85 Years of Age39MIPS
CQMProcessY3146.211.38 - 22.4322.44 - 34.7134.72 -
45.2545.26 - 58.1058.11 - 67.9767.98 - 78.4578.46 - 88.23>=

88.24NoNoCoronary Artery Bypass Graft (CABG): Preoperative
Beta-Blocker in Patients with Isolated CABG Surgery44MIPS
CQMProcessY14.792.790.35 - 95.8995.90 - 97.3897.39 - 99.99-
-------100YesYes - see "Scoring Examples" tab of
spreadsheetMedication Reconciliation Post-
Discharge46Medicare Part B ClaimsProcessY16.394.295.74 -
98.4098.41 - 99.99----------100YesYes - see "Scoring
Examples" tab of spreadsheetMedication Reconciliation Post-
Discharge46MIPS CQMProcessY17.293.394.24 - 97.6297.63 -
99.9299.93 - 99.99--------100YesYes - see "Scoring Examples"
tab of spreadsheetCare Plan47Medicare Part B
ClaimsProcessY33.178.450.32 - 82.6082.61 - 92.8892.89 -
97.4597.46 - 99.3099.31 - 99.99----100YesNoCare Plan47MIPS
CQMProcessY35.966.124.33 - 45.0145.02 - 65.7465.75 -
82.1682.17 - 91.8991.90 - 97.3197.32 - 99.7199.72 -
99.99100NoNoUrinary Incontinence: Assessment of Presence or
Absence of Urinary Incontinence in Women Aged 65 Years and
Older48Medicare Part B ClaimsProcessY43.1653.88 -
13.8513.86 - 72.4072.41 - 96.6896.69 - 99.99------100YesYes -
see "Scoring Examples" tab of spreadsheetUrinary Incontinence:
Assessment of Presence or Absence of Urinary Incontinence in
Women Aged 65 Years and Older48MIPS
CQMProcessY37.559.812.22 - 31.7431.75 - 52.3652.37 -
70.4470.45 - 84.2684.27 - 95.1095.11 - 99.5099.51 -
99.99100NoNoUrinary Incontinence: Plan of Care for Urinary
Incontinence in Women Aged 65 Years and Older50Medicare
Part B ClaimsProcessY18.294.497.30 - 98.8798.88 - 99.99-------
---100YesYes - see "Scoring Examples" tab of
spreadsheetUrinary Incontinence: Plan of Care for Urinary
Incontinence in Women Aged 65 Years and Older50MIPS
CQMProcessY26.671.447.22 - 59.9960.00 - 68.9868.99 -
75.6375.64 - 85.4985.50 - 92.5892.59 - 99.6599.66 -
99.99100NoNoChronic Obstructive Pulmonary Disease (COPD):
Spirometry Evaluation51Medicare Part B
ClaimsProcessY33.77738.10 - 77.2677.27 - 92.4492.45 -
98.7598.76 - 99.99------100YesYes - see "Scoring Examples"

tab of spreadsheetChronic Obstructive Pulmonary Disease
(COPD): Spirometry Evaluation51MIPS
CQMProcessY33.464.925.00 - 45.4445.45 - 60.4260.43 -
75.7575.76 - 86.4586.46 - 93.8293.83 - 99.3599.36 -
99.99100NoNoChronic Obstructive Pulmonary Disease (COPD):
Long-Acting Inhaled Bronchodilator Therapy52Medicare Part B
ClaimsProcessY21.989.990.14 - 98.1498.15 - 99.99----------
100YesYes - see "Scoring Examples" tab of spreadsheetChronic
Obstructive Pulmonary Disease (COPD): Long-Acting Inhaled
Bronchodilator Therapy52MIPS CQMProcessY13.493.190.16 -
95.2195.22 - 96.4896.49 - 98.8598.86 - 99.99------100YesYes -
see "Scoring Examples" tab of spreadsheetAppropriate
Treatment for Children with Upper Respiratory Infection
(URI)65eCQMProcessY15.888.180.95 - 88.3688.37 -
91.7691.77 - 93.8793.88 - 95.6095.61 - 96.8796.88 - 98.2198.22
- 99.99100NoNoAppropriate Treatment for Children with Upper
Respiratory Infection (URI)65MIPS
CQMProcessY13.993.291.49 - 95.0195.02 - 97.0297.03 -
97.8497.85 - 98.6998.70 - 99.1999.20 - 99.7499.75 -
99.99100YesYes - see "Scoring Examples" tab of
spreadsheetAppropriate Testing for Children with
Pharyngitis66eCQMProcessY29.666.736.71 - 60.0460.05 -
72.4072.41 - 78.3778.38 - 83.3283.33 - 87.6287.63 - 91.4291.43
- 94.58>= 94.59NoNoAppropriate Testing for Children with
Pharyngitis66MIPS CQMProcessY17.577.464.57 - 69.6069.61 -
75.4175.42 - 81.7481.75 - 85.5085.51 - 87.9587.96 - 91.7791.78
- 97.54>= 97.55NoNoHematology: Myelodysplastic Syndrome
(MDS) and Acute Leukemias: Baseline Cytogenetic Testing
Performed on Bone Marrow67MIPS CQMProcessY38.142.98.00
- 12.4912.50 - 22.7222.73 - 28.5228.53 - 34.6134.62 -
78.7878.79 - 99.99--100NoNoHematology: Myelodysplastic
Syndrome (MDS): Documentation of Iron Stores in Patients
Receiving Erythropoietin Therapy68MIPS CQMProcessN--------
--------------NoHematology: Multiple Myeloma: Treatment with
Bisphosphonates69MIPS CQMProcessY21.161.542.86 -
47.4947.50 - 64.5164.52 - 66.6666.67 - 71.4271.43 - 71.8771.88

- 76.9176.92 - 92.30>= 92.31NoNoHematology: Chronic
Lymphocytic Leukemia (CLL): Baseline Flow
Cytometry70MIPS CQMProcessY36.553.116.67 - 23.2023.21 -
32.2532.26 - 35.9435.95 - 67.8567.86 - 95.4495.45 - 99.99--
100NoNoPrevention of Central Venous Catheter (CVC) -
Related Bloodstream Infections76Medicare Part B
ClaimsProcessY17.393.795.24 - 98.6098.61 - 99.99----------
spreadsheetPrevention of Central Venous Catheter (CVC) -
Related Bloodstream Infections76MIPS
CQMProcessY15.794.295.67 - 99.0899.09 - 99.99----------
100YesYes - see "Scoring Examples" tab of spreadsheetAcute
Otitis Externa (AOE): Topical Therapy91Medicare Part B
ClaimsProcessY32.678.543.36 - 86.6086.61 - 93.2193.22 -
tab of spreadsheetAcute Otitis Externa (AOE): Topical
Therapy91MIPS CQMProcessY2083.267.34 - 78.7678.77 -
86.3386.34 - 91.3291.33 - 95.2395.24 - 97.3697.37 - 99.99--
100NoNoAcute Otitis Externa (AOE): Systemic Antimicrobial
Therapy - Avoidance of Inappropriate Use93Medicare Part B
ClaimsProcessY21.688.789.12 - 93.5093.51 - 96.3596.36 -
97.8297.83 - 99.9299.93 - 99.99----100YesYes - see "Scoring
Examples" tab of spreadsheetAcute Otitis Externa (AOE):
Systemic Antimicrobial Therapy - Avoidance of Inappropriate
Use93MIPS CQMProcessY23.780.163.16 - 77.3577.36 -
83.9683.97 - 89.6589.66 - 93.3293.33 - 96.1496.15 - 99.99--
100NoNoProstate Cancer: Avoidance of Overuse of Bone Scan
for Staging Low Risk Prostate Cancer
Patients102eCQMProcessY29.878.359.34 - 75.7375.74 -
83.9083.91 - 91.9992.00 - 98.3098.31 - 99.99----
100NoNoProstate Cancer: Avoidance of Overuse of Bone Scan
for Staging Low Risk Prostate Cancer Patients102MIPS
CQMProcessN----------------------NoProstate Cancer:
Combination Androgen Deprivation Therapy for High Risk or
Very High Risk Prostate Cancer104MIPS
CQMProcessY30.66939.65 - 48.1648.17 - 55.0555.06 -

76.2276.23 - 93.2593.26 - 99.5999.60 - 99.99--100NoNoAdult
Major Depressive Disorder (MDD): Suicide Risk
Assessment107eCQMProcessY3633.91.51 - 3.563.57 - 8.108.11
- 17.4817.49 - 30.2830.29 - 54.7254.73 - 77.5677.57 - 96.66>=
96.67NoNoOsteoarthritis (OA): Function and Pain
Assessment109Medicare Part B ClaimsProcessY22.989.287.28 -
95.7195.72 - 98.7198.72 - 99.8899.89 - 99.99------100YesYes -
see "Scoring Examples" tab of spreadsheetOsteoarthritis (OA):
Function and Pain Assessment109MIPS
CQMProcessY3573.734.62 - 63.0063.01 - 86.6386.64 -
94.3794.38 - 99.99------100NoNoPreventive Care and
Screening: Influenza
Immunization110eCQMProcessY28.14215.50 - 23.6323.64 -
31.2031.21 - 38.6538.66 - 46.7646.77 - 56.0156.02 - 67.4967.50
- 84.98>= 84.99NoNoPreventive Care and Screening: Influenza
Immunization110Medicare Part B
ClaimsProcessY32.364.229.52 - 41.4141.42 - 56.3156.32 -
71.1871.19 - 82.8882.89 - 94.1494.15 - 99.4199.42 -
99.99100NoNoPreventive Care and Screening: Influenza
Immunization110MIPS CQMProcessY31.461.829.85 -
41.4241.43 - 53.8453.85 - 66.0266.03 - 76.9376.94 - 87.8087.81
- 96.4096.41 - 99.99100NoNoPneumococcal Vaccination Status
for Older Adults111eCQMProcessY30.150.819.01 - 31.0631.07
- 42.7042.71 - 53.4353.44 - 62.8562.86 - 71.8171.82 -
80.4280.43 - 90.40>= 90.41NoNoPneumococcal Vaccination
Status for Older Adults111Medicare Part B
ClaimsProcessY24.871.649.76 - 61.1061.11 - 70.1070.11 -
77.3177.32 - 82.9582.96 - 89.4389.44 - 95.6695.67 -
99.99100NoNoPneumococcal Vaccination Status for Older
Adults111MIPS CQMProcessY28.458.430.23 - 44.5244.53 -
55.5555.56 - 63.6363.64 - 70.4270.43 - 76.3776.38 - 83.7683.77
- 95.44>= 95.45NoNoBreast Cancer
Screening112eCQMProcessY26.748.422.28 - 32.7432.75 -
42.3142.32 - 51.0551.06 - 58.4358.44 - 65.6765.68 - 73.4373.44
- 82.30>= 82.31NoNoBreast Cancer Screening112Medicare Part
B ClaimsProcessY24.764.644.44 - 52.0752.08 - 58.4458.45 -

64.2864.29 - 70.9670.97 - 79.8479.85 - 90.2390.24 -
99.99100NoNoBreast Cancer Screening112MIPS
CQMProcessY29.362.935.99 - 48.2548.26 - 57.5757.58 -
67.3867.39 - 75.2475.25 - 85.3085.31 - 93.4493.45 -
99.99100NoNoColorectal Cancer
Screening113eCQMProcessY28.944.413.49 - 24.0024.01 -
33.9633.97 - 44.3844.39 - 54.7954.80 - 64.0064.01 - 73.3773.38
- 83.50>= 83.51NoNoColorectal Cancer Screening113Medicare
Part B ClaimsProcessY28.966.336.60 - 50.9951.00 - 62.4962.50
- 71.2271.23 - 79.9980.00 - 88.6388.64 - 97.7297.73 -
99.99100NoNoColorectal Cancer Screening113MIPS
CQMProcessY30.465.335.90 - 49.5049.51 - 60.8260.83 -
70.8770.88 - 80.6180.62 - 90.4090.41 - 96.9796.98 -
99.99100NoNoAvoidance of Antibiotic Treatment in Adults
With Acute Bronchitis116MIPS CQMProcessY27.872.644.27 -
57.0757.08 - 72.0272.03 - 83.7783.78 - 90.9890.99 - 95.5695.57
- 97.5497.55 - 99.99100NoNoDiabetes: Eye
Exam117eCQMProcessY35.860.720.61 - 31.9932.00 -
45.5245.53 - 66.0166.02 - 89.1189.12 - 95.6495.65 - 98.2598.26
- 99.72>= 99.73NoNoDiabetes: Eye Exam117Medicare Part B
ClaimsProcessY24.986.972.00 - 96.8796.88 - 99.99----------
spreadsheetDiabetes: Eye Exam117MIPS
CQMProcessY24.785.877.26 - 89.9990.00 - 95.8195.82 -
tab of spreadsheetCoronary Artery Disease (CAD): Angiotensin-
Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor
Blocker (ARB) Therapy - Diabetes or Left Ventricular Systolic
Dysfunction (LVEF < 40%)118MIPS
CQMProcessY11.183.376.00 - 78.5678.57 - 81.0781.08 -
83.9083.91 - 86.3586.36 - 88.7288.73 - 92.2592.26 - 98.17>=
98.18NoNoDiabetes: Medical Attention for
Nephropathy119eCQMProcessY19.77967.86 - 74.7974.80 -
79.9980.00 - 84.1384.14 - 87.7387.74 - 91.1091.11 - 94.6294.63
- 98.38>= 98.39NoNoDiabetes: Medical Attention for
Nephropathy119MIPS CQMProcessY20.185.174.38 -

82.8582.86 - 87.7087.71 - 91.9391.94 - 97.2397.24 - 99.99----
100NoNoDiabetes Mellitus: Diabetic Foot and Ankle Care,
Peripheral Neuropathy - Neurological Evaluation126MIPS
CQMProcessY29.382.566.15 - 85.2285.23 - 96.4296.43 - 99.99-
-------100YesNoDiabetes Mellitus: Diabetic Foot and Ankle
Care, Ulcer Prevention - Evaluation of Footwear127MIPS
CQMProcessY27.984.870.59 - 92.8592.86 - 99.4599.46 - 99.99-
-------100YesNoPreventive Care and Screening: Body Mass
Index (BMI) Screening and Follow-Up
Plan128eCQMProcessY28.545.421.15 - 24.5824.59 - 28.5128.52
- 34.2034.21 - 43.8443.85 - 60.3060.31 - 78.2478.25 - 93.28>=
93.29NoNoPreventive Care and Screening: Body Mass Index
(BMI) Screening and Follow-Up Plan128Medicare Part B
ClaimsProcessY30.374.237.52 - 47.7747.78 - 74.4774.48 -
95.1995.20 - 99.2699.27 - 99.99----100YesNoPreventive Care
and Screening: Body Mass Index (BMI) Screening and Follow -
Up Plan128MIPS CQMProcessY31.872.634.35 - 54.2554.26 -
74.5674.57 - 90.5990.60 - 97.5597.56 - 99.8699.87 - 99.99--
100NoNoDocumentation of Current Medications in the Medical
Record130eCQMProcessY18.590.387.55 - 93.4893.49 -
96.2896.29 - 97.9897.99 - 98.9999.00 - 99.5799.58 - 99.8899.89
- 99.99100YesYes - see "Scoring Examples" tab of
spreadsheetDocumentation of Current Medications in the
Medical Record130Medicare Part B
ClaimsProcessY13.196.197.95 - 99.5199.52 - 99.9199.92 -
99.99--------100YesYes - see "Scoring Examples" tab of
spreadsheetDocumentation of Current Medications in the
Medical Record130MIPS CQMProcessY30.582.668.06 -
90.2790.28 - 97.2397.24 - 99.5099.51 - 99.99------100YesYes -
see "Scoring Examples" tab of spreadsheetPain Assessment and
Follow-Up131Medicare Part B ClaimsProcessY2587.980.57 -
96.9196.92 - 99.6399.64 - 99.99--------100YesYes - see
"Scoring Examples" tab of spreadsheetPain Assessment and
Follow-Up131MIPS CQMProcessY38.265.115.80 - 39.9940.00 -
62.7862.79 - 84.0584.06 - 95.2595.26 - 99.5499.55 - 99.99--
100NoNoPreventive Care and Screening: Screening for

Depression and Follow-Up Plan134eCQMProcessY32.237.14.88
- 10.1710.18 - 17.5917.60 - 28.2828.29 - 42.2942.30 -
56.8256.83 - 73.2973.30 - 87.49>= 87.50NoNoPreventive Care
and Screening: Screening for Depression and Follow -Up
Plan134Medicare Part B ClaimsProcessY39.669.312.94 -
53.9153.92 - 80.2280.23 - 96.9896.99 - 99.99------
100YesNoPreventive Care and Screening: Screening for
Depression and Follow-Up Plan134MIPS
CQMProcessY38.567.717.11 - 45.6445.65 - 73.8173.82 -
90.0590.06 - 98.4998.50 - 99.99----100NoNoMelanoma:
Continuity of Care - Recall System137MIPS
CQMStructureY2388.683.83 - 94.3394.34 - 98.7998.80 - 99.99--
------100NoNoMelanoma: Coordination of Care138MIPS
CQMProcessY30.275.849.44 - 63.6363.64 - 78.2578.26 -
92.5892.59 - 99.99------100NoNoPrimary Open-Angle
Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by
15% OR Documentation of a Plan of Care141Medicare Part B
ClaimsOutcomeY10.897.6--------------100YesYes - see "Scoring
Examples" tab of spreadsheetPrimary Open-Angle Glaucoma
(POAG): Reduction of Intraocular Pressure (IOP) by 15% OR
Documentation of a Plan of Care141MIPS
CQMOutcomeY26.484.873.85 - 87.4987.50 - 96.2996.30 -
99.3099.31 - 99.99------100NoNoOncology: Medical and
Radiation - Pain Intensity
Quantified143eCQMProcessY25.484.977.21 - 87.7887.79 -
94.9194.92 - 97.2697.27 - 98.3498.35 - 99.4599.46 - 99.99--
spreadsheetOncology: Medical and Radiation - Pain Intensity
Quantified143MIPS CQMProcessY17.191.990.31 - 95.3995.40 -
97.1297.13 - 98.5698.57 - 99.2599.26 - 99.99----100YesYes -
see "Scoring Examples" tab of spreadsheetOncology: Medical
and Radiation - Plan of Care for Pain144MIPS CQMProcessN---
-------------------NoRadiology: Exposure Dose or Time Reported
for Procedures Using Fluoroscopy145Medicare Part B
ClaimsProcessY26.581.966.41 - 82.9282.93 - 90.9090.91 -
95.1795.18 - 97.3997.40 - 99.0699.07 - 99.99--

100YesNoRadiology: Exposure Dose or Time Reported for
Procedures Using Fluoroscopy145MIPS
CQMProcessY24.985.173.10 - 88.0388.04 - 94.9194.92 -
98.1598.16 - 99.5399.54 - 99.99----100YesNoRadiology:
Inappropriate Use of "Probably Benign" Assessment Category in
Screening Mammograms146Medicare Part B
ClaimsProcessY1.20.30.23 - 0.01------------0YesYes - see
"Scoring Examples" tab of spreadsheetRadiology: Inappropriate
Use of "Probably Benign" Assessment Category in Screening
Mammograms146MIPS CQMProcessY3.50.50.24 - 0.120.11 -
0.050.04 - 0.01--------0YesYes - see "Scoring Examples" tab of
spreadsheetNuclear Medicine: Correlation with Existing
Imaging Studies for All Patients Undergoing Bone
Scintigraphy147Medicare Part B ClaimsProcessY22.386.276.47
- 87.1787.18 - 94.0594.06 - 97.0097.01 - 99.99------
100YesNoNuclear Medicine: Correlation with Existing Imaging
Studies for All Patients Undergoing Bone Scintigraphy147MIPS
CQMProcessY13.794.193.04 - 97.9697.97 - 99.99----------
100YesYes - see "Scoring Examples" tab of spreadsheetFalls:
Risk Assessment154Medicare Part B
ClaimsProcessY18.39496.95 - 99.99------------100YesYes - see
"Scoring Examples" tab of spreadsheetFalls: Risk
Assessment154MIPS CQMProcessY35.473.228.63 - 60.8160.82
- 84.9985.00 - 95.9695.97 - 99.7399.74 - 99.99----100YesYes -
see "Scoring Examples" tab of spreadsheetFalls: Plan of
Care155Medicare Part B ClaimsProcessY30.881.455.81 -
84.6184.62 - 99.2099.21 - 99.99--------100YesYes - see
"Scoring Examples" tab of spreadsheetFalls: Plan of
Care155MIPS CQMProcessY28.882.767.86 - 86.7886.79 -
94.9995.00 - 98.2198.22 - 99.99------100YesYes - see "Scoring
Examples" tab of spreadsheetHIV/AIDS: Pneumocystis Jiroveci
Pneumonia (PCP) Prophylaxis160eCQMProcessN-----------------
-----NoCoronary Artery Bypass Graft (CABG): Prolonged
Intubation164MIPS CQMOutcomeY5.97.611.40 - 9.109.09 -
7.707.69 - 6.816.80 - 5.565.55 - 4.294.28 - 3.093.08 - 1.55<=
1.54NoNoCoronary Artery Bypass Graft (CABG): Deep Sternal

Wound Infection Rate165MIPS CQMOutcomeY1.10.50.84 -
0.01------------0YesYes - see "Scoring Examples" tab of
spreadsheetCoronary Artery Bypass Graft (CABG):
Stroke166MIPS CQMOutcomeY1.61.32.38 - 1.801.79 - 1.271.26
- 0.720.71 - 0.01------0YesYes - see "Scoring Examples" tab of
spreadsheetCoronary Artery Bypass Graft (CABG):
Postoperative Renal Failure167MIPS CQMOutcomeY2.62.23.51
- 2.712.70 - 2.162.15 - 1.861.85 - 1.291.28 - 0.890.88 - 0.01--
0YesYes - see "Scoring Examples" tab of spreadsheetCoronary
Artery Bypass Graft (CABG): Surgical Re-Exploration168MIPS
CQMOutcomeY2.62.43.95 - 3.143.13 - 2.642.63 - 1.801.79 -
1.281.27 - 0.880.87 - 0.01--0YesNoRheumatoid Arthritis (RA):
Tuberculosis Screening176MIPS CQMProcessY3165.432.00 -
48.1448.15 - 55.5555.56 - 68.0068.01 - 80.4280.43 - 99.0399.04
- 99.99--100NoNoRheumatoid Arthritis (RA): Periodic
Assessment of Disease Activity177MIPS
CQMProcessY29.47957.23 - 74.9975.00 - 88.2388.24 -
96.0196.02 - 99.99------100YesNoRheumatoid Arthritis (RA):
Functional Status Assessment178MIPS
CQMProcessY27.28267.61 - 81.3981.40 - 90.5890.59 -
Assessment and Classification of Disease Prognosis179MIPS
CQMProcessY30.976.744.53 - 67.8867.89 - 85.3085.31 -
Glucocorticoid Management180MIPS
CQMProcessY28.679.352.68 - 75.7875.79 - 87.9587.96 -
95.0595.06 - 99.5799.58 - 99.99----100YesNoElder
Maltreatment Screen and Follow-Up Plan181Medicare Part B
ClaimsProcessY34.680.955.38 - 97.3197.32 - 99.5599.56 -
spreadsheetElder Maltreatment Screen and Follow -Up
Plan181MIPS CQMProcessY29.975.650.65 - 66.0366.04 -
77.7777.78 - 89.2889.29 - 96.7896.79 - 99.99----
100NoNoFunctional Outcome Assessment182Medicare Part B
Examples" tab of spreadsheetFunctional Outcome

Assessment182MIPS CQMProcessN----------------------
NoColonoscopy Interval for Patients with a History of
Adenomatous Polyps
- Avoidance of Inappropriate Use185Medicare Part B
ClaimsProcessY8.597.898.57 - 99.99------------100YesYes - see
"Scoring Examples" tab of spreadsheetColonoscopy Interval for
Patients with a History of Adenomatous Polyps
- Avoidance of Inappropriate Use185MIPS
CQMProcessY25.88261.64 - 84.9985.00 - 90.5390.54 -
95.4195.42 - 98.4098.41 - 99.99----100YesNoStroke and Stroke
Rehabilitation: Thrombolytic Therapy187MIPS
CQMProcessY20.590.188.89 - 96.4896.49 - 99.99----------
100YesNoCataracts: 20/40 or Better Visual Acuity within 90
Days Following Cataract
Surgery191eCQMOutcomeY18.488.585.25 - 90.6290.63 -
93.4093.41 - 95.5895.59 - 96.8796.88 - 97.8297.83 - 98.7798.78
- 99.99100NoNoCataracts: 20/40 or Better Visual Acuity within
90 Days Following Cataract Surgery191MIPS
CQMOutcomeY9.396.194.37 - 96.8796.88 - 98.9798.98 - 99.99-
-------100YesNoCataracts: Complications within 30 Days
Following Cataract Surgery Requiring Additional Surgical
Procedures192eCQMOutcomeY0.90.2--------------0YesYes - see
"Scoring Examples" tab of spreadsheetCataracts: Complications
within 30 Days Following Cataract Surgery Requiring
Additional Surgical Procedures192MIPS CQMOutcomeY6.50.9-
-------------0YesYes - see "Scoring Examples" tab of
spreadsheetRadiology: Stenosis Measurement in Carotid
Imaging Reports195Medicare Part B
ClaimsProcessY16.192.791.72 - 96.2296.23 - 98.1798.18 -
spreadsheetRadiology: Stenosis Measurement in Carotid
Imaging Reports195MIPS CQMProcessY10.796.697.81 -
99.8499.85 - 99.99----------100YesYes - see "Scoring
Examples" tab of …

Regulating New Technologies
OVERVIEW
Examples of New Technologies
Informative Links
Discussion Question
Conclusion
New Information Technologies and Public Policy
EXAMPLES (there are many more)
Autonomous Vehicles
Blockchain
Drones (airspace, photography)
Artificial Intelligence and Robotics
Mobile Phones (distracted driving, texting while walking)
Facial Recognition Software
Human RFID Chipping
Cloud Computing
Social Media
New Information Technologies and Public Policy
Useful Links about policy (not just the technology)
Autonomous Vehicles https://www.enotrans.org/wp-
content/uploads/AV-paper.pdf
Drones (airspace, photography)

http://www.sarahnilsson.org/app/download/968307096/RAND_
Report_International_Commercial_Drone_Regulation__Drone_
Delivery_Services.pdf
Artificial Intelligence and Robotics
http://faculty.engineering.asu.edu/acs/wp-
content/uploads/2016/11/Ethics-of-Artificial-Intelligence-
2015.pdf
Disruptive Information Technologies and Public Policy
More Useful Links about policy
Mobile Phones (distracted driving, texting while walking)
https://www.ajpmonline.org/article/S0749-
3797%2811%2900164-4/fulltext
Facial Recognition Software
http://www.arizonalawreview.org/pdf/55-1/55arizlrev201.pdf
Human RFID Chipping http://www.targeted-
individuals.co.uk/rfid_implants_31_ethical_implications_implan
table_chips_cancer.pdf
Week 13 Discussion
Weekly Topic: Regulating New Information Technologies
Part One
Why do new technologies require regulation? (try to provide 3
reasons, base them in literature as much as possible. This point
should apply to all new emerging technologies)

Part Two
What do you think is a new technology that presents a
significant regulatory challenge, and what do you think should
be done?
CONCLUSION
Week 12’s discussion was the best yet
No points, no pressure, so more genuine discussion?
New (or disruptive) technologies often get regulated. What
factors do they have in common that drive government
regulator’s motivations
Part Two should be your opinion. No pressure to “write like a
PhD.” Your post should say “I think regulation is needed
because...” and then let us know how you’d proceed if you were
the King or Queen of New Technologies
7
Cover Page2019 Merit-based Incentive Payment System
(MIPS)Quality Measures List4/24/19Version 3.2
InstructionsStep-by-Step Instructions to Search for Quality
Measures Using this Excel FileThis spreadsheet is a tool that
eligible clinicians can use to search for current 2019 quality
measures. The third tab of this file, titled "2019 MIPS Quality
Measures List" includes the full set of current measures
reportable through any collection type, as of 2019. Eligible
clinicians can use this resource to find measures in any number

of ways and then then use the measure specification manuals to
dive deeper into any given measure.
For guidance on how to search for measures, please see step by
step instructions on how to execute the following basic
functions:
1. Search by measure number
2 Search by NQS domain
3. Search by collection type
4. Search using keywords1. Search by measure numberStep 1:
Identify the type of measure number you are searching by
(CMS, NQF, Quality) and click on the arrow below that
program.Step 2: Once the arrow is selected, a drop down menu
will appear. Input the measure number you are searching for and
select "OK."Step 3: This excel function will filter out all other
measures, leaving you with just the measure with the number
you are searching for.Step 4: To undo your search (so that you
might search for something else), reclick the arrow that is
filtered and select "Clear Filter From '…'." 2. Search by NQS
DomainStep 1: Select the arrow below the NQS Domain header
(in Column G).Step 2: Once the arrow is selected, a drop down
menu will appear. Select all NQS Domains you are searching
for (e.g., Effective Clinical Care)and select "OK."Step 3: This
will filter out all other measures, leaving you only with
measures in the NQS Domain you are searching for.Step 4: To
undo your search (so that you might search for something else),
reclick the arrow that is filtered and select "Clear Filter From
'NQS Domain' ". 3. Search by Collection TypeStep 1: Select the
arrow below the collection type you are searching forStep 2:
Once the arrow is selected, a drop down menu will appear.
Unselect the "-" so that only the "X" is marked. Then select
"OK."Step 3: This excel function will filter out all other
measures, leaving you only with measures reportable via the
chosen collection type.Step 4: To undo your search (so that you
might search for something else), reclick the arrow that is

filtered and select "Clear Filter From 'MIPS CQM' ". 4. Search
using KeywordsStep 1: Select the arrow below the Measure
Title column.Step 2: Once the arrow is selected, a drop down
menu will appear. Input a key word you are searching for (e.g.,
"Parkinson") and select "OK."Step 3: This excel function will
filter out all other measures, leaving you only with measures
with the word "Parkinson" in the measure title.Step 4: To undo
your search (so that you might search for something else),
reclick the arrow that is filtered and select "Measure Title' ".
Note: this same function can be conducted in the measure
description column as well.
2019 MIPS Quality Measures ListMeasure NumberCollection
Type(s)Specialty Measure SetsUse in Other Reporting
Program(s)Measure TitleCMS eCQM IDeCQM
NQFNQFQuality Number (Q#)Measure DescriptionNQS
DomainMeasure TypeMeaningful Measure AreaHigh Priority
Appropriate UsePrimary Measure StewardMedicare Part B
ClaimsCSVeCQMCMS
Web Interface Administrative ClaimsMIPS CQMAllergy/
ImmunologyAnesthesiologyCardiologyElectro-physiology
Cardiac SpecialistGastro-enterologyDermatologyEmergency
MedicineFamily MedicineInternal MedicineObstetrics/
GynecologyOphthalmologyOrthopedic
SurgeryOtolaryngologyPathologyPediatricsPhysical
MedicinePlastic
SurgeryPreventive MedicineNeurologyMental/ Behavioral
HealthDiagnostic RadiologyInterventi onal RadiologyVascular
SurgeryGeneral SurgeryThoracic
SurgeryUrologyOncologyRadiation
OncologyHospitalistsRheumatologyNephrologyInfectious
DiseaseNeurosurgicalPodiatryPhysical Therapy/ Occupational
TherapyGeriatricsUrgent CareSkilled Nursing
FacilityDentistryACO(s)Million HeartsDiabetes: Hemoglobin
A1c (HbA1c) Poor Control
(>9%)CMS122v7N/A0059001Percentage of patients 18-75 years
of age with diabetes who had hemoglobin A1c > 9.0% during

the measurement periodEffective Clinical Care Intermediate
OutcomeManagement of Chronic ConditionsX-National
Committee for Quality AssuranceX-XX-X-------XX--------X-----
-------X--------X-Heart Failure (HF): Angiotensin-Converting
Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker
(ARB) Therapy for Left Ventricular Systolic Dysfunction
(LVSD)CMS135v7
0081e
0081
005Percentage of patients aged 18 years and older with a
diagnosis of heart failure (HF) with a current or prior left
ventricular ejection fraction (LVEF) < 40% who were
prescribed ACE inhibitor or ARB therapy either within a 12-
month period when seen in the outpatient setting OR at each
hospital dischargeEffective Clinical CareProcessManagement of
Chronic Conditions--Physician Consortium for Performance
Improvement--X--X--X----XX-------------------X------------
Coronary Artery Disease (CAD): Antiplatelet
TherapyN/AN/A0067006Percentage of patients aged 18 years
and older with a diagnosis of coronary artery disease (CAD)
seen within a 12 month period who were prescribed aspirin or
clopidogrelEffective Clinical CareProcessManagement of
Chronic Conditions--American Heart Association-----X--X----
XX----------------------------X---Coronary Artery Disease (CAD):
Beta-Blocker Therapy – Prior Myocardial Infarction (MI) or
Left Ventricular Systolic Dysfunction (LVEF <
40%)CMS145v7N/A
0070
007Percentage of patients aged 18 years and older with a
diagnosis of coronary artery disease seen within a 12-month
period who also have a prior MI or a current or prior LVEF <
40% who were prescribed beta-blocker therapyEffective
Clinical CareProcessManagement of Chronic Conditions--
Physician Consortium for Performance Improvement--X--X--X--
--XX----------------------------X---Heart Failure (HF): Beta-

Blocker Therapy for Left Ventricular Systolic Dysfunction
(LVSD)CMS144v70083e0083008Percentage of patients aged 18
years and older with a diagnosis of heart failure (HF) with a
current or prior left ventricular ejection fraction (LVEF) < 40%
who were prescribed beta-blocker therapy either within a 12-
month period when seen in the outpatient setting OR at each
hospital dischargeEffective Clinical CareProcessManagement of
Chronic Conditions--Physician Consortium for Performance
Improvement--X--X--X----XX-------------------X--------X---Anti-
Depressant Medication
ManagementCMS128v7N/A0105009Percentage 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.
a. Percentage of patients who remained on an antidepressant
medication for at least 84 days (12 weeks).
b. Percentage of patients who remained on an antidepressant
medication for at least 180 days (6 months)Effective Clinical
CareProcessPrevention and Treatment of Opioid and Substance
Use Disorders--National Committee for Quality Assurance--X---
-------XX----------X---------------------Primary Open-Angle
Glaucoma (POAG): Optic Nerve
EvaluationCMS143v7N/A0086012Percentage of patients aged
18 years and older with a diagnosis of primary open-angle
glaucoma (POAG) who have an optic nerve head evaluation
during one or more office visits within 12 monthsEffective
Clinical CareProcessManagement of Chronic Conditions--
Physician Consortium for Performance ImprovementX-X--X-----
-----X------------------------------Age-Related Macular
Degeneration (AMD): Dilated Macular
ExaminationN/AN/A0087014Percentage of patients aged 50
years and older with a diagnosis of age-related macular
degeneration (AMD) who had a dilated macular examination
performed which included documentation of the presence or
absence of macular thickening or geographic atrophy or

hemorrhage AND the level of macular degeneration severity
during one or more office visits within the 12 month
performance periodEffective Clinical CareProcessManagement
of Chronic Conditions--American Academy of
OphthalmologyX----X----------X------------------------------
Diabetic Retinopathy: Communication with the Physician
Managing Ongoing Diabetes
CareCMS142v7N/A0089019Percentage of patients aged 18
years and older with a diagnosis of diabetic retinopathy who
had a dilated macular or fundus exam performed with
documented communication to the physician who manages the
ongoing care of the patient with diabetes mellitus regarding the
findings of the macular or fundus exam at least once within 12
monthsCommunication and Care Coordination ProcessTransfer
of Health Information and InteroperabilityX-Physician
Consortium for Performance ImprovementX-X--X----------X-----
-------------------------Perioperative Care: Selection of
Prophylactic Antibiotic – First OR Second-Generation
CephalosporinN/AN/A0268021Percentage of surgical patients
aged 18 years and older undergoing procedures with the
indications for a first OR second-generation cephalosporin
prophylactic antibiotic who had an order for a first OR second-
generation cephalosporin for antimicrobial prophylaxisPatient
SafetyProcessHealthcare Associated Infections XXAmerican
Society of Plastic SurgeonsX----X-----------XX---X-----XXX----
---X--------Perioperative Care: Venous Thromboembolis m
(VTE) Prophylaxis (When Indicated in ALL
Patients)N/AN/AN/A023Percentage of surgical patients aged 18
years and older undergoing procedures for which venous
thromboembolism (VTE) prophylaxis is indicated in all patients,
who had an order for Low Molecular Weight Heparin (LMWH),
Low-Dose Unfractionated Heparin (LDUH), adjusted-dose
warfarin, fondaparinux or mechanical prophylaxis to be given
within 24 hours prior to incision time or within 24 hours after
surgery end timePatient SafetyProcessPreventive CareX-
American Society of Plastic SurgeonsX----X-----------XX---X---

--XXXX------X--------Communication with the Physician or
Other Clinician Managing On-Going Care Post-Fracture for Men
and Women Aged 50 Years and OlderN/AN/AN/A024Percentage
of patients aged 50 years and older treated for a fracture with
documentation of communication, between the physician
treating the fracture and the physician or other clinician
managing the patient’s on-going care, that a fracture occurred
and that the patient was or should be considered for
osteoporosis treatment or testing. This measure is submitted by
the physician who treats the fracture and who therefore is held
accountable for the communicationCommunication and Care
CoordinationProcessTransfer of Health Information and
InteroperabilityX-National Committee for Quality AssuranceX--
--X-------XX--X-----X-----------X-----------Screening for
Osteoporosis for Women Aged 65-85 Years of
AgeN/AN/A0046039Percentage of female patients aged 65-85
years of age who ever had a central dual-energy X-ray
absorptiometry (DXA) to check for osteoporosisEffective
Clinical CareProcessPreventive Care--National Committee for
Quality AssuranceX----X-------XX--------X-----------X-----X-----
Coronary Artery Bypass Graft (CABG): Preoperative Beta-
Blocker in Patients with Isolated CABG
SurgeryN/AN/A0236044Percentage of isolated Coronary Artery
Bypass Graft (CABG) surgeries for patients aged 18 years and
older who received a beta-blocker within 24 hours prior to
surgical incisionEffective Clinical CareProcessMedication
Management--Centers for Medicare & Medicaid Services-----X-
X---------------------------------------Medication Reconciliation
Post-DischargeN/AN/A0097046The percentage of discharges
from any inpatient facility (e.g. hospital, skilled nursing
facility, or rehabilitation facility) for patients 18 years of age
and older 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 submitted as three rates stratified by age group:
• Submission Criteria 1: 18-64 years of age
• Submission Criteria 2: 65 years and older
• Total Rate: All patients 18 years of age and
olderCommunication and Care CoordinationProcessMedication
ManagementX-National Committee for Quality AssuranceX----
X-----------X-----------X------X----X-----Advance Care
PlanN/AN/A0326047Percentage 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 planCommunication
and Care CoordinationProcessCare is Personalized and Aligned
with Patient’s GoalsX-National Committee for Quality
AssuranceX----X--X-X--XXX-XX--X-XX---XXXXX-XXX----
X-X---Urinary Incontinence: Assessment of Presence or
Absence of Urinary Incontinence in Women Aged 65 Years and
Older N/AN/AN/A048Percentage of female patients aged 65
years and older who were assessed for the presence or absence
of urinary incontinence within 12 monthsEffective Clinical
CareProcessPreventive Care--National Committee for Quality
AssuranceX----X-------XXX-------X-------X---------------Urinary
Incontinence: Plan of Care for Urinary Incontinence in Women
Aged 65 Years and OlderN/AN/AN/A050Percentage of female
patients aged 65 years and older with a diagnosis of urinary
incontinence with a documented plan of care for urinary
incontinence at least once within 12 monthsPerson and
Caregiver-Centered Experience and
OutcomesProcessManagement of Chronic ConditionsX-National
Committee for Quality AssuranceX----X-------XXX---------------
X---------X-----Chronic Obstructive Pulmonary Disease
(COPD): Spirometry EvaluationN/AN/A0091051Percentage of
patients aged 18 years and older with a diagnosis of COPD who
had spirometry results documentedEffective Clinical
CareProcessManagement of Chronic Conditions--American

Thoracic SocietyX----X-----------------------------------------
Chronic Obstructive Pulmonary Disease (COPD): Long-Acting
Inhaled Bronchodilator TherapyN/AN/A0102052Percentage of
patients aged 18 years and older with a diagnosis of COPD
(FEV1/FVC < 70%) and who have an FEV1 less than 60%
predicted and have symptoms who were prescribed a long-acting
inhaled bronchodilatorEffective Clinical
Thoracic SocietyX----X-----------------------------------------
Appropriate Treatment for Children with Upper Respiratory
Infection (URI)CMS154v7N/A0069065Percentage of children 3
months - 18 years of age who were diagnosed with upper
respiratory infection (URI) and were not dispensed an antibiotic
prescription on or three days after the episodeEfficiency and
Cost ReductionProcessAppropriate Use of
HealthcareXXNational Committee for Quality Assurance--X--X-
------X----X-X---------------------X----Appropriate Testing for
Children with PharyngitisCMS146v7N/AN/A066Percentage of
children 3-18 years of age who were diagnosed with
pharyngitis, ordered an antibiotic and received a group A
streptococcus (strep) test for the episodeEfficiency and Cost
ReductionProcessAppropriate Use of HealthcareXXNational
Committee for Quality Assurance--X--X------XX------X----------
-----------X---- Hematology: Myelodysplastic Syndrome (MDS)
and Acute Leukemias: Baseline Cytogenetic Testing Performed
on Bone Marrow N/AN/A0377067Percentage of patients aged
18 years and older with a diagnosis of myelodysplastic
syndrome (MDS) or an acute leukemia who had baseline
cytogenetic testing performed on bone marrowEffective Clinical
Society of Hematology-----X-----------------------------------------
Hematology: Myelodysplastic Syndrome (MDS): Documentation
of Iron Stores in Patients Receiving Erythropoietin
TherapyN/AN/A0378068Percentage of patients aged 18 years
and older with a diagnosis of myelodysplastic syndrome (MDS)
who are receiving erythropoietin therapy with documentation of

iron stores within 60 days prior to initiating erythropoietin
therapyEffective Clinical CareProcessManagement of Chronic
Conditions--American Society of Hematology-----X--------------
--------------------------- Hematology: Multiple Myeloma:
Treatment with Bisphosphonates N/AN/AN/A069Percentage of
patients aged 18 years and older with a diagnosis of multiple
myeloma, not in remission, who were prescribed or received
intravenous bisphosphonate therapy within the 12-month
reporting periodEffective Clinical CareProcessManagement of
Chronic Conditions--American Society of Hematology-----X----
-------------------------------------Hematology: Chronic
Lymphocytic Leukemia (CLL): Baseline Flow
CytometryN/AN/AN/A070Percentage of patients aged 18 years
and older, seen within a 12-month reporting period, with a
diagnosis of chronic lymphocytic leukemia (CLL) made at any
time during or prior to the reporting period who had baseline
flow cytometry studies performed and documented in the
chartEffective Clinical CareProcessManagement of Chronic
Conditions--Physician Consortium for Performance
Improvement-----X-----------------------------------------
Prevention of Central Venous Catheter (CVC) - Related
Bloodstream Infections N/AN/A2726076Percentage of patients,
regardless of age, who undergo central venous catheter (CVC)
insertion for whom CVC was inserted with all elements of
maximal sterile barrier technique, hand hygiene, skin
preparation and, if ultrasound is used, sterile ultrasound
techniques followedPatient SafetyProcessHealthcare Associated
Infections X-American Society of AnesthesiologistsX----X-X---
----------------X------X------------Acute Otitis Externa (AOE):
Topical TherapyN/AN/A0653091Percentage of patients aged 2
years and older with a diagnosis of AOE who were prescribed
topical preparationsEffective Clinical CareProcessAppropriate
Use of HealthcareXXAmerican Academy of Otolaryngology –
Head and Neck SurgeryX----X------XXX---X-X-------------------
--X----Acute Otitis Externa (AOE): Systemic Antimicrobial
Therapy – Avoidance of Inappropriate

UseN/AN/A0654093Percentage of patients aged 2 years and
older with a diagnosis of AOE who were not prescribed
systemic antimicrobial therapyEfficiency and Cost
ReductionProcessAppropriate Use of HealthcareXXAmerican
Academy of Otolaryngology – Head and Neck SurgeryX----X---
---XXX---X-X---------------------X----Prostate Cancer:
Avoidance of Overuse of Bone Scan for Staging Low Risk
Prostate Cancer PatientsCMS129v8N/A0389102Percentage of
patients, regardless of age, with a diagnosis of prostate cancer
at low (or very low) risk of recurrence receiving interstitial
prostate brachytherapy, OR external beam radiotherapy to the
prostate, OR radical prostatectomy, OR cryotherapy who did not
have a bone scan performed at any time since diagnosis of
prostate cancerEfficiency and Cost
ReductionProcessAppropriate Use of HealthcareXXPhysician
Consortium for Performance Improvement--X--X------------------
-------XXX-------------Prostate Cancer: Combination Androgen
Deprivation Therapy for High Risk or Very High Risk Prostate
Cancer N/AN/A0390104Percentage of patients, regardless of
age, with a diagnosis of prostate cancer at high or very high risk
of recurrence receiving external beam radiotherapy to the
prostate who were prescribed androgen deprivation therapy in
combination with external beam radiotherapy to the prostate
Effective Clinical CareProcessManagement of Chronic
Conditions--American Urological Association Education and
Research-----X-------------------------X---------------Adult Major
Depressive Disorder (MDD): Suicide Risk
AssessmentCMS161v7N/A0104107Percentage 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
identifiedEffective Clinical CareProcessPrevention, Treatment,
and Management of Mental Health--Physician Consortium for
Performance Improvement--X---------XX-----------X--------------
-------Osteoarthritis (OA): Function and Pain Assessment
N/AN/AN/A109Percentage of patient visits for patients aged 21

years and older with a diagnosis of osteoarthritis (OA) with
assessment for function and painPerson and Caregiver-Centered
Experience and OutcomesProcessPatient's Experience of Care
X-American Academy of Orthopedic SurgeonsX----X-------X---
X---X-X-----------------------Preventive Care and Screening:
Influenza ImmunizationCMS147v8N/A0041110Percentage 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
immunizationCommunity/Population HealthProcessPreventive
Care--Physician Consortium for Performance ImprovementX-
XX-XX------XXX--X-X--X--------X--XXX---X-X-X-
Pneumococcal Vaccination Status for Older
AdultsCMS127v7N/AN/A111Percentage of patients 65 years of
age and older who have ever received a pneumococcal
vaccineCommunity/Population HealthProcessPreventive Care--
National Committee for Quality AssuranceX-X--XX------XXX--
X----X--------X--XXX---X-----Breast Cancer
ScreeningCMS125v7N/A2372112Percentage of women 50 - 74
years of age who had a mammogram to screen for breast
cancerEffective Clinical CareProcessPreventive Care--National
Committee for Quality AssuranceX-XX-X-------X-X-------X-----
----------------X-Colorectal Cancer
ScreeningCMS130v7N/A0034113Percentage of patients 50-75
years of age who had appropriate screening for colorectal
cancerEffective Clinical CareProcessPreventive Care--National
Committee for Quality AssuranceX-XX-X-------X---------X------
---------------X-Avoidance of Antibiotic Treatment in Adults
With Acute BronchitisN/AN/A0058116The percentage of adults
18–64 years of age with a diagnosis of acute bronchitis who
were not prescribed or dispensed an antibiotic
prescriptionEfficiency and Cost ReductionProcessAppropriate
Use of Healthcare XXNational Committee for Quality
Assurance-----X------XXX--------X------------------X----
Diabetes: Eye ExamCMS131v7N/A0055117Percentage of
patients 18 - 75 years of age with diabetes who had a retinal or

dilated eye exam by an eye care professional during the
measurement period or a negative retinal or dilated eye exam
(no evidence of retinopathy) in the 12 months prior to the
measurement periodEffective Clinical CareProcessManagement
of Chronic Conditions--National Committee for Quality
AssuranceX-X--X-------XX-X------------------------------
Coronary Artery Disease (CAD): Angiotensin-Converting
Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker
(ARB) Therapy - Diabetes or Left Ventricular Systolic
Dysfunction (LVEF < 40%)N/AN/A0066118Percentage of
patients aged 18 years and older with a diagnosis of coronary
artery disease seen within a 12 month period who also have
diabetes OR a current or prior Left Ventricular Ejection
Fraction (LVEF) < 40% who were prescribed ACE inhibitor or
ARB therapyEffective Clinical CareProcessManagement of
Chronic Conditions--American Heart Association-----X--X------
----------------------------X---Diabetes: Medical Attention for
NephropathyCMS134v7N/A0062119The percentage of patients
18-75 years of age with diabetes who had a nephropathy
screening test or evidence of nephropathy during the
measurement periodEffective Clinical CareProcessManagement
of Chronic Conditions--National Committee for Quality
Assurance--X--X-------XX--------X-------X----X----------
Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral
Neuropathy – Neurological
EvaluationN/AN/A0417126Percentage of patients aged 18 years
and older with a diagnosis of diabetes mellitus who had a
neurological examination of their lower extremities within 12
monthsEffective Clinical CareProcessPreventive Care--
American Podiatric Medical Association-----X-------XX--------
X---------------X-------Diabetes Mellitus: Diabetic Foot and
Ankle Care, Ulcer Prevention – Evaluation of
FootwearN/AN/A0416127Percentage of patients aged 18 years
and older with a diagnosis of diabetes mellitus who were
evaluated for proper footwear and sizingEffective Clinical
CareProcessPreventive Care--American Podiatric Medical

Association-----X---------------------------------X-------Preventive
Care and Screening: Body Mass Index (BMI) Screening and
Follow-Up PlanCMS69v7N/A0421128Percentage of patients
aged 18 years and older with a BMI documented during the
current encounter or during the previous twelve months AND
with a BMI outside of normal parameters, a follow-up plan is
documented during the encounter or during the previous twelve
months of the current encounter
Normal Parameters: Age 18 years and older BMI ≥ 18.5 and <
25 kg/m2Community/Population HealthProcessPreventive Care-
-Centers for Medicare & Medicaid ServicesX-X--X--X-X--
XXX-XX--X-X-X--XX-X---X---XX-----XDocumentation of
Current Medications in the Medical
RecordCMS68v8N/A0419130Percentage of visits for patients
aged 18 years and older for which the eligible professional or
eligible clinician 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
administrationPatient SafetyProcessMedication ManagementX-
Centers for Medicare & Medicaid ServicesX-X--XX-X-XX-
XXXXXX--XXXXX--XXXXX-XXXXX-XXX----Pain
Assessment and Follow-UpN/AN/A0420131Percentage of visits
for patients aged 18 years and older with documentation of a
pain assessment using a standardized tool(s) on each visit AND
documentation of a follow-up plan when pain is
presentCommunication and Care CoordinationProcessPatient's
Experience of Care X-Centers for Medicare & Medicaid
ServicesX----X-----------X---X---------X---X----XXX----
Preventive Care and Screening: Screening for Depression and
Follow-Up PlanCMS2v8N/A0418134Percentage 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 screenCommunity/Population
HealthProcessPrevention, Treatment, and Management of
Mental Health --…
4508 Final Quality Project
Part 4: Clinical Quality Measures for Eligible Providers
Overview
This activity focuses on the Quality Payment Program under
MACRA (Medicare Access and CHIP
Reauthorization Act). The activity uses online resources from
the CMS website. This activity
focuses on the Merit Based Incentive Payment System (MIPS)
and Advanced Alternative
Payment Models (APMs) for the eligible professional.
Resources
Go to the website CMS.gov (Centers for Medicare & Medicaid
Services) to complete the
following:
1. Watch an introduction to MIPS:
https://youtu.be/CN7_gBGXYq4
2. Watch a video about performance categories:
https://youtu.be/oTBkl07SRRo
a. Weights changed for 2018: Quality = 50% and Cost= 10%
b. Weights changed for 2019: Quality= 45% and Cost= 15%

Background
In the past, providers had several quality payment programs that
they participated in to receive
reimbursement from CMS. These included a Sustainable
Growth Rate, Value-For Service (Fee-
for-Service), Physician Quality Reporting, Meaningful Use, and
Value Based Modifiers. Under
the Medicare Access and CHIP Reauthorization Act of 2015
(MACRA), a new Quality Payment
Program was instituted that replaced all of the previous
programs. Providers are now
reimbursed under 1 of 2 programs, the Merit-Based Incentive
Payment System (MIPS) or the
Advanced Alternative Payment Models (APMs). Depending on
a providers eligibility, they will
be reimbursed using the metrics provided by the appropriate
program.
Under the MIPS program, providers are rated on a 100 point
scale. Their score will determine
reductions or incentives from the standard Medicare payment
rate. As MIPS is a recent
program, starting on January 1, 2017, the first few years are
seen as transitional. For 2017, a
minimum of 3 points was required in order to stay neutral and
not receive any payment
reductions. This raised in 2018 to 15 points to remain neutral
and not receive any reductions.
This is a two year process, so for those who reported for 2017,
CMS reviews the scores and data
in 2018, and then adjusts the payments for 2019. If a provider
falls below the threshold of 3
points for 2017, they will receive a payment reduction in 2019.
The table below shows the
payment structure for the first few years:

https://youtu.be/CN7_gBGXYq4
https://youtu.be/oTBkl07SRRo
Year Reported Year Adjusted Maximum Reduction Maximum
Increase
2017 2019 -4% +12%
2018 2020 -5% +15%
2019 2021 -7% +21%
2020+ 2022+ -9% +27%
There are bonuses available through the program for the first 5
years for the very top
performers. If a provider scores 70 or higher in 2017, they are
eligible for this bonus.
A key factor of the program is that it is “budget neutral”. This
means that the money received
from reductions is used to provide the incentives. While
providers may be eligible for an
amount up to the maximum increase, their increase will depend
on the amount of funds saved
from the reductions in payments.
MIPS-Eligible Providers:
• Doctors of Medicine (MD)
• Doctors of Osteopathy (DO)
• Doctors of Dental Surgery (DDS)
• Doctors of Dental Medicine (DMD)

• Doctors of Podiatric Medicine (DPM)
• Doctors of Optometry (OD)
• Doctors of Chiropractic (DC)
• Physicians Assistants (PA)
• Nurse Practitioners (NP)
• Clinical Nurse Specialists (CNS)
• Certified Registered Nurse Anesthetists (CRNA)
MIPS-Exempt Providers (will remain under Standard Medicare
Payment Rate)
• Those not on the above list (through at least the year 2021)
• Provider is in their first year of billing under Medicare (under
any entity)
• Provide bills ≤$90,000 in Medicare per year
• Provide sees ≤200 Medicare patients per year
• Providers in an Advanced APM (only those classified as
Advanced, see next section)
APMs
An alternative payment model gives added incentive payments
to high-quality and cost-
efficient care. Advanced APMs accept risk based on the quality
and effectiveness of care
provided like an Accountable Care Organization (ACO).
Advanced APMs base payment on
quality measures comparable to those in MIPS, require use of
certified EHR technology, and
bear more than nominal financial risk for monetary losses OR
are a Medical Home Model under

the CMS Innovation Center Authority. Advanced APMs are not
required to report under MIPS
due to the cost-sharing and risk structure already in place.
Providers in Advanced APMs will
instead earn 5% incentive payments in 2020 as long as they
receive 25% of Medicare Part B
payments of 20% Medicare patients.
Quality under MIPS
The Quality section under MIPS replaces the Physician Quality
Reporting System (PQRS) and the
quality component of the Value Based Modifier (VBM)
program. While this differs in name, it
uses the same measures. Under the MIPS Quality reporting,
providers are required to report
data on 6 measures or participate in a specialty measure set.
This must include 1 outcome
based measure or another high priority one if an outcome based
measure is not available. CMS
will compare the providers performance rate to a national
benchmark (which is established by
looking at the performance rate for the two prior years). The
benchmark is divided into deciles
which determines the providers score. An example is provided
below:
Measure 236: 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 (<140/90mmHg)
during the measurement period
Measure 236: Controlling High Blood Pressure (EHR
Submission)
Decile Quality Measure Benchmarks (%) Possible Points

Decile 3 51.46-56.82 3
Decile 4 56.83-60.94 4
Decile 5 60.95-64.67 5
Decile 6 64.68-68.17 6
Decile 7 68.18-72.00 7
Decile 8 72.01-76.25 8
Decile 9 76.26-82.20 9
Decile 10 >=82.21 10
If a provider reports that in 2019 they had 72.5% of patients
between 18-85 years old with a
diagnosis of hypertension and adequately controlled blood
pressure they would receive 8
points towards their MIPS Quality category.
There are 270 quality measures to choose from among two
types, outcome and high priority
measures. Remember, the provider must choose one outcome
measure if applicable. In order
to become more applicable to all types of providers, there are
currently 34 designated specialty
measure sets available including:
• Allergy/Immunology
• Anesthesiology
• Cardiology
• Gastroenterology
• Dermatology

• Emergency Medicine
• Pathology
• Mental/Behavioral Health
Activity 1 – Answer the following questions:
Determine if the following providers are considered “Eligible
Professionals” for MIPS. (Y/N)
1. A Doctor of Medicine (MD) who bills $200,000 in Medicare
payments per year
2. A Nurse Practitioner (NP) who has 125 Medicare patients
3. A Doctor of Medicine (MD) who is part of an Accountable
Care Organization that meets
Advanced APM status
4. A Physician Assistant (PA) who is a member of an APM, but
the APM is not considered
Advanced
Critical Thinking Questions
5. The quality category of MIPS decreased the past two years
from 60% down to 45%. The
cost category rose from 0% to 15%. What are the implications
of this for organizations?
Will quality be affected? (*Remember this is the percentage of
the score they are graded
on, not the facility’s actual score. So they are being graded with
less of an emphasis on
quality and more of an emphasis on cost*)

6. If providers are hospital based, are they exempt from MIPS?
Why?
7. A provider in your organization is upset about the changes to
the reimbursement
programs. They are upset CMS has imposed an all-new quality
payment program that
changes everything they were doing previously. They feel this
is too much new
information to learn. Do you agree? Why?
Activity 2
Now that you have a better understanding of MIPS, address the
following scenario:
You work for a multi-physician pediatric practice. Your
organization is preparing for the next
year and you are researching quality measures to address under
MIPS.
• Open the MIPS Quality Measures file
• Go to tab titled 2019 MIPS Quality Measures List
• Scroll to the left to find the Specialty Measure Sets, starting in
column T
• Locate and Filter the list for Pediatric Specialty Measures
• You will notice that there are 22 measures available to choose
from.

8. Which measure must we report on as it is an outcome
measure? (use the quality
number)
After reviewing the quality measures available you make the
decision to choose measures that
have previous deciles available so that you can perform a
comparison and set a quality plan for
the year.
• Open the 2019 MIPS Quality Benchmarks
• Select the MIPS Benchmark Results tab
• Locate all 22 measures from the previous file in the MIPS
Benchmark Results tab
9. Do all 22 Pediatric Specialty Measures have benchmarks to
compare against?
Your team completed an audit and found the results of several
measures for your facility. The
results are listed below in the chart. Compare the “% of charts
that meet the standard” with
the decile scores in the MIPS Benchmark Results tab and
determine the decile the facility’s
current score falls. Record the decile in the table below, you
will use these to answer the next
few questions. Some measures will be listed multiple times as
they have different submission
methods available. If available, use the eCQM method line. If

they do not have the ability to
use eCQM, use the MIPS CQM method line.
10. Does the facility have at least 5 measures that fall in the
10th decile?
The facility’s CEO has determined that the 2 lowest scoring
measures need to be addressed
with quality improvement plans.
11. Which measure falls into the lowest decile (use quality
number in answer)?
12. Which measure falls into the second lowest decile (use
quality number in answer)?
You will now choose one of these 2 measures to begin with. A
meeting has been scheduled to
discuss the quality improvement initiative.
13. What is the quality number of the measure you choose to
focus on first?
14. Why did you choose to address this measure first?

15. Outline a high-level action plan to take to the meeting.
(Must include steps of quality
improvement including use of quality improvement tools; this
does not have to be an in-
depth plan specific to the measure, it only needs to outline the
high-level steps of a QI
plan.)
Quality
Number
(Q#)
# of
Applicable
Charts
# of
Charts
that
meet
standard
% of charts
that meet
standard
Decile
65 70 68 97%
66 30 28 93%
91 55 55 100%
93 55 55 100%
110 395 99 25%
134 200 124 62%

239 395 218 55%
240 395 297 75%
305 25 4 16%
310 50 40 80%
379 395 12 3%
402 75 66 88%
This activity focuses on the Quality Payment Program under
MACRA (Medicare Access and CHIP Reauthorization Act). The
activity uses online resources from the CMS website. This
activity focuses on the Merit Based Incentive Payment System
(MIPS) and Adv...Resources
4508 Final Quality
Project
Part 3: Core Measures
The Hospital Inpatient Quality Reporting Program was
originally mandated by Section 501(b) of the
Medicare Prescription Drug, Improvement, and Modernization
Act (MMA) of 2003. This section of the
MMA authorized CMS to pay hospitals that successfully report
designated quality measures a higher
annual update to their payment rates. Initially, the MMA
provided for a 0.4 percentage point
reduction in the annual market basket (the measure of inflation
in costs of goods and services used
by hospitals in treating Medicare patients) update for hospitals
that did not successfully report. The
Deficit Reduction Act of 2005 increased that reduction to 2.0
percentage points. This was modified by
the American Recovery and Reinvestment Act of 2009 and the

Affordable Care Act of 2010, which
provided that beginning in fiscal year (FY) 2015, the reduction
would be by one-quarter of such
applicable annual payment rate update if all Hospital Inpatient
Quality Reporting Program
requirements are not met.
Under the Hospital Inpatient Quality Reporting Program, CMS
collects quality data from hospitals
paid under the Inpatient Prospective Payment System, with the
goal of driving quality improvement
through measurement and transparency by publicly displaying
data to help consumers make more
informed decisions about their health care. It is also intended to
encourage hospitals and clinicians to
improve the quality and cost of inpatient care provided to all
patients. The data collected through the
program are available to consumers and providers on the
Hospital Compare. Data for selected
measures are also used for paying a portion of hospitals based
on the quality and efficiency of care,
including the Hospital Value-Based Purchasing Program,
Hospital-Acquired Condition Reduction
Program, and Hospital Readmissions Reduction Program.
Additional measures are selected with wide
agreement from CMS, the hospital industry and public
stakeholders like The Joint Commission (TJC),
the National Quality Forum (NQF), and the Agency for
Healthcare Research and Quality (AHRQ).
Hospital Compare is a consumer-oriented website that provides
information on how well hospitals
provide recommended care to their patients. This information
can help consumers make informed
decisions about where to go for health care. Hospital Compare
allows consumers to select multiple

hospitals and directly compare performance measure
information related to heart attack, heart
failure, pneumonia, surgery and other conditions. These results
are organized by:
• General information
• Survey of patients' experiences
• Timely & effective care
• Complications
• Readmissions & deaths
• Use of medical imaging
• Payment & value of care
Hospital Compare was created through the efforts of Medicare
and the Hospital Quality Alliance
(HQA). The HQA: Improving Care Through Information was
created in December 2002. The HQA
was a public-private collaboration established in December
2002 to promote reporting on hospital
quality of care. The HQA consisted of organizations that
represented consumers, hospitals,
providers, employers, accrediting organizations, and federal
agencies. The HQA effort was
intended to make it easier for consumers to make informed
health care decisions and to support
efforts to improve quality in U.S. hospitals. Since it's inception,
many new measures and topics
have been displayed in the site.
• In 2005, the first set of 10 "core" process of care measures

were displayed on such topics
as heart attack, heart failure, pneumonia and surgical care.
• In March 2008, data from the Hospital Consumer Assessment
of Healthcare Providers and
Systems (HCAHPS) survey, also known as the CAHPS Hospital
Survey, was added to Hospital
Compare. HCAHPS provides a standardized instrumen t and data
collection methodology
for measuring patient's perspectives on hospital care. Also in
2008, data on hospital 30-
day mortality for heart attack and heart failure was displayed.
Later in 2008, mortality
rates for pneumonia was added.
• In 2009, CMS added data on hospital outpatient facilities,
which included outpatient
imaging efficiency data as well as emergency department and
surgical process of care
measures.
• 2010 saw the addition of 30-day readmission measures for
heart attack, heart failure and
pneumonia patients.
• In 2011, CMS began posting data on Hospital Associated
Infections (HAIs) received from
the Centers for Disease Control and Preventions (CDC) National
Healthcare Safety Network

(NHNS). The measure sets have been expanded to include
ICU's and other hospital wards.
• In 2012, we added the CMS readmission reduction program
and measures that were
voluntarily submitted by hospitals participating the American
College of Surgeons National
Surgical Quality Improvement Program. The three measures
are:
o Lower Extremity Bypass surgical outcomes
o Outcomes in Surgeries for Patients 65 Years of Age or Older
o Colon Surgery Outcomes
• Hospital Compare saw the addition of the Hospital Value
Based Purchasing program data in
2013.
CMS continues to evolve the website, with the addition of the
Overall Hospital Quality Star Rating
in July 2016 and the re-introduction of measure data from
Veterans Health Administration
Hospitals.

After reading and following the directions, you will be provided
with 10 questions. The key
performance data that you will discover is readily available to
the general public, your health care
competitors, insurance companies and managed care
organizations, and all stakeholders in your
organization. Hospital administrators (e.g., CEO, CFO, COO)
must be aware of this data, read it,
understand it, and act on it to improve the quality of care
provided in their organizations, which is
necessary to best serve their communities and maintain their
institution’s financial success and
competitive edge.
DIRECTIONS:
• Go to https://www.medicare.gov/hospitalcompare/ and read
through the general
information provided.
• Under the title “Hospital Compare,” type in the location
Orlando, FL.
• Click on “Find Hospitals.”
• When the hospitals within this area appear, select to compare
“Orlando Health Orlando
Regional Medical Center,” “AdventHealth Orlando,” and
“Health Central,” then
COMPARE.

• From the data displayed, locate the answers to the following
10 questions:
1. From the complications and death measures, which of the
following three hospitals
scored "Better than U.S. National Rate" on "Death Rate for
COPD Patients"?
a. Orlando Health Orlando Regional Medical Center
b. AdventHealth Orlando
c. Health Central
2. From the timely and effective care measures, which of the
following three hospitals
scored 90% on the process of care measure for “Healthcare
Workers Given Influenza
Vaccination”?
c. Health Central
3. From the survey of patients’ hospital experiences, in
comparing the three hospitals, what
did you find was the national average for all reporting hospitals
in the United States for the
“percent of patients who reported that their nurses ‘always’
communicated well.”
a. 77%
b. 76%
c. 81%

d. 78%
e. 79%
https://www.medicare.gov/hospitalcompare/
4. From the timely and effective measures, which of the
following three hospitals scored the
highest on the process of care measure for percent of
““Percentage of patients who received
appropriate care for severe sepsis and septic shock”?
c. Orlando Health
5. From the survey of patients’ hospital experiences, which of
the following three hospitals scored
the lowest percentage on “Patients who reported YES, they
would definitely recommend the
hospital (to friends and family).”?
c. Health Central
6. From the complications of care measures, which of the
following three hospitals scored Better
than the National Benchmark for “Surgical site infections (SSI)
from colon surgery”?

c. Health Central
7. From the timely and effective measures, which of the
following three hospitals had the lowest
percentage on the measure for percent of “Outpatients who had
a follow-up mammogram,
breast ultrasound, or breast MRI within the 45 days after a
screening mammogram ”?
c. Health Central
8. From the payment and value of care measures, which of the
following three hospitals had
Greater than the National Average Payment on the measure for
“Payment for heart attack
patients”?
c. Health Central
9. From the unplanned hospital visits measures, what did you
find was the national rate for all
reporting hospitals in the United States for the “Rate of
readmission after discharge from
hospital (hospital-wide).”

a. 15.3%
b. 16.3%
c. 14.3%
10. From the timely and effective care measures, what did you
find was the rate for the state of
Florida for all reporting hospitals for the “Percent of mothers
whose deliveries were scheduled
too early (1-2 weeks early), when a scheduled delivery was not
medically necessary.”
a. 0%
b. 1%
c. 2%

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