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Hospital-Wide All-Cause Unplanned Readmission Measure (HWR)

  • This measure estimates a hospital-level, risk-standardized readmission rate (RSRR) of unplanned, all-cause readmission within 30 days of discharge from an index admission with an eligible condition or procedure. The measure reports a single summary RSRR, derived from the volume-weighted results of five different models, one for each of the following specialty cohorts based on groups of discharge condition categories or procedure categories: surgery/gynecology, general medicine, cardiorespiratory, cardiovascular, and neurology.

    CBE ID
    3656

Clinician-Level and Clinician Group-Level Total Hip Arthroplasty and/or Total Knee Arthroplasty (THA and TKA) Patient-Reported Outcome-Based Performance Measure (PRO-PM)

  • This patient-reported outcome-based performance measure uses the same measure specifications as the NQF-endorsed (NQF # 3559) hospital-level risk-standardized improvement rate (RSIR) following elective primary THA/TKA with the following exception: this measure attributes the outcome to a clinician or clinician group. Specifically, this measure will estimate a clinician-level and/or a clinician group-level RSIR following elective primary THA/TKA for Medicare fee-for-service (FFS) patients 65 years of age and older.

    CBE ID
    3639

Quarterly Reporting of COVID-19 Vaccination Coverage among Healthcare Personnel

  • This quarterly measure identifies the average percentage of healthcare personnel (HCP) who are considered up to date with recommended COVID-19 vaccines among the total number of HCP who regularly work in the facility.  

    The measure is reported for a quarter (3-month period). The quarterly COVID-19 vaccination coverage is determined by selecting one week per month and calculating the percentage of HCP who are considered up to date with recommended COVID-19 vaccines, then averaging 3 weekly percentages (one week from each of the 3 months in the quarter).

    CBE ID
    3636

Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Clinician Level)

  • This electronic clinical quality measure (eCQM) provides a standardized method for monitoring the performance of diagnostic CT to discourage unnecessarily high radiation doses, a risk factor for cancer, while preserving image quality. It is expressed as a percentage of eligible CT exams that are out-of-range based on having either excessive radiation dose or inadequate image quality, relative to evidence-based thresholds based on the clinical indication for the exam.

    CBE ID
    3633e

Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels Measure

  • The Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for patients who undergo surgery for lumbar spine fusion during the performance period. The measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician.

    CBE ID
    3626

Non-Emergent Coronary Artery Bypass Graft (CABG) Measure

  • The Non-Emergent CABG episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for patients who undergo a CABG procedure during the performance period. The measure score is the clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician. This procedural measure includes costs of services that are clinically related to the attributed clinician’s role in managing care during each episode from 30 days prior to the clinical event that opens, or “triggers,” the episode through 90 days after the trigger.

    CBE ID
    3625

Elective Primary Hip Arthroplasty Measure

  • The Elective Primary Hip Arthroplasty episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for patients who receive an elective primary hip arthroplasty during the performance period. The measure score is a clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician.

    CBE ID
    3623

Composite weighted average for 3 CT Exam Types: Overall Percent of CT exams for which Dose Length Product is at or below the size-specific diagnostic reference level (for CT Abdomen-pelvis with contrast/single phase scan, CT Chest without contrast/single

  • Measure title continued: Composite weighted average for 3 CT Exam Types: Overall Percent of CT exams for which Dose Length Product is at or below the size-specific diagnostic reference level (for CT Abdomen-pelvis with contrast/single phase scan, CT Chest without contrast/single phase scan and CT Head/Brain without contrast/single phase scan)

    CBE ID
    3621

Adult Immunization Status

  • The percentage of adults 19 years of age and older who are up-to-date on Advisory Committee on Immunization Practice (ACIP) recommended routine vaccines for influenza, tetanus and diphtheria (Td) or tetanus, diphtheria and acellular pertussis (Tdap), zoster and pneumococcal.

    CBE ID
    3620