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Hospital: Outpatient

Valid for Measure Submission

Patient Understanding of Key Information Related to Recovery After a Facility-Based Outpatient Procedure or Surgery, Patient Reported Outcome-Based Performance Measure

This measure assesses how well facilities provide clear, personalized discharge instructions to patients aged 18 years or older who had a surgery or procedure at an outpatient facility. It uses a 9-item survey to obtain patient’s feedback on 3 domains: applicability; medications; and daily activities. Facility scores are calculated by averaging the individual patient scores for each facility.

CBE ID
4210

Rate of Timely Follow-up on Abnormal Screening Mammograms for Breast Cancer Detection

This electronic Clinical Quality Measure (eCQM) reports the percentage of female patients aged 40 to 75 years with at least one abnormal screening (BI-RADS 0) or screening-to-diagnostic (BI-RADS 4, 5) mammogram during the measurement period (i.e., calendar year) who received timely diagnostic resolution defined as either follow-up imaging with negative/benign/probably benign results or a breast biopsy within 60 days after their index (i.e., first) abnormal screening mammogram.

CBE ID
4700e

Rate of Timely Follow-up on Positive Stool-based Tests for Colorectal Cancer Detection

This electronic Clinical Quality Measure (eCQM) reports the percentage of patients aged 45 to 75 years with at least one positive stool-based colorectal cancer screening test (i.e., high-sensitivity guaiac fecal occult blood test, fecal immunochemical test, or Cologuard) during the measurement period (i.e., calendar year) who completed a colonoscopy within 180 days after their index (i.e., first) positive stool-based test result date.

CBE ID
4705e

Risk-standardized Complication Rate (RSCR) following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) for Eligible Clinicians and Eligible Clinician Groups

The primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) complication measure assesses risk-standardized complication rates (RSCRs) for individual clinicians or groups of clinicians to improve the quality of care delivered to their patients.  

This re-specified measure includes THA/TKA procedures performed in both inpatient and outpatient (hospital outpatient department and Ambulatory Surgery Centers [ASC]) settings among eligible Medicare Fee-For-Service (FFS) beneficiaries who are at least 65 years of age. 

CBE ID
3493

Timely Follow-Up After Acute Exacerbations of Chronic Conditions

This is a measure of follow-up clinical visits for patients with chronic conditions who have experienced an acute exacerbation of one of six conditions (eight categories) of interest (coronary artery disease [CAD] {high or low acuity}, hypertension {high or medium acuity}, heart failure [HF], diabetes, asthma, and chronic obstructive pulmonary disease [COPD]) and are among adult Medicare Fee-for-Service (FFS) beneficiaries who are attributed to entities participating in the CMMI Accountable Care Organization (ACO) Realizing Equity, Access, and Community Health (REACH) model.

CBE ID
3455

Use of Pharmacotherapy for Opioid Use Disorder

The Use of Pharmacotherapy for Opioid Use Disorder measure evaluates the percentage of Medicaid or Medicare-Medicaid participants, aged 18 years and older, who have been diagnosed with an opioid use disorder (OUD) who filled a prescription for, were administered, or dispensed, a Food and Drug Administration (FDA)-approved medication to treat or manage OUD during the measurement year.

CBE ID
3400