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Systematic assessment of face validity of performance measure score as an indicator of quality or resource use (i.e., the score is an accurate reflection of performance on quality or resource use and can distinguish good from poor performance).

Valid for Measure Submission

Breast Cancer Screening Recall Rates

  • The Breast Cancer Screening Recall Rates measure calculates the percentage of beneficiaries with mammography or digital breast tomosynthesis (DBT) screening studies that are followed by a diagnostic mammography, DBT, ultrasound, or magnetic resonance imaging (MRI) of the breast in an outpatient or office setting within 45 days.

    CBE ID
    4220

Continuity of Care After Inpatient or Residential Treatment for Substance Use Disorder

  • The Continuity of Care After Inpatient or Residential Treatment for Substance Use Disorder measure evaluates the percentage of discharges from inpatient or residential treatment for diagnoses of substance use disorders (SUD) among Medicaid or Medicare-Medicaid beneficiaries, aged 18 years and older, which were followed by a treatment service for SUD.

    CBE ID
    3453

Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy

  • This measure was developed to improve the quality of care delivered to patients undergoing outpatient colonoscopy procedures. The Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy Measure, estimates a facility-level rate of risk-standardized, all-cause, unplanned hospital visits within seven days of a colonoscopy procedure performed at a hospital outpatient department (HOPD) or ambulatory surgical center (ASC) among Medicare Fee-for-Service (FFS) patients aged 65 years and older.

    CBE ID
    2539

Facility-Level 7-Day Hospital Visits after General Surgery Procedures Performed at Ambulatory Surgical Centers

  • This measure was developed to improve the quality of care delivered to patients undergoing general surgery procedures in an ambulatory surgical center (ASC). To assess quality, the measure calculates the risk-standardized rate of return to a hospital for an acute, unplanned hospital visit within seven days of qualified general surgery procedures performed at an ambulatory surgical center (ASC) among Medicare Fee-For-Service (FFS) patients aged 65 years and older.

    CBE ID
    3357

Global Malnutrition Composite Score

  • This composite measure assesses the percentage of hospitalizations for adults aged 18 years and older at the start of the inpatient encounter during the measurement period with a length of stay equal to or greater than 24 hours who received optimal malnutrition care during the current inpatient hospitalization where care performed was appropriate to the patient's level of malnutrition risk and severity.

    CBE ID
    3592e

Home and Community-Based Services (HCBS) Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Measures

  • The Home and Community-Based Services (HCBS) Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey consists of 19 measures that assess the experiences of Medicaid participants’ age 18 and older receiving long-term services and supports (LTSS). The measures report a case-mix adjusted top-box score. Measure scores are calculated based on participant responses to a cross-disability survey about their experiences with the LTSS they receive in the community, delivered through a Medicaid-funded HCBS program.

    CBE ID
    2967

Hospital Visits after Orthopedic Ambulatory Surgical Center Procedures

  • This measure was developed to improve the quality of care delivered to patients undergoing orthopedic procedures in an ambulatory surgical center (ASC). To assess quality, the measure calculates the risk-standardized rate of acute, unplanned hospital visits within seven days of qualified orthopedic surgeries or procedures performed at an ASC among Medicare fee-for-service (FFS) patients aged 65 years and older. An unplanned hospital visit is defined as an emergency department (ED) visit, observation stay, or unplanned inpatient admission.

    CBE ID
    3470

Hospital Visits After Urology Ambulatory Surgical Center Procedures

  • This measure was developed to improve the quality of care delivered to patients undergoing urology procedures in an ambulatory surgical center (ASC). The measure estimates a facility-level rate of risk-standardized, all-cause, unplanned hospital visits within seven days of a urology surgery at an ASC among Medicare fee-for-service (FFS) patients aged 65 years and older. An unplanned hospital visit is defined as an emergency department (ED) visit, observation stay, or unplanned inpatient admission. 

    CBE ID
    3366

Hospital-Wide 30-Day, All-Cause, Unplanned Readmission Rate (HWR) for the Merit-Based Incentive Payment System (MIPS) Eligible Clinician Groups

  • The 30-day Hospital-Wide, All-Cause Unplanned Readmission (HWR) Rate for the Merit-based Incentive Payment System (MIPS) Groups measure is a risk-standardized readmission rate for beneficiaries age 65 or older who were hospitalized and experienced an unplanned readmission for any cause to a short-stay acute-care hospital within 30 days of discharge. The measure attributes readmissions to up to three MIPS participating clinician groups, as identified by their Medicare Taxpayer Identification Number (TIN), and assesses each group’s readmission rate.

    CBE ID
    3495