Assessing the quality and efficiency impact of the use of endorsed measures and making that assessment available to the public at least every three years. (The 2012 and 2015 editions of that report and related documents are available at the .) Fulfilling DHHS’s Requirement to Make Its Measures under Consideration Publicly Available The attached MUC List, which is compiled by CMS, will be posted on the . This posting will satisfy an important requirement of the pre-rulemaking process by making public the quality and efficiency measures described in section 1890(b)(7)(B) of the Act that DHHS is considering for use under Medicare. Additionally, the CMS website will indicate that the MUC list is being posted on the NQF website. Included Measures This MUC List identifies the quality and efficiency measures under consideration by the Secretary of DHHS for use in certain Medicare quality programs. Measures that appear on this list but are not selected for use under the Medicare program for the current rulemaking cycle will remain under consideration for future rulemaking cycles. They remain under consideration only for purposes of the particular program or other use for which CMS was considering them when they were placed on the MUC List. These measures can be selected for those previously considered purposes and programs/uses in future rulemaking cycles. This MUC List as well as prior year MUC Lists and Measure Applications Partnership (MAP) Reports can be found at: .
Intermediate Outcome: Refers to a change produced by a health care intervention that leads to a longer-term outcome (e.g., a reduction in blood pressure is an intermediate outcome that leads to a reduction in the risk of longer-term outcomes such as cardiac infarction or stroke). Outcome: The health status of a patient (or change in health status) resulting from healthcare, which can be desirable or adverse. Patient Reported Outcome: Refers to a measure of a patient's feelings or what they are able to do as they are dealing with diseases or conditions. These types of measures may include Patient Reported Outcome Measures (PROMs) and Patient Reported Outcome-Based Performance Measures (PRO-PMs). Process: A healthcare service provided to, or on behalf of, a patient. This may include, but is not limited to, measures that address adherence to recommendations for clinical practice on evidence or consensus. Structure: Features of a healthcare organization or clinician relevant to the capacity to provide healthcare. This may include, but is not limited to, measures that address health IT infrastructure, provider capacity, systems, and other healthcare infrastructure supports. Measure Steward: Refers to the party responsible for updating and maintaining a measure. CMS Program(s): Refers to the applicable Medicare program(s) that may adopt the measure through rulemaking in the future. Measures under Consideration trial
MUC ID Measure Title Description Measure Type Measure Steward CMS Program(s) Continuity of Pharmacotherapy for Opioid Use Disorder Percentage of adults with pharmacotherapy for opioid use disorder (OUD) who have at least 180 days of continuous treatment Process RAND Corporation MIPS Average change in functional status following lumbar spine fusion surgery For patients age 18 and older undergoing lumbar spine fusion surgery, the average change from pre-operative functional status to one year (nine to fifteen months) post-operative functional status using the Oswestry Disability Index (ODI version 2.1a) patient reported outcome tool. Patient Reported Outcome MN Community Measurement MIPS Average change in functional status following total knee replacement surgery For patients age 18 and undergoing total knee replacement surgery, the average change from pre-operative functional status to one year (nine to fifteen months) post-operative functional status using the Oxford Knee Score (OKS) patient reported outcome tool. Patient Reported Outcome MN Community Measurement MIPS Average change in functional status following lumbar discectomy laminotomy surgery For patients age 18 and older undergoing lumbar discectomy laminotomy surgery, the average change from pre-operative functional status to three months (6 to 20 weeks) functional status using the Oswestry Disability Index (ODI version 2.1a) patient reported outcome tool. Patient Reported Outcome MN Community Measurement MIPS Appropriate Use of DXA in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture Percentage of female patients aged 50 to 64 without select risk factors for osteoporotic fracture who received an for a dual-energy x-ray absorptiometry (DXA) scan during the measurement period. Process/Overuse Centers for Medicare & Medicaid Services MIPS
Medication Reconciliation for Patients Receiving Care at Dialysis Facilities Percentage of patient-months for which medication reconciliation* was performed and documented by an eligible professional.** * “Medication reconciliation” is defined as the process of creating the most accurate list of all home medications that the patient is taking, including name, indication, dosage, frequency, and route, by comparing the most recent medication list in the dialysis medical record to one or more external list(s) of medications obtained from a patient or caregiver (including patient-/caregiver-provided “brown bag” information), pharmacotherapy information network (e.g., Surescripts), hospital, or other provider. ** For the purposes of medication reconciliation, “eligible professional” is defined as: physician, RN, ARNP, PA, pharmacist, or pharmacy technician. Process/Care Coordination KCQA ESRD QIP Average change in leg pain following lumbar spine fusion surgery For patients age 18 and older undergoing lumbar spine fusion surgery, the average change from pre-operative leg pain to one year (nine to fifteen months) post-operative leg pain using the Visual Analog Scale (VAS) patient reported outcome tool. Patient Reported Outcome MN Community Measurement MIPS 30-Day Unplanned Readmissions for Cancer Patients 30-Day Unplanned Readmissions for Cancer Patients measure is a cancer-specific measure. It provides the rate at which all adult cancer patients covered as Fee-for-Service Medicare beneficiaries have an unplanned readmission within 30 days of discharge from an acute care hospital. The unplanned readmission is defined as a subsequent inpatient admission to a acute care hospital, which occurs within 30 days of the discharge date of an eligible index admission and has an admission type of “emergency” or “urgent.” Outcome Seattle Cancer Care Alliance PCHQR term
allowed contraindications or exceptions are present Hospital-Wide Risk Standardized Mortality Measure This measure estimates hospital-level, mortality rate (RSMR) for Medicare fee-for-service (FFS) patients who are between the ages of 65 and 94. Death is defined as death from any cause within 30 days after the index admission date. This is a claims-based version of the Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Measure. Outcome Centers for Medicare & Medicaid Services HIQR Hybrid All-Cause Risk Standardized Mortality Measure This measure estimates mortality rate (RSMR) for Medicare fee-for-service (FFS) patients who are between the ages of 65 and 94. Death is defined as death from any cause within 30 days after the index admission date. The measure is referred to as a hybrid because it will use Medicare (FFS) administrative claims to derive the cohort and outcome, and claims and clinical electronic health record (EHR) data for risk adjustment. Outcome Centers for Medicare & Medicaid Services HIQR; EHR Incentive/EH/CAH Hospital Harm Performance Measure: Opioid Related Adverse Respiratory Events This measure will assess opioid related adverse respiratory events in the hospital setting. The goal for this measure is to assess the rate at which naloxone is given for opioid related adverse respiratory events that occur in the hospital setting, using a valid method that reliably allows comparison across hospitals. Outcome Centers for Medicare & Medicaid Services HIQR; EHR Incentive/EH/CAH Diabetes A1c Control (< 8.0) The percentage of patients 18-75 years of age who had a diagnosis of type 1 or type 2 diabetes and whose most recent HbA1c during the measurement period was less than 8.0 mg/dL. Intermediate Outcome MN Community Measurement MIPS; MSSP Lumbar Spine Imaging for Low Back Pain This measure calculates the percentage of CT (computed tomography) or MRI (magnetic resonance imaging) studies of the lumbar spine with a diagnosis of low back pain on the imaging claim and for which the patient did not have Process/Overuse Centers for Medicare & Medicaid Services HOQR standardized
ST-Elevation Myocardial Infarction (STEMI) with Percutaneous Coronary Intervention (PCI) The STEMI with PCI cost measure applies to clinicians who manage the inpatient care of Medicare beneficiaries hospitalized for a STEMI requiring PCI. The cost measure is calculated by determining the risk-adjusted episode cost, averaged across all of a clinician’s episodes during the measurement period. The cost of each episode is the sum of the cost to Medicare for services performed by the attributed clinician and other healthcare providers during the episode window (from the trigger date to 30 days after the trigger date). Cost/Resource Use Centers for Medicare & Medicaid Services MIPS Revascularization for Lower Extremity Chronic Critical Limb Ischemia The Revascularization for Extremity Chronic Critical Limb Ischemia cost measure applies to clinicians who perform elective revascularization for lower extremity chronic critical limb ischemia for Medicare beneficiaries. The cost measure is calculated by determining the episode cost, averaged across all of a clinician’s episodes during the measurement period. The cost of each episode is the sum of the cost to Medicare for services performed by the attributed clinician and other healthcare providers during the episode window (from 30 days prior to the trigger date to 90 days after the trigger date). Cost/Resource Use Centers for Medicare & Medicaid Services MIPS Zoster (Shingles) Vaccination The percentage of patients 60 years of age and older who have a Varicella Zoster (shingles) vaccination Process PPRNet MIPS Patient reported and clinical outcomes following ilio-femoral venous stenting Composite outcome assessment documenting an improvement in the clinical evaluation of patients using the venous clinical severity score (VCSS) and on a disease-specific PRO survey instrument following ilio-femoral venous stenting Composite Outcome Society of Interventional Radiology; MIPS Elective Outpatient Percutaneous The Elective Outpatient PCI cost measure applies to clinicians who perform elective Cost/Resource Use Centers for Medicare & MIPS adjusted
- Marfan's syndrome - Lupus Medication Reconciliation for Patients Receiving Care at Dialysis Facilities Number of for which medication reconciliation was performed and documented by an eligible professional during the reporting period. The medication reconciliation MUST: - Include the name or other unique identifier of the eligible professional; AND - Include the date of the reconciliation; AND - Address ALL known home medications (prescriptions, herbals, vitamin/mineral/dietary (nutritional) supplements, and medical marijuana); AND - Address for EACH home medication: Medication name(1), indication(2), dosage(2), frequency(2), route of administration(2), start and end date (if number of patient-months for all patients permanently assigned to a dialysis facility during the reporting period. DENOMINATOR STEP 1. Identify all in-center and home hemodialysis and peritoneal dialysis patients permanently assigned to the dialysis facility in the given calculation month. DENOMINATOR STEP 2. For all patients included in the denominator in the given calculation month in “Denominator Step 1”, identify and remove all in-center hemodialysis patients who received < 7 dialysis treatments in the calculation month. DENOMINATOR STEP 3. Repeat “Denominator Step 1” and “Denominator Step 2” for each month of the one-year reporting period. In-center patients who receive < 7 hemodialysis treatments in the facility during the reporting month. As detailed in “Denominator Step 2” above, transient patients, defined as in-center patients who receive < 7 hemodialysis treatments in the facility during the reporting month, are excluded from the measure.
period. AND At least one established patient office visit (Established Pt Diabetes & Vasc Value Set) for any reason during the measurement period during measurement period - Documentation that diagnosis was coded in error - Patient had only urgent care visits during the measurement period Lumbar Spine Imaging for Low Back Pain CT or MRI of the lumbar spine studies with a diagnosis of low back pain (from the denominator) without the patient having claims-based evidence of prior antecedent conservative therapy. CT or MRI of the lumbar studies with a diagnosis of low back pain on the imaging claim. Indications for measure exclusion include any patients with diagnosis codes associated with: cancer, congenital spine & spinal cord malformations, human immunodeficiency virus (HIV), infectious conditions, inflammatory and autoimmune disorders, intraspinal abscess, intravenous drug abuse, lumbar spine surgery, neoplastic abnormalities, neurologic impairment, postoperative fluid collections and soft-tissue changes, spinal abnormalities associated with scoliosis, spinal cord infarctions, spinal vascular malformations, syringohydromyelia, treatment fields for radiation therapy, trauma, and unspecified immune deficiencies.
Hospital Visits following General Surgery Ambulatory Surgical Center Procedures For each ASC, the numerator of the ratio is the number of hospital visits predicted for the ASC’s patients, accounting for its observed rate, the number and complexity of general surgery procedures performed at the ASC, and the case mix. The denominator is the number of hospital visits expected nationally for the ASC’s case/procedure mix. Procedures for patients who survived at least 7 days, but were not continuously enrolled in Medicare FFS Parts A and B in the 7 days after the surgery are excluded. These patients are excluded to ensure all patients have full data available for outcome assessment. Ischemic Vascular Disease Use of Aspirin or Medication Denominator patients with documentation that the patient was on daily aspirin or medication during the measurement period, unless allowed contraindications or exceptions are present. 18 years or older at the start of the measurement period AND less than 76 years at the end of the measurement period AND Patient had a diagnosis of ischemic vascular disease (Ischemic Vascular Disease Value Set) with any contact during the current or prior measurement period OR had ischemic vascular disease (Ischemic Vascular Disease Value Set) present on an active problem list at any time during the measurement period. AND At least one established patient office visit (Established Pt Diabetes & Vasc Value Set) for any reason during the measurement period The following exclusions are allowed to be applied to the eligible population: - Patient was a permanent nursing home resident at any time during the measurement period - Patient was in hospice or receiving palliative care at any time during the measurement period - Patient died prior to the end of the measurement period - Documentation that diagnosis was coded in error - Patient had only urgent care visits during the measurement period Routine Cataract Removal with Intraocular Lens (IOL) Implantation The numerator of the Routine Cataract Removal with IOL Implantation cost The cost measure denominator is the total number of episodes from the Routine Cataract Removal with IOL Implantation The following episode-level exclusions apply: (a) The beneficiary has a primary payer other than Medicare for any
particular facility, the patient must meet one of the two criteria: - The patient is on the kidney or transplant waitlist or - The patient has received a living donor transplant the first ESRD service until the patient dies or the data collection cutoff date is reached. For each patient, a new record is created each time he/she changes facility or treatment modality. Each record represents a time period associated with a specific modality and dialysis facility. CROWNWeb is the primary basis for placing patients at dialysis facilities and dialysis claims are used as an additional source. Information regarding first ESRD service date, death, and transplant is obtained from CROWNWeb (including the CMS Medical Evidence Form (Form CMS-2728) and the Death Notification Form (Form and Medicare claims, as well as the Organ Procurement and Transplant Network (OPTN) and the Social Security Death Master File. The denominator of the SWR for a given facility represents the number of expected events (waitlistings or living-donor transplants) at the facility. The estimation of this expected number accounts for the time and risk profile of each patient. The risk profile is quantified through covariate effects estimated through Cox Medical Evidence Form as institutionalized and SNF/Long Term Care Facility, respectively, or who had evidence of admission to a skilled nursing facility based on the MDS before their first service date and were not discharged prior to initiation of dialysis were identified as SNF patients. Hospice status is determined from a separate CMS file that contains final action claims submitted by Hospice providers. Once a beneficiary elects Hospice, all Hospice related claims will be found in this file, regardless if the beneficiary is in Medicare or in a Medicare managed care plan. Patients are identified as receiving hospice care if they have any final action claims submitted to Medicare by hospice providers in the current month. up
regression (Cox, 1972; SAS Institute Inc., 2004; Kalbfleisch and Prentice, 2002; Collett, 1994). Colonoscopy The numerator of the Screening/Surveillance Colonoscopy cost measure is the sum of the ratio of observed to expected cost to Medicare for all episodes attributed to a clinician. This is then multiplied by the national average observed episode cost to generate a dollar figure. The cost measure denominator is the number of episodes from the Screening/Surveillance Colonoscopy episode group attributed to a clinician. The following episode-level exclusions apply: (a) The beneficiary has a primary payer other than Medicare for any amount of time overlapping the episode window or in the 120 days prior to the episode trigger day. (b) No attributed clinician is found for the episode. (c) The episode is not attributed to at least one main clinician. (d) The beneficiary’s date of birth is missing. (e) The beneficiary’s death date occurred before the trigger date. (f) The beneficiary’s date occurred before the episode ended. (g) The beneficiary was not enrolled in Medicare Part A and B for the entirety of the 120-day lookback period plus episode window, or is enrolled in Part C for any part of the lookback period plus episode window. (h) The episode trigger was not performed in an office, IP, OP, or ASC setting based on its place of service. CoreQ: Short Stay Discharge Measure The numerator is the sum of the individuals in the facility that have an average satisfaction score of greater than or The denominator includes all of the patients that are admitted to the SNF, regardless of payor source, for post-acute care, that are discharged within 100 days; Exclusions made at the time of sample selection and the following: (1) Patients who died during SNF stay; (2) Patients discharged to a hospital, another SNF, psychiatric
documentation of the occurrence of an HIV test between their 15th and 66th birthdays and before the end of the measurement period who had an outpatient visit during the measurement period patients diagnosed with HIV to the start of the measurement period APPENDIX B: MEASURE RATIONALES Legend for Measure Rationales MUC ID: Gives users an identifier to refer to a measure. Measure Title: Refers to the title of the measure. Rationale: Refers to the rationale for the measure, the peer-reviewed evidence justifying the measure, and/or the impact the measure is anticipated to achieve. Measure Rationales MUC ID Measure Title Rationale Continuity of Pharmacotherapy for Opioid Use Disorder In this section, first we summarize the evidence from the systematic reviews and meta-analyses cited by the 2015 “VA/DoD clinical practice guideline for the management of substance use disorders” that support the recommendations related to pharmacotherapy for treatment of opioid use disorder. Following that, we present evidence in support of the measure definition: using a minimum of 6 months’ duration of pharmacotherapy, and no gaps of more than seven days.
MUC ID CMS Program Measure Title Priority SNF QRP CoreQ: Short Stay Discharge Measure Patient and Family Engagement; Communication and Care Coordination Skilled Nursing Facility Value-Based Purchasing Program MUC ID CMS Program Measure Title Priority No new candidate measures were approved for consideration this program in the current year.
Ambulatory Care and Meaningful Use Measures Programs Medicare Shared Savings Program MUC ID CMS Program Measure Title Priority MSSP Optimal Diabetes Care Effective Prevention and Treatment MSSP Diabetes A1c Control (< 8.0) Effective Prevention and Treatment MSSP Ischemic Vascular Disease Use of Aspirin or Anti-platelet Medication Effective Prevention and Treatment Merit-Based Incentive Payment System (MIPS) MUC ID CMS Program Measure Title Priority MIPS Continuity of Pharmacotherapy for Opioid Use Disorder Effective Prevention and Treatment MIPS Average change in functional status following lumbar spine fusion surgery Patient and Family Engagement MIPS Average change in functional status following total knee replacement surgery Patient and Family Engagement MIPS Average change in functional status following lumbar discectomy laminotomy surgery Patient and Family Engagement MIPS Appropriate Use of DXA in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture Making Care Affordable MIPS Average change in leg pain following lumbar spine fusion surgery Patient and Family Engagement MIPS Optimal Diabetes Care Effective Prevention and Treatment MIPS Optimal Vascular Care Effective Prevention and Treatment MIPS Diabetes A1c Control (< 8.0) Effective Prevention and Treatment MIPS Ischemic Vascular Disease Use of Aspirin or Anti-platelet Medication Effective Prevention and Treatment MIPS Routine Cataract Removal with Intraocular Lens (IOL) Implantation Making Care Affordable MIPS International Prostate Symptom Score (IPSS) or American Urological Association-Symptom Index (AUA-SI) change 6-12 months after diagnosis of Benign Prostatic Hyperplasia Patient and Family Engagement MIPS Screening/Surveillance Colonoscopy Making Care Affordable MIPS Knee Arthroplasty Making Care Affordable
MIPS ST-Elevation Myocardial Infarction (STEMI) with Percutaneous Coronary Intervention (PCI) Making Care Affordable MIPS Revascularization for Lower Extremity Chronic Critical Limb Ischemia Making Care Affordable MIPS Zoster (Shingles) Vaccination Effective Prevention and Treatment MIPS Patient reported and clinical outcomes following ilio-femoral venous stenting Patient and Family Engagement MIPS Elective Outpatient Percutaneous Coronary Intervention (PCI) Making Care Affordable MIPS Intracranial Hemorrhage or Cerebral Infarction Making Care Affordable MIPS Simple Pneumonia with Hospitalization Making Care Affordable MIPS HIV Screening Effective Prevention and Treatment
Hospital Measures Programs Ambulatory Surgical Center Quality Reporting MUC ID CMS Program Measure Priority ASCQR Hospital Visits following General Surgery Ambulatory Surgical Center Procedures Making Care Safer; Communication and Care Coordination End-Stage Renal Disease Quality Incentive Program MUC ID CMS Program Measure Title Priority ESRD QIP Medication Reconciliation for Patients Receiving Care at Dialysis Facilities Making Care Safer; Communication and Care Coordination ESRD QIP Percentage of Prevalent Patients Waitlisted (PPPW) Effective Prevention and Treatment ESRD QIP Standardized First Kidney Transplant Waitlist Ratio for Incident Dialysis Patients (SWR) Effective Prevention and Treatment Hospital-Acquired Condition Reduction Program MUC ID CMS Program Measure Title Priority No new candidate measures were approved for consideration under this program in the current year. Hospital Inpatient Quality Reporting MUC ID CMS Program Measure Title Priority HIQR Hospital-Wide All-Cause Risk Standardized Mortality Measure Patient and Family Engagement; Making Care Safer; Communication and Care