3 Component/s Yes Start typing to get a list of possible matches or press down to select. Enter CMS program(s) for which the measure is being submitted. New for 2018: If you are submitting for MIPS, there are two choices of program. Choose MIPS-Quality for measures that pertain to quality and/or efficiency. Choose the new program MIPS-Cost only for measures that pertain to cost. Do not select both MIPS-Quality and MIPS-Cost for the same measure. If you select MIPS (either Quality or Cost), please navigate to the Additional Resources list at this web site: download the “MIPS Peer Review Template and a Completed Sample,” and attach the completed form to your JIRA submission using the “Attachments” field at the bottom of this web page. Ambulatory Surgical Center Quality Reporting Program End-Stage Renal Disease Quality Incentive Program Home Health Quality Reporting Program Hospice Quality Reporting Program Hospital-Acquired Condition Reduction Program Hospital Inpatient Quality Reporting Program Hospital Outpatient Quality Reporting Program Hospital Readmissions Reduction Program Hospital Value-Based Purchasing Program Inpatient Psychiatric Facility Quality Reporting Program Inpatient Rehabilitation Facility Quality Reporting Program Long-Term Care Hospital Quality Reporting Program Medicaid and Medicare EHR Incentive Program for Eligible Hospitals and Critical Access Hospitals Medicare Shared Savings Program Incentive Payment System-Cost Merit-based Incentive Payment Prospective Payment System-Exempt Cancer Hospital Quality Reporting Program Skilled Nursing Facility Quality Reporting Program Skilled Nursing Facility Value-Based Purchasing Program
Skilled Nursing Facility Value-Based Purchasing Program 8 Summary Yes Provide the measure title only (255 characters or less). Put program-specific ID number in the next field, not in the title. Note: Do not enter the NQF ID, former JIRA MUC ID number, or any other ID numbers here (see below). Free text 255 characters max 9 Measure ID No Alphanumeric identifier (if applicable), such as a recognized program ID number for this measure (20 characters or less). Examples: 199 GPRO HF-5; ACO 28; CTM-3; PQI #08. Fields for the NQF ID number and previous year(s) JIRA MUC ID number are provided in data fields within this form. Free text 20 characters max 10 Measure description Yes Provide a brief description of the measure (700 characters or less). When you paste text, any content over the limit will be truncated. Free text 700 characters or less)
34 Year of next anticipated NQF CDP endorsement review No Select one Select one None 2018 2019 2020 2021 2022 35 In what state of development is the measure? Yes Select as many as Hold down the Ctrl button while choosing to make multiple selections. Early Development Field Testing Fully Developed select
50 Was this measure published on a previous year's Measures under Consideration list? Yes If yes, you are submitting an existing measure for expansion into additional CMS programs or the measure has substantially changed since originally published, then proceed to the following subset of data fields including: In what prior year(s) was this measure published?, What were the MUC IDs for the measure in each year?, Why was the measure not recommended by the MAP workgroups in those year(s)?, What were the programs that NQF MAP reviewed the measure for in each year?, List the NQF MAP workgroup(s) in each year, What was the NQF MAP recommendation each year?, and NQF MAP report page number being referenced for each year. If no, then skip these subset questions. Select one Yes No 51 In what prior year(s) was this measure published? No Select as many as apply. Hold down the Ctrl button while choosing to make multiple selections. None 2011 2012 2013 2014 2015 2016 2017 Other (enter in Comments at far bottom of this screen) 52 What were the MUC IDs for the measure in each year? No List both the year and the associated MUC ID number in each year. If unknown, enter N/A. Free text
62 Long-Term Measure Steward (if different) No Entity or entities that will be the permanent measure steward(s), responsible for maintaining the measure and conducting NQF maintenance review. Use the scroll bar to view all available stewards. Hold down the Ctrl button choosing to make multiple selections. See Appendix A.60-62 for list choices. 63 Long-Term Measure Steward Contact Information No If different from Steward above: Last name, First name; Affiliation; Telephone number; Email address Free text 64 Primary Submitter Contact Information Yes If different from Steward above: Last name, First name; Affiliation; Telephone number; Email address Free text 65 Secondary Submitter Contact Information No If different from name(s) above: Last name, First name; Affiliation; Telephone number; Email address Free text 66 Comments No Any notes, qualifiers, external references, or other information not specified above. For OTHER entries: please indicate the type of additional data you are providing, such as Measure Type, Setting, Level of Analysis, or Measure Steward. Free text
68 MIPS Journal Article Requirement No For those submitting measures to MIPS program, click “Yes” after you have attached your completed Peer Reviewed Journal Article Requirement form. Radio button Yes No Appendix: Lengthy Drop-Down List Choices A.22 Choices for What area of specialty best fits the measure? None Addiction medicine Allergy/immunology Anesthesiology Cardiac electrophysiology Cardiac surgery Cardiovascular disease (cardiology) Chiropractic medicine Colorectal surgery (proctology) Critical care medicine (intensivists) Dermatology Diagnostic radiology Electrophysiology Emergency medicine Endocrinology Family practice Gastroenterology General practice General surgery Geriatric medicine Gynecological oncology Hand surgery Hematology/oncology Hospice and palliative care Infectious disease Internal medicine Interventional pain management Interventional radiology Maxillofacial surgery Medical oncology Mental health professionals Nephrology Neurology Neuropsychiatry Neurosurgery Nuclear medicine Obstetrics/gynecology Ophthalmology Optometry Oral surgery (dentists only) Orthopedic surgery Osteopathic manipulative medicine Otolaryngology Pain management Palliative care Pathology Pediatric medicine Peripheral vascular disease Physical medicine and rehabilitation Plastic and reconstructive surgery Podiatry Preventive medicine Primary care Psychiatry Pulmonary disease Pulmonology Radiation oncology Rheumatology Sleep medicine Sports medicine Surgical oncology Thoracic surgery Urology Vascular surgery Other (enter in Comments at far bottom of this screen)