Left ventricular ejection fraction (lvef) >= 40% or documentation as normal or mildly depressed left ventricular systolic function

Left ventricular ejection fraction (lvef) not performed or documented

Dilated macular or fundus exam performed, including documentation of the presence or absence of macular edema and level of severity of retinopathy

Dilated macular or fundus exam not performed

Patient with documented results of a central dual-energy x-ray absorptiometry (dxa) ever being performed

Patient with central dual-energy x-ray absorptiometry (dxa) results not documented, reason not given

Clinician documented that patient was not an eligible candidate for screening

Lower extremity neurological exam performed and documented

Lower extremity neurological exam not performed

Clinician documented that patient was not an eligible candidate for lower extremity neurological exam measure

Footwear evaluation performed and documented

Footwear evaluation was not performed

Clinician documented that patient was not an eligible candidate for footwear evaluation measure

Bmi is documented above normal parameters and a follow-up plan is documented

Bmi is documented below normal parameters and a follow-up plan is documented

Bmi documented outside normal parameters, no follow-up plan documented, no reason given

Bmi is documented within normal parameters and no follow-up plan is required

Bmi not documented and no reason is given

Bmi not documented, documentation the patient is not eligible for bmi calculation

Eligible clinician attests to documenting in the medical record they obtained, updated, or reviewed the patient's current medications

Current list of medications not documented as obtained, updated, or reviewed by the eligible clinician, reason not given

Eligible clinician attests to documenting in the medical record the patient is not eligible for a current list of medications being obtained, updated, or reviewed by the eligible clinician

Screening for depression is documented as being positive and a follow-up plan is documented

Depression screening not documented, reason not given

Screening for depression not completed, documented reason

Pain assessment not documented as being performed, documentation the patient is not eligible for a pain assessment using a standardized tool at the time of the encounter

Beta-blocker therapy prescribed

Beta-blocker therapy for lvef < 40% not prescribed for reasons documented by the clinician (e.g., low blood pressure, fluid overload, asthma, patients recently treated with an intravenous positive inotropic agent, allergy, intolerance, other medical reasons, patient declined, other patient reasons, or other reasons attributable to the healthcare system)

Beta-blocker therapy not prescribed

Clinician documented that patient is not an eligible candidate for genotype testing; patient not receiving antiviral treatment for hepatitis c during the measurement period (e.g. genotype test done prior to the reporting period, patient declines, patient not a candidate for antiviral treatment)

Clinician documented that patient is not an eligible candidate for quantitative rna testing at week 12; patient not receiving antiviral treatment for hepatitis c

Patient receiving antiviral treatment for hepatitis c during the measurement period

Clinician documented that prostate cancer patient is not an eligible candidate for adjuvant hormonal therapy; low or intermediate risk of recurrence or risk of recurrence not determined

High or very high risk of recurrence of prostate cancer

Angiotensin converting enzyme (ace) inhibitor or angiotensin receptor blocker (arb) therapy prescribed

Angiotensin converting enzyme (ace) inhibitor or angiotensin receptor blocker (arb) therapy not prescribed for reasons documented by the clinician (e.g., allergy, intolerance, pregnancy, renal failure due to ace inhibitor, diseases of the aortic or mitral valve, other medical reasons) or (e.g., patient declined, other patient reasons) or (e.g., lack of drug availability, other reasons attributable to the health care system)

Angiotensin converting enzyme (ace) inhibitor or angiotensin receptor blocker (arb) therapy not prescribed, reason not given

Most recent blood pressure has a systolic measurement of < 140 mmhg and a diastolic measurement of < 90 mmhg

Most recent blood pressure has a systolic measurement of >= 140 mmhg and/or a diastolic measurement of >= 90 mmhg

Blood pressure measurement not performed or documented, reason not given

Influenza immunization administered or previously received

Influenza immunization was not administered for reasons documented by clinician (e.g., patient allergy or other medical reasons, patient declined or other patient reasons, vaccine not available or other system reasons)

Influenza immunization was not administered, reason not given

I intend to report the diabetes mellitus (dm) measures group

I intend to report the preventive care measures group

I intend to report the chronic kidney disease (ckd) measures group

I intend to report the coronary artery disease (cad) measures group

I intend to report the rheumatoid arthritis (ra) measures group

I intend to report the hiv/aids measures group

I intend to report the perioperative care measures group

I intend to report the back pain measures group

All quality actions for the applicable measures in the diabetes mellitus (dm) measures group have been performed for this patient

All quality actions for the applicable measures in the chronic kidney disease (ckd) measures group have been performed for this patient

All quality actions for the applicable measures in the preventive care measures group have been performed for this patient

All quality actions for the applicable measures in the coronary artery bypass graft (cabg) measures group have been performed for this patient

All quality actions for the applicable measures in the coronary artery disease (cad) measures group have been performed for this patient

All quality actions for the applicable measures in the rheumatoid arthritis (ra) measures group have been performed for this patient

All quality actions for the applicable measures in the hiv/aids measures group have been performed for this patient

All quality actions for the applicable measures in the perioperative care measures group have been performed for this patient

All quality actions for the applicable measures in the back pain measures group have been performed for this patient

Patient receiving angiotensin converting enzyme (ace) inhibitor or angiotensin receptor blocker (arb) therapy

Pain assessment documented as positive using a standardized tool, follow-up plan not documented, reason not given

Screening for depression is documented as negative, a follow-up plan is not required

Screening for depression documented as positive, follow-up plan not documented, reason not given

Autogenous av fistula received

Clinician documented that patient was not an eligible candidate for autogenous av fistula

Clinician documented that patient received vascular access other than autogenous av fistula, reason not given

Elder maltreatment screen not documented; documentation that patient is not eligible for the elder maltreatment screen at the time of the encounter

No documentation of an elder maltreatment screen, reason not given

Functional outcome assessment documented as positive using a standardized tool and a care plan based on identified deficiencies on the date of functional outcome assessment, is documented

Functional outcome assessment not documented as being performed, documentation the patient is not eligible for a functional outcome assessment using a standardized tool at the time of the encounter

Functional outcome assessment using a standardized tool not documented, reason not given

Functional outcome assessment using a standardized tool is documented; no functional deficiencies identified, care plan not required

Documentation of a positive functional outcome assessment using a standardized tool; care plan not documented, reason not given

I intend to report the coronary artery bypass graft (cabg) measures group

I intend to report the hepatitis c measures group

I intend to report the ischemic vascular disease (ivd) measures group

I intend to report the heart failure (hf) measures group

All quality actions for the applicable measures in the hepatitis c measures group have been performed for this patient

All quality actions for the applicable measures in the heart failure (hf) measures group have been performed for this patient

All quality actions for the applicable measures in the ischemic vascular disease (ivd) measures group have been performed for this patient

Patient referred to a physician (preferably a physician with training in disorders of the ear) for an otologic evaluation

Patient has a history of active drainage from the ear within the previous 90 days

Patient is not eligible for the referral for otologic evaluation for patients with a history of active drainage measure

Patient does not have a history of active drainage from the ear within the previous 90 days

Patient not referred to a physician (preferably a physician with training in disorders of the ear) for an otologic evaluation, reason not given

Patient was referred to a physician (preferably a physician with training in disorders of the ear) for an otologic evaluation, reason not specified)

Verification and documentation of sudden or rapidly progressive hearing loss

Patient is not eligible for the "referral for otologic evaluation for sudden or rapidly progressive hearing loss" measure

Patient does not have verification and documentation of sudden or rapidly progressive hearing loss

Patient was not referred to a physician (preferably a physician with training in disorders of the ear) for an otologic evaluation, reason not given

Prolonged postoperative intubation (> 24 hrs) required

Prolonged postoperative intubation (> 24 hrs) not required

Development of deep sternal wound infection/mediastinitis within 30 days postoperatively

No deep sternal wound infection/mediastinitis

Stroke following isolated cabg surgery

No stroke following isolated cabg surgery

Developed postoperative renal failure or required dialysis

No postoperative renal failure/dialysis not required

Re-exploration required due to mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction or other cardiac reason

Re-exploration not required due to mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction or other cardiac reason

Antiplatelet medication at discharge

Antiplatelet medication contraindicated

No antiplatelet medication at discharge

Beta-blocker at discharge

Beta-blocker contraindicated

No beta-blocker at discharge

Anti-lipid treatment at discharge

Anti-lipid treatment contraindicated

No anti-lipid treatment at discharge

Lipid profile results documented and reviewed (must include total cholesterol, hdl-c, triglycerides and calculated ldl-c)

Lipid profile not performed, reason not given

Most recent ldl-c < 100 mg/dl

Most recent ldl-c >= 100 mg/dl

Aspirin or another antiplatelet therapy used

Aspirin or another antiplatelet therapy not used, reason not given

Iv t-pa initiated within three hours (<= 180 minutes) of time last known well

Iv t-pa not initiated within three hours (<= 180 minutes) of time last known well for reasons documented by clinician

Iv t-pa not initiated within three hours (<= 180 minutes) of time last known well, reason not given

Surgical procedure performed within 30 days following cataract surgery for major complications (e.g., retained nuclear fragments, endophthalmitis, dislocated or wrong power iol, retinal detachment, or wound dehiscence)

Surgical procedure not performed within 30 days following cataract surgery for major complications (e.g., retained nuclear fragments, endophthalmitis, dislocated or wrong power iol, retinal detachment, or wound dehiscence)

Documentation of order for prophylactic parenteral antibiotic to be given within one hour (if fluoroquinolone or vancomycin, two hours) prior to surgical incision (or start of procedure when no incision is required)

Documentation that administration of prophylactic parenteral antibiotics was initiated within one hour (if fluoroquinolone or vancomycin, two hours) prior to surgical incision (or start of procedure when no incision is required), as ordered

Clinician documented that patient was not an eligible candidate for ordering prophylactic parenteral antibiotics to be given within one hour (if fluoroquinolone or vancomycin, two hours) prior to surgical incision (or start of procedure when no incision is required)

Prophylactic parenteral antibiotics were not ordered to be given or given within one hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required), reason not given

Pharmacologic therapy (other than minierals/vitamins) for osteoporosis prescribed

Clinician documented patient not an eligible candidate to receive pharmacologic therapy for osteoporosis

Pharmacologic therapy for osteoporosis was not prescribed, reason not given

I intend to report the asthma measures group

All quality actions for the applicable measures in the asthma measures group have been performed for this patient

Risk-adjusted functional status change residual score for the knee impairment successfully calculated and the score was equal to zero (0) or greater than zero (> 0)

Risk-adjusted functional status change residual score for the knee impairment successfully calculated and the score was less than zero (< 0)

Risk-adjusted functional status change residual score for the knee impairment not measured because the patient did not complete the fs status survey near discharge, patient not appropriate

Risk-adjusted functional status change residual score for the knee impairment not measured because the patient did not complete the knee fs prom at initial evaluation and/or near discharge, reason not given

Risk-adjusted functional status change residual score for the hip impairment successfully calculated and the score was equal to zero (0) or greater than zero (> 0)

Risk-adjusted functional status change residual score for the hip impairment successfully calculated and the score was less than zero (< 0)

Risk-adjusted functional status change residual scores for the hip impairment not measured because the patient did not complete the fs status survey near discharge, patient not appropriate

Risk-adjusted functional status change residual score for the hip impairment not measured because the patient did not complete the fs intake survey on admission and/or follow up fs status survey near discharge, reason not given

Risk-adjusted functional status change residual score for the lower leg, foot or ankle impairment successfully calculated and the score was equal to zero (0) or greater than zero ( > 0)

Risk-adjusted functional status change residual score for the lower leg, foot or ankle impairment successfully calculated and the score was less than zero (< 0)

Risk-adjusted functional status change residual score for the lower leg, foot or ankle impairment not measured because the patient did not complete the fs status survey near discharge, patient not appropriate

Risk-adjusted functional status change residual score for the lower leg, foot or ankle impairment not measured because the patient did not complete the fs intake survey on admission and/or follow up fs status survey near discharge, reason not given

Risk-adjusted functional status change residual score for the low back impairment successfully calculated and the score was equal to zero (0) or greater than zero (> 0)

Risk-adjusted functional status change residual score for the low back impairment successfully calculated and the score was less than zero (< 0)

Risk-adjusted functional status change residual score for the low back impairment not measured because the patient did not complete the fs status survey near discharge, patient not appropriate

Risk-adjusted functional status change residual score for the low back impairment not measured because the patient did not complete the low back fs prom at initial evaluation and/or near discharge, reason not given

Risk-adjusted functional status change residual score for the shoulder impairment successfully calculated and the score was equal to zero (0) or greater than zero (> 0)

Risk-adjusted functional status change residual score for the shoulder impairment successfully calculated and the score was less than zero (< 0)

Risk-adjusted functional status change residual score for the shoulder impairment not measured because the patient did not complete the fs status survey near discharge, patient not appropriate

Risk-adjusted functional status change residual score for the shoulder impairment not measured because the patient did not complete the shoulder fs prom at initial evaluation and/or near discharge, reason not given

Risk-adjusted functional status change residual score for the elbow, wrist or hand impairment successfully calculated and the score was equal to zero (0) or greater than zero (> 0)

Risk-adjusted functional status change residual score for the elbow, wrist or hand impairment successfully calculated and the score was less than zero (< 0)

Risk-adjusted functional status change residual score for the elbow, wrist or hand impairment not measured because the patient did not complete the fs status survey near discharge, patient not appropriate

Risk-adjusted functional status change residual score for the elbow, wrist or hand impairment not measured because the patient did not complete the elbow/wrist/hand fs prom at initial evaluation and/or near discharge, reason not given

Risk-adjusted functional status change residual score for the neck, cranium, mandible, thoracic spine, ribs or other general orthopedic impairment successfully calculated and the score was equal to zero (0) or greater than zero (> 0)

Risk-adjusted functional status change residual score for the neck, cranium, mandible, thoracic spine, ribs or other general orthopedic impairment successfully calculated and the score was less than zero (< 0)

Risk-adjusted functional status change residual score for the neck, cranium, mandible, thoracic spine, ribs or other general orthopedic impairment not measured because the patient did not complete the fs status survey near discharge, patient not appropriate

Risk-adjusted functional status change residual score for the neck, cranium, mandible, thoracic spine, ribs or other general orthopedic impairment not measured because the patient did not complete the general orthopedic fs prom at initial evaluation and/or near discharge, reason not given

Lvf testing documented as being performed prior to discharge or in the previous 12 months

Lvf testing not performed prior to discharge or in the previous 12 months for a medical or patient documented reason

Lvf testing not documented as being performed prior to discharge or in the previous 12 months, reason not given

Left ventricular ejection fraction (lvef) < 40%

Antithrombotic therapy prescribed at discharge

Antithrombotic therapy not prescribed for documented reasons (e.g., patient had stroke during hospital stay, patient expired during inpatient stay, other medical reason(s)); (e.g., patient left against medical advice, other patient reason(s))

Antithrombotic therapy was not prescribed at discharge, reason not given

Rehabilitation services (occupational, physical or speech) ordered at or prior to discharge

Rehabilitation services (occupational, physical or speech) not indicated at or prior to discharge

Rehabilitation services were not ordered, reason not otherwise specified

Documentation that prophylactic antibiotics were given within 4 hours prior to surgical incision or intraoperatively

Documentation that prophylactic antibiotics were neither given within 4 hours prior to surgical incision nor intraoperatively

12-lead electrocardiogram (ecg) performed

Documentation of medical reason(s) for not performing a 12-lead electrocardiogram (ecg)

Documentation of patient reason(s) for not performing a 12-lead electrocardiogram (ecg)

12-lead electrocardiogram (ecg) not performed, reason not given

Patient not prescribed or dispensed antibiotic

Patient prescribed or dispensed antibiotic for documented medical reason(s) within three days after the initial diagnosis of uri (e.g., intestinal infection, pertussis, bacterial infection, lyme disease, otitis media, acute sinusitis, acute pharyngitis, acute tonsillitis, chronic sinusitis, infection of the pharynx/larynx/tonsils/adenoids, prostatitis, cellulitis, mastoiditis, or bone infections, acute lymphadenitis, impetigo, skin staph infections, pneumonia/gonococcal infections, venereal disease (syphilis, chlamydia, inflammatory diseases (female reproductive organs)), infections of the kidney, cystitis or uti, and acne)

Patient prescribed or dispensed antibiotic

Prescribed or dispensed antibiotic

Antibiotic not prescribed or dispensed

Spkt/v greater than or equal to 1.2 (single-pool clearance of urea [kt] / volume [v])

Hemodialysis treatment performed exactly three times per week for > 90 days

Spkt/v less than 1.2 (single-pool clearance of urea [kt] / volume [v]), reason not given

Total kt/v greater than or equal to 1.7 per week (total clearance of urea [kt] / volume [v])

Total kt/v less than 1.7 per week (total clearance of urea [kt] / volume [v])

Pt category (primary tumor), pn category (regional lymph nodes), and histologic grade were documented in pathology report

Documentation of medical reason(s) for not including the pt category, the pn category or the histologic grade in the pathology report (e.g., re-excision without residual tumor; non-carcinomasanal canal)

Specimen site is other than anatomic location of primary tumor

Pt category, pn category and histologic grade were not documented in the pathology report, reason not given

Fasting lipid profile performed (triglycerides, ldl-c, hdl-c and total cholesterol)

Clinician has documented reason for not performing fasting lipid profile (e.g., patient declined, other patient reasons)

Fasting lipid profile not performed, reason not given

Pain assessment documented as positive using a standardized tool and a follow-up plan is documented

Pain assessment using a standardized tool is documented as negative, no follow-up plan required

No documentation of pain assessment, reason not given

Elder maltreatment screen documented as positive and a follow-up plan is documented

Elder maltreatment screen documented as negative, no follow-up required

Elder maltreatment screen documented as positive, follow-up plan not documented, reason not given

Most current ldl-c <100mg/dl

Most current ldl-c >=100mg/dl

Left ventricular ejection fraction (lvef) < 40% or documentation of severely or moderately depressed left ventricular systolic function

Left ventricular ejection fraction (lvef) >= 40% or documentation as normal or mildly depressed left ventricular systolic function

Left ventricular ejection fraction (lvef) not performed or assessed, reason not given

Absence of signs of melanoma (tenderness, jaundice, localized neurologic signs such as weakness, or any other sign suggesting systemic spread) or absence of symptoms of melanoma (cough, dyspnea, pain, paresthesia, or any other symptom suggesting the possibility of systemic spread of melanoma)

Smoking status and exposure to second hand smoke in the home not assessed, reason not given

Most recent systolic blood pressure < 140 mmhg

Most recent systolic blood pressure >= 140 mmhg

Most recent diastolic blood pressure < 90 mmhg

Most recent diastolic blood pressure >= 90 mmhg

No documentation of blood pressure measurement, reason not given

All quality actions for the applicable measures in the chronic obstructive pulmonary disease (copd) measures group have been performed for this patient

All quality actions for the applicable measures in the inflammatory bowel disease (ibd) measures group have been performed for this patient

All quality actions for the applicable measures in the sleep apnea measures group have been performed for this patient

All quality actions for the applicable measures in the dementia measures group have been performed for this patient

All quality actions for the applicable measures in the parkinson's disease measures group have been performed for this patient

All quality actions for the applicable measures in the hypertension (htn) measures group have been performed for this patient

All quality actions for the applicable measures in the cardiovascular prevention measures group have bee performed for this patient

All quality actions for the applicable measures in the cataract measures group have been performed for this patient

Lipid panel results documented and reviewed (must include total cholesterol, hdl-c, triglycerides and calculated ldl-c)

Documentation of medical reason(s) for not performing lipid profile (e.g., patients with palliative goals or for whom treatment of hypertension with standard treatment goals is not clinically appropriate)

Lipid profile not performed, reason not given

Urine protein test result documented and reviewed

Documentation of diagnosis of chronic kidney disease

Documentation of medical reason(s) for not performing urine protein test (e.g., patients with palliative goals or for whom treatment of hypertension with standard treatment goals is not cllinically appropriate)

Urine protein test was not performed, reason not given

Serum creatinine test result documented and reviewed

Documentation of medical reason(s) for not performing serum creatinine test (e.g., patients with palliative goals or for whom treatment of hypertension with standard treatment goals is not clinically appropriate)

Serum creatinine test not performed, reason not given

Diabetes screening test performed

Documentation of medical reason(s) for not performing diabetes screening test (e.g., patients with a diagnosis of diabetes, or with palliative goals or for whom treatment of hypertension with standard treatment goals is not clinically appropriate)

Diabetes screening test not performed, reason not given

Counseling for diet and physical activity performed

Documentation of medical reason(s) for patient not receiving counseling for diet and physical activity (e.g., patients with palliative goals or for whom treatment of hypertension with standard treatment goals is not clinically appropriate)

Counseling for diet and physical activity not performed, reason not given

Normal blood pressure reading documented, follow-up not required

Patient not eligible (e.g., documentation the patient is not eligible due to active diagnosis of hypertension, patient refuses, urgent or emergent situation)

Blood pressure reading not documented, reason not given

Specimen site other than anatomic location of esophagus

Specimen site other than anatomic location of prostate

Performance of trans-abdominal or trans-vaginal ultrasound and pregnancy location documented

Trans-abdominal or trans-vaginal ultrasound not performed for reasons documented by clinician (e.g., patient has visited the ed multiple times within 72 hours, patient has a documented intrauterine pregnancy [iup])

Trans-abdominal or trans-vaginal ultrasound not performed, reason not given

Rh-immunoglobulin (rhogam) ordered

Rh-immunoglobulin (rhogam) not ordered for reasons documented by clinician (e.g., patient had prior documented receipt of rhogam within 12 weeks, patient refusal)

Documentation rh-immunoglobulin (rhogam) was not ordered, reason not given

Documented reason in the medical records for why the statin therapy was not prescribed (i.e., lower extremity bypass was for a patient with non-artherosclerotic disease)

Statin medication prescribed at discharge

Statin therapy not prescribed at discharge, reason not given

Patient discharge to home no later than post-operative day #7

Patient not discharged to home by post-operative day #7

Patient discharge to home no later than post-operative day #2 following evar

Patient not discharged to home by post-operative day #2 following evar

Patient discharged to home no later than post-operative day #2 following cea

Patient not discharged to home by post-operative day #2 following cea

Sleep apnea symptoms assessed, including presence or absence of snoring and daytime sleepiness

Documentation of reason(s) for not documenting an assessment of sleep symptoms (e.g., patient didn't have initial daytime sleepiness, patient visited between initial testing and initiation of therapy)

Sleep apnea symptoms not assessed, reason not given

Apnea hypopnea index (ahi) or respiratory disturbance index (rdi) measured at the time of initial diagnosis

Documentation of reason(s) for not measuring an apnea hypopnea index (ahi) or a respiratory disturbance index (rdi) at the time of initial diagnosis (e.g., psychiatric disease, dementia, patient declined, financial, insurance coverage, test ordered but not yet completed)

Apnea hypopnea index (ahi) or respiratory disturbance index (rdi) not measured at the time of initial diagnosis, reason not given

Positive airway pressure therapy prescribed

Moderate or severe obstructive sleep apnea (apnea hypopnea index (ahi) or respiratory disturbance index (rdi) of 15 or greater)

Mild obstructive sleep apnea (apnea hypopnea index (ahi) or respiratory disturbance index (rdi) of less than 15)

Documentation of reason(s) for not prescribing positive airway pressure therapy (e.g., patient unable to tolerate, alternative therapies use, patient declined, financial, insurance coverage)

Positive airway pressure therapy not prescribed, reason not given

Objective measurement of adherence to positive airway pressure therapy, documented

Positive airway pressure therapy prescribed

Positive airway pressure therapy not prescribed

Documentation of reason(s) for not objectively measuring adherence to positive airway pressure therapy (e.g., patient didn't bring data from continous positive airway pressure [cpap], therapy not yet initiated, not available on machine)

Objective measurement of adherence to positive airway pressure therapy not performed, reason not given