Percentage of all patient visits for those patients that are 17 years of age or older at the start of the measurement period in which a new or recurrent diagnosis of major depressive disorder (MDD) was identified and a suicide risk assessment was completed during the visit

Percentage of emergency department (ED) encounters for patients 18 years and older with a diagnosis of ST-segment elevation myocardial infarction (STEMI) that received appropriate treatment, defined as fibrinolytic therapy within 30 minutes of ED arrival, percutaneous coronary intervention (PCI) within 90 minutes of ED arrival, or transfer within 45 minutes of ED arrival

Percentage of cataract surgeries for patients aged 18 and older with a diagnosis of uncomplicated cataract and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved in the operative eye within 90 days following the cataract surgery

Percentage of patient visits for those patients aged 6 through 16 at the start of the measurement period with a diagnosis of major depressive disorder (MDD) with an assessment for suicide risk

Percentage of patients 18-85 years of age who had a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period, and whose most recent blood pressure was adequately controlled (<140/90 mmHg) during the measurement period

Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once during the measurement period.

Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period

The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event

Ischemic stroke patients prescribed or continuing to take antithrombotic therapy at hospital discharge

This measure assesses the percentage of hospitalizations of adults aged 65 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 where care performed was appropriate to the patient's level of malnutrition risk and severity. Malnutrition care best practices recommend that for each hospitalization, adult inpatients are (1) screened for malnutrition risk or for a hospital dietitian referral order to be placed, (2) assessed by a registered dietitian (RD) or registered dietitian nutritionist (RDN) to confirm findings of malnutrition risk, and if identified with a "moderate" or "severe" malnutrition status in the current performed malnutrition assessment , (3) receive a current "moderate" or "severe" malnutrition diagnosis by a physician or eligible provider as defined by CMS, and (4) have a current nutrition care plan performed by an RD/RDN.

Percentage of patients 13 years of age and older with a diagnosis of HIV who had tests for syphilis, gonorrhea, and chlamydia performed within the measurement period

Percentage of patients aged 15-65 at the start of the measurement period who were between 15-65 years old when tested for Human immunodeficiency virus (HIV)

Percentage of patients, regardless of age, diagnosed with HIV prior to or during the first 90 days of the measurement period, with an eligible encounter in the first 240 days of the measurement period, whose last HIV viral load test result was less than 200 copies/mL during the measurement period

This logic is intended to extract electronic clinical data. This is not an electronic clinical quality measure and this logic will not produce measure results. Instead, it will produce a file containing the data that CMS will link with administrative claims to risk adjust the Hybrid HWM outcome measure. It is designed to extract the first resulted set of vital signs and basic laboratory results obtained from encounters for adult Medicare Fee-For-Service patients admitted to acute care short stay hospitals.

This logic is intended to extract electronic clinical data. This is not an electronic clinical quality measure and this logic will not produce measure results. Instead, it will produce a file containing the data that CMS will link with administrative claims to risk adjust the Hybrid HWR outcome measure. It is designed to extract the first resulted set of vital signs and basic laboratory results obtained from encounters for adult Medicare Fee-For-Service patients admitted to acute care short stay hospitals.

Percentage of patients aged 18-75 years with a diagnosis of diabetes who received a kidney health evaluation defined by an Estimated Glomerular Filtration Rate (eGFR) AND Urine Albumin-Creatinine Ratio (uACR) within the measurement period

Example measure supporting testing of the multi-provider patient scenario for encounter-based measures

Example measure supporting testing of the multi-provider patient scenario for patient-based measures

Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the measurement period AND who had a follow-up plan documented if BMI was outside of normal parameters

Percentage of patients aged 12 years and older screened for depression on the date of the encounter or up to 14 days prior to the date of the encounter using an age-appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of or up to two days after the date of the qualifying encounter

Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more visits within 12 months

Proportion of inpatient hospitalizations for patients 18 years of age and older prescribed, or continued on, two or more opioids or an opioid and benzodiazepine concurrently at discharge

Patients with severe obstetric complications which occur during the inpatient delivery hospitalization

Percentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the measurement period:

• All patients who were previously diagnosed with or currently have a diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD), including an ASCVD procedure; OR
• Patients aged 20 - 75 years who have ever had a low-density lipoprotein cholesterol (LDL-C) level >= 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial hypercholesterolemia; OR
• Patients aged 40 - 75 years with a diagnosis of diabetes; OR
• Patients aged 40 - 75 with a 10-year ASCVD risk score of >= 20 percent

Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class. Three rates are reported.

1. Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class.
2. Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class, except for appropriate diagnoses.
3. Total rate (the sum of the two numerators divided by the denominator, deduplicating for patients in both numerators).