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Meaningful Use Clinical Quality Measures:
Alignment across Quality Initiatives


The clinical quality measures (CQMs) for eligible professionals included in the EHR Incentive Program align with measures used in other Federal quality initiatives. The same CQMs are also aggregated to measure and improve quality of providers, health plans, and state-funded medical programs like Medicaid and Children’s Health Insurance Program (CHIP). This factsheet describes how providers’ efforts to measure and improve quality using EHRs aligns with the quality initiatives listed on the next page. Note this list of initiatives is not exhaustive. Other federal, state, and/or health plan quality measurement initiatives may overlap with EHR Incentive Program requirements.

This factsheet is for informational purposes only. Best efforts have been made to ensure the accuracy of the information presented here, but CMS policies may change over time. Further, CMS identification numbers may change over time, and measure names may vary slightly between programs and over time.

For further information on CQMs and Meaningful Use, please visit: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms/


Provider-Level Initiatives
State-Level Initiatives
Health Plan-Level Initiatives

The following table provides a summary of the various initiatives to which 2014 Meaningful Use CQMs also apply It also provides a column with the total number of initiatives (inclusive of Meaningful Use) to which each measure applies.

Clinical Quality Measure Comparison1

Meaningful Use 2014 Measure Total # of Initiatives Meaningful Use PQRS2 MSSP ACO3 Million Hearts4 CHIPRA5 Medicare Advantage6 VBM7 CPCI8,9
ADE Prevention and Monitoring: Warfarin Time in Therapeutic Range (NQF# 0527; CMS171v6) 1
ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication (NQF# 0108; CMS136v8) 2
Adult Weight Screening and Follow-up (NQF# 0421; CMS69v7) 4
Anti-Depressant Medication Management: (a) Effective Acute Phase Treatment, (b) Effective Continuation Phase Treatment (NQF# 0105; CMS128v7) 2
Appropriate Testing for Children with Pharyngitis (NQF# Not Applicable; CMS146v7) 4
Appropriate Treatment for Children with Upper Respiratory Infection (URI) (NQF# 0069; CMS154v7) 2
Bipolar Disorder and Major Depression: Appraisal For Alcohol or Chemical Substance Use (NQF# Not Applicable; CMS169v7) 1
Breast Cancer Screening10 (NQF# 2372; CMS125v7) 6
Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery (NQF# 0565; CMS133v7) 3
Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures (NQF# 0564; CMS132v7) 3
Cervical Cancer Screening (NQF# 0032; CMS124v7) 3
Child and Adolescent Major Depressive Disorder: Suicide Risk Assessment (NQF# 1365; CMS177v7) 1
Childhood Immunization Status (NQF# 0038; CMS117v7) 4
Children Who Have Dental Decay or Cavities (NQF# Not Applicable; CMS75v7) 1
Chlamydia Screening for Women (NQF# 0033; CMS153v7) 4
Closing the referral loop: receipt of specialist report (NQF# Not Applicable; CMS50v7) 1
Colorectal Cancer Screening (NQF# 0034; CMS130v7) 6
Controlling High Blood Pressure (NQF# 0018; CMS165v7) 7
Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI) (NQF# 0070; CMS145v7) 3
Dementia: Cognitive Assessment (NQF# 2872; CMS149v7) 3
Depression Remission at 12 months (NQF# 0710; CMS159v7) 3
Depression Utilization of the PHQ-9 Tool (NQF# 0712; CMS160v7) 1
Diabetes: HbA1c Poor Control (NQF# 0059; CMS122v7) 6
Diabetes: Eye Exam (NQF# 0055; CMS131v7) 4
Diabetes: Foot Exam (NQF# 0056; CMS123v7) 3
Diabetes: LDL Management & Control (NQF# Not Applicable; CMS163v5) 6
Diabetes: Urine Screening (NQF# 0062; CMS134v7) 4
Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care (NQF# 0089; CMS142v7) 3
Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy (NQF# 0088; CMS167v7) 3
Documentation of Current Medications in the Medical Record (NQF# 0419; CMS68v8) 3
Functional Status Assessment for Complex Chronic Conditions (NQF# Not Applicable; CMS90v8) 1
Functional Status Assessment for Hip Replacement (NQF# Not Applicable; CMS56v7) 1
Functional Status Assessment for Knee Replacement (NQF# Not Applicable; CMS66v7) 1
Heart Failure (HF) : Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) (NQF# 0081; CMS135v7) 3
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) (NQF# 0083; CMS144v7) 5
Hemoglobin A1c Test for Pediatric Patients (NQF# Not Applicable; CMS148v5) 2
HIV/AIDS: Medical Visit (NQF# Not Applicable; CMS62v5) 1
HIV/AIDS: Pneumocystis jiroveci pneumonia (PCP) Prophylaxis (NQF# 0405; CMS52v7) 3
HIV/AIDS: RNA control for patients with HIV (NQF# Not Applicable; CMS77v5) 3
Hypertension: Improvement in blood pressure (NQF# Not Applicable; CMS65v8) 3
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: (a) Initiation, (b) Engagement (NQF# 0004; CMS137v7) 3
Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control (NQF# Not Applicable; CMS182v6) 6
Ischemic Vascular Disease (IVD): Use of Aspirin or another Antithrombotic (NQF# 0068; CMS164v7) 5
Low Back Pain: Use of Imaging Studies (NQF# 0052; CMS166v7) 3
Major Depressive Disorder (MDD): Suicide Risk Assessment (NQF# 0104; CMS161v7) 3
Maternal Depression Screening (NQF# Not Applicable; CMS82v6) 1
Oncology Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer (NQF# 0387; CMS140v5) 3
Oncology Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients (NQF# 0385; CMS141v6) 3
Oncology: Medical and Radiation - Pain Intensity Quantified (NQF# 0384; CMS157v7) 3
Pneumonia Vaccination Status for Older Adults (NQF# Not Applicable; CMS127v7) 4
Pregnant Women that had HBsAg testing (NQF# Not Applicable; CMS158v7) 1
Preventive Care and Screening Measure Pair: a) Tobacco Use Assessment (NQF# 0028; CMS138v7) 6
Preventive Care and Screening Measure Pair: b) Tobacco Cessation Intervention (NQF# 0028; CMS138v7) 6
Preventive Care and Screening: Cholesterol-Fasting Low Density Lipoprotein (LDL-C) Test Performed (NQF# Not Applicable; CMS61v6) 3
Preventive Care and Screening: Influenza Immunization for Patients ≥ 50 Years Old (NQF# 0041; CMS147v8) 6
Preventive Care and Screening: Risk-Stratified Cholesterol-Fasting Low Density Lipoprotein (LDL-C) Test Performed (NQF# Not Applicable; CMS64v6) 3
Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan (NQF# 0418; CMS2v8) 5
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented (NQF# Not Applicable; CMS22v7) 4
Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists (NQF# Not Applicable; CMS74v8) 1
Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation (NQF# 0086; CMS143v7) 3
Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients (NQF# 0389; CMS129v8) 3
Screening for Future Fall Risk (NQF# 0101; CMS139v7) 5
Use of Appropriate Medications for Asthma (NQF# Not Applicable; CMS126v5) 4
Use of High-Risk Medications in the Elderly (NQF# 0022; CMS156v7) 4
Use of Imaging Studies for Low Back Pain (NQF# 0052; CMS166v7) 3
Weight Assessment and Counseling for Children and Adolescents (NQF# 0024; CMS155v7) 5

Many clinical quality measures apply to more than one quality initiative. This table groups the 2014 Meaningful Use CQMs by the number of quality programs to which they apply.

Alignment by Number of Initiatives

Number of Programs Meaningful Use Stage 2/2014 CQM
Measures that apply to 7 (seven) quality reporting initiatives Controlling High Blood Pressure (NQF# 0018; CMS165v7)
Measures that apply to 6 (six) quality reporting initiatives Breast Cancer Screening11 (NQF# 2372; CMS125v7)
Colorectal Cancer Screening (NQF# 0034; CMS130v7)
Diabetes: HbA1c Poor Control (NQF# 0059; CMS122v7)
Diabetes: LDL Management & Control (NQF# Not Applicable; CMS163v5)
Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control (NQF# Not Applicable; CMS182v6)
Preventive Care and Screening Measure Pair: a) Tobacco Use Assessment (NQF# 0028; CMS138v7)
Preventive Care and Screening Measure Pair: b) Tobacco Cessation Intervention (NQF# 0028; CMS138v7)
Preventive Care and Screening: Influenza Immunization for Patients ≥ 50 Years Old (NQF# 0041; CMS147v8)
Measures that apply to 5 (five) quality reporting initiatives Ischemic Vascular Disease (IVD): Use of Aspirin or another Antithrombotic (NQF# 0068; CMS164v7)
Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan (NQF# 0418; CMS2v8)
Screening for Future Fall Risk (NQF# 0101; CMS139v7)
Weight Assessment and Counseling for Children and Adolescents (NQF# 0024; CMS155v7)
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) (NQF# 0083; CMS144v7)
Measures that apply to 4 (four) quality reporting initiatives Adult Weight Screening and Follow-up (NQF# 0421; CMS69v7)
Appropriate Testing for Children with Pharyngitis (NQF# Not Applicable; CMS146v7)
Childhood Immunization Status (NQF# 0038; CMS117v7)
Chlamydia Screening for Women (NQF# 0033; CMS153v7)
Diabetes: Eye Exam (NQF# 0055; CMS131v7)
Diabetes: Urine Screening (NQF# 0062; CMS134v7)
Pneumonia Vaccination Status for Older Adults (NQF# Not Applicable; CMS127v7)
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented (NQF# Not Applicable; CMS22v7)
Use of Appropriate Medications for Asthma (NQF# Not Applicable; CMS126v5)
Use of High-Risk Medications in the Elderly (NQF# 0022; CMS156v7)
Measures that apply to 3 (three) quality reporting initiatives Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery (NQF# 0565; CMS133v7)
Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures (NQF# 0564; CMS132v7)
Cervical Cancer Screening (NQF# 0032; CMS124v7)
Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI) (NQF# 0070; CMS145v7)
Dementia: Cognitive Assessment (NQF# 2872; CMS149v7)
Depression Remission at 12 months (NQF# 0710; CMS159v7)
Diabetes: Foot Exam (NQF# 0056; CMS123v7)
Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care (NQF# 0089; CMS142v7)
Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy (NQF# 0088; CMS167v7)
Documentation of Current Medications in the Medical Record (NQF# 0419; CMS68v8)
Heart Failure (HF) : Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) (NQF# 0081; CMS135v7)
HIV/AIDS: Pneumocystis jiroveci pneumonia (PCP) Prophylaxis (NQF# 0405; CMS52v7)
HIV/AIDS: RNA control for patients with HIV (NQF# Not Applicable; CMS77v5)
Hypertension: Improvement in blood pressure (NQF# Not Applicable; CMS65v8)
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: (a) Initiation, (b) Engagement (NQF# 0004; CMS137v7)
Low Back Pain: Use of Imaging Studies (NQF# 0052; CMS166v7)
Major Depressive Disorder (MDD): Suicide Risk Assessment (NQF# 0104; CMS161v7)
Oncology Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer (NQF# 0387; CMS140v5)
Oncology Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients (NQF# 0385; CMS141v6)
Oncology: Medical and Radiation - Pain Intensity Quantified (NQF# 0384; CMS157v7)
Preventive Care and Screening: Cholesterol-Fasting Low Density Lipoprotein (LDL-C) Test Performed (NQF# Not Applicable; CMS61v6)
Preventive Care and Screening: Risk-Stratified Cholesterol-Fasting Low Density Lipoprotein (LDL-C) Test Performed (NQF# Not Applicable; CMS64v6)
Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation (NQF# 0086; CMS143v7)
Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients (NQF# 0389; CMS129v8)
Use of Imaging Studies for Low Back Pain (NQF# 0052; CMS166v7)
Measures that apply to 2 (two) quality reporting initiatives ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication (NQF# 0108; CMS136v8)
Anti-Depressant Medication Management: (a) Effective Acute Phase Treatment, (b) Effective Continuation Phase Treatment (NQF# 0105; CMS128v7)
Appropriate Treatment for Children with Upper Respiratory Infection (URI) (NQF# 0069; CMS154v7)
Hemoglobin A1c Test for Pediatric Patients (NQF# Not Applicable; CMS148v5)
Measures that apply to 1 (one) quality reporting initiatives (EHR Incentive Program) ADE Prevention and Monitoring: Warfarin Time in Therapeutic Range (NQF# Not Applicable; CMS179v5)
Bipolar Disorder and Major Depression: Appraisal For Alcohol or Chemical Substance Use (NQF# Not Applicable; CMS169v7)
Child and Adolescent Major Depressive Disorder: Suicide Risk Assessment (NQF# 1365; CMS177v7)
Children Who Have Dental Decay or Cavities (NQF# Not Applicable; CMS75v7)
Closing the referral loop: receipt of specialist report (NQF# Not Applicable; CMS50v7)
Depression Utilization of the PHQ-9 Tool (NQF# 0712; CMS160v7)
Functional Status Assessment for Complex Chronic Conditions (NQF# Not Applicable; CMS90v8)
Functional Status Assessment for Hip Replacement (NQF# Not Applicable; CMS56v7)
Functional Status Assessment for Knee Replacement (NQF# Not Applicable; CMS66v7)
HIV/AIDS: Medical Visit (NQF# Not Applicable; CMS62v5)
Maternal Depression Screening (NQF# Not Applicable; CMS82v6)
Pregnant Women that had HBsAg testing (NQF# Not Applicable; CMS158v7)
Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists (NQF# Not Applicable; CMS74v8)

To assess compliance with and monitor the progress of the varied initiatives, most programs require that the CQM results be reported. In many initiatives, information may be collected and reported by various entities using combinations of different mechanisms, such as claims data or surveys. The table below focuses on the role of the provider in reporting.

The table below indicates which providers or organizations are responsible for reporting CQM information, the source of CQM data, the mechanism by which providers report CQM information, and the initiative related purpose of such reporting. Note that for some programs the measures that can be reported can vary by reporting mechanism, for example, in the PQRS program, providers who report Group Practice Reporting Option (GPRO) web-interface have a more restricted set of measures. As another example, providers who report VBM measures using the administrative claims option use a more restricted set of measures.

Although all clinical quality measurement initiatives aim to improve healthcare quality and outcomes, there are often specific incentives or goals associated with specific initiatives. Providers who are reporting CQMs for multiple initiatives will now – or soon be – making their measures ‘count’ multiple times, by measuring and reporting them only once.

Provider Reporting of Clinical Quality Measures in 2014

Quality Initiative Who Reports CQMs Source of Data Provider Reporting Mechanism Purpose of Reporting
EHR Incentive Program Eligible providers Electronic medical record Attestation or e-reporting Determine eligibility for EHR incentive payment or payment adjustment
Physician Quality Reporting System12 Eligible Medicare physicians or group practices Medical records & claims Group Practice Reporting Option (GPRO) Web Interface, or EHR Determine eligibility for PQRS incentive payment
Value-Based Modifier12 Group practices ≥ 100 Medical records & claims Same as PQRS Avoid a negative payment adjustment13
MSSP Accountable Care Organizations14 Medicare approved ACOs Medical records, surveys, & claims Group Practice Reporting Option (GPRO) Web Interface Determine eligibility to share in savings
Million Hearts Campaign Provider volunteers Provider determined Optional15 Prevent cardiac related deaths
Children's Health Insurance Program Medicaid & CHIP agencies Claims N/A - State reported Monitor and improve quality for Medicaid & CHIP beneficiaries
Medicare Advantage Part C Medicare Health Plans Medical records, surveys, & claims Determined by health plan where applicable Provide publicly available quality ratings for Medicare Advantage Plans
Comprehensive Primary Care Initiative16 Eligible primary care providers Electronic medical records, surveys, & claims EHR Determine eligibility to share in savings
  1. Meaningful Use reports 2014 measures in 2014. All other programs mentioned here report 2013 measures.in 2014. Therefore 2013 measures are presented here for those programs.
  2. http://www.cms.gov/apps/ama/license.asp?file=/PQRS/downloads/2013_PQRS_MeasuresList_ImplementationGuide_12192012.zip
  3. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO-NarrativeMeasures-Specs.pdf
  4. http://millionhearts.hhs.gov/docs/Field_Engagement_Opportunities.pdf
  5. http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SHO-13-002.pdf
  6. http://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovGenIn/PerformanceData.html
  7. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/CY2015ValueModifierPolicies.pdf
  8. http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/CPC_CQM_InstructionGuide.pdf
  9. Measure 0101 and 0418 are CPCI measures for 2014 and 2015, not 2013
  10. This measure can only be electronically reported for the EHR Incentive Program due to the e-specifications varying from the most current specification of the measure.
  11. This measure can only be electronically reported for the EHR Incentive Program due to the e-specifications varying from the most current specification of the measure.
  12. The PQRS and VBM program reports on claims, and medical record based measures. Individual physicians or groups are directly responsible only for reporting on medical record based measures using GPRO or their EHRs.
  13. Practices that volunteer for the quality-tiering option in VBM assume additional risk relative to quality reporting.
  14. The ACO program reports on survey, claims, and medical record based measures. Individual ACOs are directly responsible only for reporting on medical record based measures using GPRO.
  15. Million Hearts is a voluntary program, including whether or not a provider reports on the associated quality measures.
  16. CPCI participants report on survey, claims, and medical record based measures. Individual physicians or groups are directly responsible only for reporting on medical record based measures using their EHRs
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