New Jersey Quality Metrics Alignment Quality Metrics from ......New Jersey Quality Metrics Alignment CMS – AHIP PCMH = CMS – American Health Insurance Plans Patient Centered Medical

New Jersey Quality Metrics Alignment CMS – AHIP PCMH = CMS – American Health Insurance Plans Patient Centered Medical Home NJ Innovation Institute PTN Project = Practice Transformation Network

Quality Metrics from State and National Programs CMS-AHIP ACO = CMS – American Health Insurance Plans ACO NJ MCO = NJ Medicaid Managed Care Contract

DSRIP = Delivery System Reform Incentive Payment PCPI = Physician Consortium for Performance Improvement®

EHR = Electronic Health Records (EHR) Incentive Programs, CMS Performance Based Incentive Program = CMS Merit-Based Incentive Payment System (MIPS)

HEDIS = Healthcare Effectiveness Data and Information Set PQRS = Physician Quality Reporting System

Leapfrog = Leapfrog Hospital Survey SIM = State Innovation Models

Medicaid = 2016 Core Set of Adult Health Care Quality Measures for Medicaid (Adult Core Set)

Medicaid/CHIP = 2015 Core Set of Children’s Health Care Quality Measures for Medicaid and CHIP (Child Core Set)

From PQRS File

Setting Category Target Measure Title CMS NQF PQRSAHRQ Prevention

Quality Indicators

Behavioral

Health Homes

CMS-AHIP

ACO

CMS-AHIP

PCMHDSRIP HER

Medicaid/

CHIP

Health

Home

HEDIS Leapfrog

NJ Innovation

Institute PTN

Project

NJ MCO MedicaidMedicaid/

CHIP

NJ Medicaid ACO

DemoPCPI PQRS

Performance

Based Incentive

Program

SIM

Inpt

Care Coordination Utilization 30-Day All-Cause Readmission Following Chronic Obstructive

Pulmonary Disease (COPD) Hospitalization1891

P P

Inpt

Care Coordination Utilization 30-Day All-Cause Readmission Following Heart Failure (HF)

Hospitalization330

P P

Inpt

Care Coordination Utilization 30-Day All-Cause Readmission Following Pneumonia (PN)

Hospitalization506

P P P

Inpt Care Coordination Cardiac

30-day all-cause risk- standardized mortality rate following

percutaneous

coronary intervention (PCI) for patients without ST segment elevation

myocardial infarction (STEMI) and without cardiogenic shock (See

also NQF #536)

535

P

Inpt Care Coordination Cardiac

30-day all-cause risk-standardized mortality rate following

Percutaneous Coronary

Intervention (PCI) for patients with ST segment elevation myocardial

infarction (STEMI) or cardiogenic shock (See also NQF #535)

536

P

Otpt Population Health Psych Abstinence: ATOD-related suspensions and expulsions (Future)NA NA

Otpt Clinical Care ENT

Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy –

Avoidance of Inappropriate UseN/A 0654 093

P P P

Otpt Clinical Care ENT Acute Otitis Externa (AOE): Topical Therapy N/A 0653 091 P P P

Inpt Efficiency and Cost Reduction Misc

addressing Medicaid value and costs, especially for high utilizing

patientsNA NA

P

Otpt Clinical Care Cardiac

ADE Prevention and Monitoring: Warfarin Time in Therapeutic

Range179v4 N/A 380

P P

Otpt Clinical Care Pediatrics

ADHD: Follow-Up Care for Children Prescribed Attention-

Deficit/Hyperactivity Disorder (ADHD) Medication136v5 0108 366

P P P P P P

Otpt Clinical Care Psych

Adherence to Antipsychotic Medications for Individuals with

SchizophreniaN/A 1879 383

P P P

Otpt Care Coordination Psych

Adherence to Antipsychotics for Individuals with Schizophrenia

(SAA)NA NA

P P

Otpt Clinical Care Diabetes

Adherence to Chronic Medications for People with Diabetes Mellitus:

Hypoglycemic agents545

P

Otpt Clinical Care Heme/Onc

Adjuvant chemotherapy is considered or administered within 4

months (120 days) of diagnosis to patients under the age of 80 with

AJCC III (lymph node positive) colon cancer

223

P

Otpt Population Health Pediatrics Adolescent Well-Care Visit (AWC) NA NA P P P P P

Otpt Care Coordination Asthma Adult Asthma Admission Rate 283 P P P

Otpt Population Health Misc Adult Body Mass Index (BMI) Assessment NA NA P P P

Otpt Population Health Misc Adult Body Mass Index Assessment (ABA) NA NA P

Otpt Population Health Smoking Adult Current Smoking Prevalence 2020 P

Otpt Population Health Neph Adult Kidney Disease: Blood Pressure Management N/A N/A 122 P P

Otpt Clinical Care NephAdult Kidney Disease: Catheter Use at Initiation of Hemodialysis N/A N/A 329

P P

Otpt Clinical Care Neph

Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90

DaysN/A N/A 330

P P

Otpt Clinical Care Neph Adult Kidney Disease: Laboratory Testing (Lipid Profile) N/A N/A 121 P P

Otpt Clinical Care Neph Adult Kidney Disease: Referral to Hospice N/A N/A 403 P P


Adult Major Depressive Disorder (MDD): Coordination of Care of

Patients with Specific Comorbid ConditionsN/A N/A 325

P P

Otpt Clinical Care PsychAdult Major Depressive Disorder (MDD): Suicide Risk Assessment 161v4 0104 107

P P P P

Both Inpt and OtptClinical Care Eye

Adult Primary Rhegmatogenous Retinal Detachment Surgery: No

Return to the Operating Room Within 90 Days of SurgeryN/A N/A 384

P P


Adult Primary Rhegmatogenous Retinal Detachment Surgery: Visual

Acuity Improvement Within 90 Days of SurgeryN/A N/A 385

P P

Page1 of 24









From PQRS File


Quality Indicators

Behavioral

Health Homes

CMS-AHIP

ACO

CMS-AHIP

PCMHDSRIP HER

Medicaid/

CHIP

Health

Home

HEDIS Leapfrog

NJ Innovation

Institute PTN

Project


CHIP

NJ Medicaid ACO

DemoPCPI PQRS

Performance

Based Incentive

Program

SIM


Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis -

Appropriate useN/A N/A 331

P P P


Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With

or Without Clavulanate Prescribed for Patients with Acute Bacterial

Sinusitis (Appropriate Use)

N/A N/A 332

P P

Otpt Clinical Care Radiology

Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis

(Overuse)N/A N/A 333

P P


Adult Sinusitis: More than One Computerized Tomography (CT)

Scan Within 90 Days for Chronic Sinusitis (Overuse)N/A N/A 334

P P

Otpt Population Health Prevention/Screening Age Appropriate Screening Colonoscopy N/A N/A 439 P P P P

Otpt Clinical Care Eye

Age-Related Macular Degeneration (AMD): Counseling on

Antioxidant SupplementN/A 0566 140

P P


Age-Related Macular Degeneration (AMD): Dilated Macular

ExaminationN/A 0087 014

P P

Inpt Care Coordination Utilization All Hospitalizations NA NA P

ER Care Coordination Utilization

Ambulatory Care – Emergency Department (ED) Visits (AMB) / rate

and/or preventableNA NA

P P P P P

Otpt Clinical Care NeuroAmyotrophic Lateral Sclerosis (ALS) Patient Care Preferences N/A N/A 386

P P

Inpt Clinical Care Surgical Anastomotic Leak Intervention N/A N/A 354 P P

Inpt Clinical Care Smoking Anesthesiology Smoking Abstinence N/A N/A 404 P P

Otpt Population Health OB/GYN

Annual cervical cancer screening or follow-up in high-risk women 579

P

Otpt Population Health Prevention/Screening

Annual Hepatitis C Virus (HCV) Screening for Patients who are

Active Injection Drug UsersN/A N/A 387

P P

Both Inpt and OtptClinical Care PharmacyAnnual Monitoring for Patients on Persistent Medications (MPM) 2371

P P P P

Otpt Clinical Care Pulmonary

Antibiotic Treatment for Adults with Acute Bronchitis: Avoidance of

Inappropriate UseN/A 0058 116

P P P P

Otpt Clinical Care Psych Anti-Depressant Medication Management 128v4 0105 009 P P P P P P

Otpt Clinical Care CardiacAnticoagulant Therapy Prescribed for Atrial Fibrillation at Discharge

P

Inpt Clinical Care Cardiac Aortic Valve Replacement NA NA P

Otpt Clinical Care RadiologyAppropriate Follow-up Imaging for Incidental Abdominal Lesions N/A N/A 405

P P


Appropriate Follow-Up Imaging for Incidental Thyroid Nodules in

PatientsN/A N/A 406

P P


Appropriate Follow-Up Interval for Normal Colonoscopy in Average

Risk PatientsN/A 0658 320

P P P P

Otpt Clinical Care Pediatrics Appropriate Testing for Children with Pharyngitis 146v4 0002 066 P P P


Appropriate Treatment for Children with Upper Respiratory Infection

(URI)154v4 0069 065

P P P

Otpt Clinical Care Infection Control

Appropriate Treatment of Meticillin-Sensitive Staphylococcus Aureus

(MSSA) BacteremiaN/A N/A 407

P P

Inpt Clinical Care OB/GYN Appropriate Work Up Prior to Endometrial Ablation Procedure 567 P

Otpt Population Health Asthma Asthma in Younger Adults Admission 283 P P P

Otpt Population Health Asthma Asthma Medication Ratio 1800 P P

Otpt Clinical Care Asthma

Asthma: Pharmacologic Therapy for Persistent Asthma - Ambulatory

Care SettingN/A 0047 053

P P P

Both Clinical Care Cardiac

Appropriate Assessment of Retrievable Inferior Vena Cava Filters for

RemovalN/A N/A 421

P P

Otpt Clinical Care GI Barrett's Esophagus N/A 1854 249 P P

Otpt Population Health Psych Behavioral Health Risk Assessment NA NA P

Otpt Population Health OB/GYNBehavioral Health Risk Assessment (for Pregnant Women) (BHRA) NA NA

P

Inpt Clinical Care Surgical Biopsy Follow-Up N/A N/A 265 P P

Page2 of 24









From PQRS File


Quality Indicators

Behavioral

Health Homes

CMS-AHIP

ACO

CMS-AHIP

PCMHDSRIP HER

Medicaid/

CHIP

Health

Home

HEDIS Leapfrog

NJ Innovation

Institute PTN

Project


CHIP

NJ Medicaid ACO

DemoPCPI PQRS

Performance

Based Incentive

Program

SIM


Bipolar Disorder and Major Depression: Appraisal for alcohol or

chemical substance use110

P P


Bipolar Disorder and Major Depression: Appraisal for Alcohol or

Chemical Substance Use169v4 N/A 367

P P P

Otpt Population Health OB/GYN Birth outcomes through smoking cessation efforts NA NA P


Breast Cancer Resection Pathology Reporting: pT Category (Primary

Tumor) and pN Category (Regional Lymph Nodes) with Histologic

Grade

N/A 0391 099

P P

Otpt Population Health Prevention/Screening Breast Cancer Screening (See NQF 2372) 31 P P P

Otpt Population Health Prevention/Screening Breast Cancer Screening (See NQF 31) 125v4 2372 112 P P P P P P P


Breast Cancer: Hormonal Therapy for Stage IC -IIIC Estrogen

Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer140v4 0387 071

P P

Otpt Clinical Care Asthma CAC-1: Relievers for Inpatient Asthma 143 P

Otpt Clinical Care Asthma CAC-2 systemic corticosteroids for Inpatient Asthma 144 P

Otpt Patient/Caregiver Experience Satisfaction

CAHPS ( Appointments, How Well Providers Communicate with

Patients; and Access to Specialists)

5

P P P P P

Both Inpt and OtptClinical Care Cardiac Atrial Fib/Flutter Assessment of thromboembolic risk factors P

Both Inpt and OtptClinical Care Cardiac Atrial Fib/Flutter Chronic anticoagulation therapy P

Both Inpt and OtptClinical Care Cardiac

Atrial Fib/Flutter Monthly international normalized ratio (INR)

measurement P


Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation

TherapyN/A 1525 326

P P P

Otpt Population Health Psych

Cardiovascular health screening for people with schizophrenia or

bipolar disorder who are prescribed antipsychotic medications1927

P


Cardiovascular Monitoring for People with Cardiovascular Disease

and Schizophrenia1933

P

Both Inpt and OtptCare Coordination Documentation Care Plan N/A 0326 047 P P P


Cataract Surgery with Intra-Operative Complications (Unplanned

Rupture of Posterior Capsule Requiring Unplanned VitrectomyN/A N/A 388

P P

Both Inpt and OtptClinical Care EyeCataract Surgery: Difference Between Planned and Final Refraction N/A N/A 389

P P


Cataracts: 20/40 or Better Visual Acuity within 90 Days Following

Cataract Surgery133v4 0565 191

P P


Cataracts: Complications within 30 Days Following Cataract Surgery

Requiring Additional Surgical Procedures132v4 0564 192

P P


Cataracts: Improvement in Patient’s Visual Function within 90 Days

Following Cataract SurgeryN/A 1536 303

P P


Cataracts: Patient Satisfaction within 90 Days Following Cataract

SurgeryN/A N/A 304

P P

Inpt Clinical Care Infection ControlCentral Line-Associated Bloodstream Infection (CLABSI) Event 139

P P

Otpt Population Health Prevention/Screening Cervical Cancer Screening 124v4 0032 309 P P P P P P P P P P


Child and Adolescent Major Depressive Disorder (MDD): Suicide

Risk Assessment177v4 1365 382

P P P P

Otpt Population Health PediatricsChild and Adolescents’ Access to Primary Care Practitioners (CAP) NA NA

P P

Otpt Clinical Care Pediatrics Childhood Immunization Status 117v4 0038 240 P P P P P P P

Otpt Clinical Care PediatricsChildren Age 6-17 Years who Engage in Weekly Physical Activity 1348

P

Otpt Clinical Care Pediatrics Children Who Have Dental Decay or Cavities 75v4 N/A 378 P P

Otpt Population Health Prevention/Screening Chlamydia Screening and Follow Up 1395 P

Otpt Population Health Prevention/Screening Chlamydia Screening for Women 153v4 0033 310 P P P P P P P P

Both Inpt and OtptClinical Care Cardiac CAD Antiplatelet Therapy P

Page3 of 24









From PQRS File


Quality Indicators

Behavioral

Health Homes

CMS-AHIP

ACO

CMS-AHIP

PCMHDSRIP HER

Medicaid/

CHIP

Health

Home

HEDIS Leapfrog

NJ Innovation

Institute PTN

Project


CHIP

NJ Medicaid ACO

DemoPCPI PQRS

Performance

Based Incentive

Program

SIM

Inpt Care Coordination Utilization Chronic Condition Hospital Admission indicators. NA NA P


Chronic Obstructive Pulmonary Disease (COPD): Inhaled

Bronchodilator TherapyN/A 0102 052

P P P


Chronic Obstructive Pulmonary Disease (COPD): Spirometry

EvaluationN/A 0091 051

P P P P

Inpt Clinical Care Neuro Clinical Outcome Post-Endovascular Stroke Treatment N/A N/A 409 P P

Both Inpt and OtptSafety Documentation Closing the Referral Loop: Receipt of Specialist Report 50v4 N/A 374 P P


Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer

Patients141v5 0385 072

P P

Otpt Safety Prevention/Screening

Colonoscopy Interval for Patients with a History of Adenomatous

Polyps – Avoidance of Inappropriate UseN/A 0659 185

P P P


Colorectal Cancer Resection Pathology Reporting: pT Category

(Primary Tumor) and pN Category (Regional Lymph Nodes) with

Histologic Grade

N/A 0392 100

P P

Otpt Population Health Prevention/Screening Colorectal Cancer Screening 130v4 0034 113 P P P P P P


Combination chemotherapy is considered or administered within 4

months (120 days) of diagnosis for women under 70 with AJCC T1c,

or Stage II or III hormone receptor negative breast cancer.

559

P

Otpt Care Coordination Ortho

Communication with the Physician or Other Clinician Managing On-

going Care Post-Fracture for Men and Women Aged 50 Years and

Older

N/A 0045 024

P P

Otpt Population Health Diabetes

Comprehensive Diabetes Care (CDC): Hemoglobin A1C (HbA1C)

testing57

P P P P P P P P


Consumer Assessment of Healthcare Providers and Systems

(CAHPS®) 5.0H (Child Version Including Medicaid and Children

with Chronic Conditions Supplemental Items) (CPC)

NA NA

P


Consumer Assessment of Healthcare Providers and Systems

(CAHPS®) Health Plan Survey, Version 5.0 (Medicaid) (CPA)

6

P

Both Inpt and OtptPatient/Caregiver Experience Satisfaction

Consumer Evaluation of Care: Family Members Reporting on

Participation In Treatment Planning for Themselves and Their

Children

NA NA

Inpt Care Coordination Utilization COPD Admission Rate 275 P P P


CAD Cardiac Rehabilitation Patient Referral From an Outpatient

Setting P

Both Inpt and OtptClinical Care Cardiac CAD Lipid Control P

Both Inpt and OtptClinical Care Cardiac CAD Symptom & Activity Assessment P

Both Inpt and OtptClinical Care Cardiac CAD Symptom Management P

Both Inpt and OtptPopulation Health Cardiac CAD Tobacco Use: Screening and Cessation Intervention P

Otpt Clinical Care CardiacCardiac Rehabilitation Patient Referral from an Outpatient Setting N/A 0643 243

P P


Cardiac Stress Imaging Not Meeting Appropriate Use Criteria:

Preoperative Evaluation in Low-Risk Surgery PatientsN/A N/A 322

P P

Inpt Clinical Care Cardiac


Routine Testing After Percutaneous Coronary Intervention (PCI)N/A N/A 323

P P



Testing in Asymptomatic, Low-Risk PatientsN/A N/A 324

P P P

Otpt Clinical Care CardiacCholesterol Management for Patients with Cardiovascular Conditions NA NA

P

Otpt Clinical Care Cardiac Controlling High Blood Pressure 165v4 0018 236 P P P P P P P P P P P P

Otpt Patient/Caregiver Experience Elderly Dementia: Caregiver Education and Support N/A N/A 288 P P

Otpt Clinical Care Elderly Dementia: Cognitive Assessment 149v4 N/A 281 P P

Otpt Clinical Care Elderly Dementia: Counseling Regarding Risks of Driving N/A N/A 287 P P

Otpt Clinical Care Elderly Dementia: Counseling Regarding Safety Concerns N/A N/A 286 P P

Page4 of 24









From PQRS File


Quality Indicators

Behavioral

Health Homes

CMS-AHIP

ACO

CMS-AHIP

PCMHDSRIP HER

Medicaid/

CHIP

Health

Home

HEDIS Leapfrog

NJ Innovation

Institute PTN

Project


CHIP

NJ Medicaid ACO

DemoPCPI PQRS

Performance

Based Incentive

Program

SIM

Otpt Clinical Care Elderly Dementia: Functional Status Assessment N/A N/A 282 P P

Otpt Clinical Care Elderly Dementia: Management of Neuropsychiatric Symptoms N/A N/A 284 P P

Otpt Clinical Care Elderly Dementia: Neuropsychiatric Symptom Assessment N/A N/A 283 P P

Otpt Clinical Care Elderly Dementia: Staging of Dementia N/A N/A 280 P P

Otpt Care Coordination Psych Depression Remission at Six Months N/A 0711 411 P P P

Otpt Care Coordination Psych Depression Remission at Twelve Months 159v4 0710 370 P P P P P P


Depression Response at Twelve Months- Progress Towards

Remission

1885

P P

Otpt Clinical Care Psych Depression Utilization of the PHQ-9 Tool 160v4 0712 371 P P P

Otpt Population Health PediatricsDevelopmental Screening in the First Three Years of Life (DEV) 1448

P P

Inpt Care Coordination Diabetes Diabetes Long-Term Complications Admission Rate 274 P P


Diabetes Mellitus: Daily Aspirin or Antiplatelet Medication Use for

Patients with Diabetes and Ischemic Vascular Disease729

P


Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral

Neuropathy – Neurological EvaluationN/A 0417 126

P P P


Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention –

Evaluation of FootwearN/A 0416 127

P P

Otpt Population Health PsychDiabetes Monitoring for People with Diabetes and Schizophrenia 1934

P


Diabetes screening for people with schizophrenia or bipolar disorder

who are prescribed antipsychotic medications (SSD)1932

P P

Inpt Care Coordination Diabetes Diabetes Short-Term Complications Admission Rate 272 P P P

Otpt Population Health Diabetes Diabetes: Eye Exam 131v4 0055 117 P P P P P P

Otpt Population Health Diabetes Diabetes: Foot Exam 123v4 0056 163 P P P

Otpt Clinical Care Diabetes Diabetes: Hemoglobin A1c Poor Control 122v4 0059 001 P P P P P P P

Otpt Clinical Care DiabetesDiabetes: Low Density Lipoprotein (LDL-C) Control (<100 mg/dL) 163v4 64 002

P P P P

Otpt Clinical Care Diabetes Diabetes: Medical Attention for Nephropathy 134v4 0062 119 P P P P P P

Otpt Population Health Diabetes

Diabetic Retinopathy: Communication with the Physician Managing

Ongoing Diabetes Care142v4 0089 019

P P


Diabetic Retinopathy: Documentation of Presence or Absence of

Macular Edema and Level of Severity of Retinopathy167v4 0088 018

P P

Otpt Care Coordination PsychDiagnosis of mental illness - Follow-up after acute inpatient stay

P


Diagnosis of mental illness - Advance care plan/Advance directives

or surrogate decision maker documented OR documented reason for

not providing advance care plan P


Diagnosis of mental illness - At least one outpatient visit during

reporting period with a diagnosis of hypertension P

ED Safety Psych

Diagnosis of mental illness - Cannot screening because patient is in

an urgent or emergent situation where time is of the essence and to

delay treatment would jeopardize the patient's health status P


Diagnosis of mental illness - enrollment in the BHH program for at

least 90 days during the measurement year during which an outpatient

visit occurred P


Diagnosis of mental illness - Enrollment in the BHH program from at

least the date of discharge throgh 30 days after mental health

discharge? P


Diagnosis of mental illness - Outpatient visit during the measurement

year P

Otpt Safety Psych Diagnosis of mental illness - Patient Refuses to participate screening? P


Diagnosis of mental illness - Post-discharge/patient self-management:

Patient instructions P

Page5 of 24









From PQRS File


Quality Indicators

Behavioral

Health Homes

CMS-AHIP

ACO

CMS-AHIP

PCMHDSRIP HER

Medicaid/

CHIP

Health

Home

HEDIS Leapfrog

NJ Innovation

Institute PTN

Project


CHIP

NJ Medicaid ACO

DemoPCPI PQRS

Performance

Based Incentive

Program

SIM


Diagnosis of mental illness - Post-discharge/patient self-management:

Studies pending at discharge (or documentation that no studies are

pending) P

Otpt Safety Psych

Diagnosis of mental illness - Situations where the patient's functional

capacity or motivation to improve may impact the accuracy of results

of nationally recognized standardized depression asessment tools.

For ex. Certain court-appointed cases or cases of delirium P

Otpt Clinical Care Misc

Disabled (SSI) Adults Members age 21–64 years and older who have

been enrolled for 320 days or moreNA NA

P


Disabled (SSI) Children Members age 0–20 years as of December

31st of the measurement year who have been enrolled for 320 days or

more

NA NA

P

Both Inpt and OtptSafety Pharmacy Doctors order medications through a computer NA NA P

Both Inpt and OtptSafety Pharmacy Documentation of Current Medications in the Medical Record 68v5 0419 130 P P P

Otpt Safety Psych Documentation of Signed Opioid Treatment Agreement N/A N/A 412 P P


Coronary Artery Bypass Graft (CABG): Deep Sternal Wound

Infection RateN/A 0130 165

P P

Otpt Clinical Care Elderly Elder Maltreatment Screen and Follow-Up Plan N/A N/A 181 P P

ER Population Health Psych Emergency Department Alcohol Use Screening and Follow-up NA NA P

Inpt Clinical Care CardiacCoronary Artery Bypass Graft (CABG): Postoperative Renal Failure N/A 0114 167

P P P


Emergency Medicine: Community-Acquired Bacterial Pneumonia

(CAP): Empiric Antibiotic96

P P

ER Clinical Care Radiology

Emergency Medicine: Emergency Department Utilization of CT for

Minor Blunt Head Trauma for Patients Aged 18 Years and OlderN/A N/A 415

P P

ER Clinical Care Radiology

Emergency Medicine: Emergency Department Utilization of CT for

Minor Blunt Head Trauma for Patients Aged 2 through 17 YearsN/A N/A 416

P P

Otpt Population Health OB/GYN

Epilepsy: Counseling for Women of Childbearing Potential with

EpilepsyN/A 1814 268

P P

Inpt Clinical Care Surgical Esophageal Resection NA NA P

Otpt Safety Psych Evaluation or Interview for Risk of Opioid Misuse N/A N/A 414 P P

Both Inpt and OtptSafety Falls Falls: Plan of Care N/A 0101 155 P P

Both Inpt and OtptSafety Falls Falls: Risk Assessment N/A 0101 154 P P

Both Inpt and OtptSafety Falls Falls: Screening for Fall Risk 139v4 0101 318 P P

Otpt Clinical Care Prevention/Screening Flu Vaccinations for Adults Age 18 and Older (FVA) 39 P

Otpt Care Coordination Psych Follow-up after hospitalization for a substance use disorder NA NA P

Otpt Care Coordination Psych Follow-up After Hospitalization for Mental Illness (FUH) N/A 0576 391 P P P P P P P P P

Otpt Clinical Care OB/GYN Frequency of Ongoing Prenatal Care 1391 P P P P

Otpt Clinical Care Ortho

Functional Deficit: Change in Risk-Adjusted Functional Status for

Patients with Elbow, Wrist or Hand ImpairmentsN/A 0427 222

P P



Patients with Hip ImpairmentsN/A 0423 218

P P



Patients with Knee ImpairmentsN/A 0422 217

P P



Patients with Lower Leg, Foot or Ankle ImpairmentsN/A 0424 219

P P



Patients with Lumbar Spine ImpairmentsN/A 0425 220

P P



Patients with Neck, Cranium, Mandible, Thoracic Spine, Ribs, or

Other General Orthopedic Impairments

N/A 0428 223

P P



Patients with Shoulder ImpairmentsN/A 0426 221

P P

Page6 of 24









From PQRS File


Quality Indicators

Behavioral

Health Homes

CMS-AHIP

ACO

CMS-AHIP

PCMHDSRIP HER

Medicaid/

CHIP

Health

Home

HEDIS Leapfrog

NJ Innovation

Institute PTN

Project


CHIP

NJ Medicaid ACO

DemoPCPI PQRS

Performance

Based Incentive

Program

SIM

Both Inpt and OtptEfficiency and Cost Reduction Documentation Functional Outcome Assessment N/A 2624 182 P P

Both Inpt and OtptEfficiency and Cost Reduction Documentation Functional Status Assessment for Complex Chronic Conditions 90v4 N/A 377 P P

Inpt Efficiency and Cost Reduction Ortho Functional Status Assessment for Hip Replacement 56v4 N/A 376 P P

Inpt Efficiency and Cost Reduction Ortho Functional Status Assessment for Knee Replacement 66v4 N/A 375 P P

Otpt Population Health Infection Control Gap in HIV Visits 2080 P

Both Inpt and OtptCare Coordination Documentation Health Promotion and Education NA NA P

Both Inpt and OtptEfficiency and Cost Reduction Documentation Health Status/Functional Status NA NA P


Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker

in Patients with Isolated CABG SurgeryN/A 0236 044

P P P

Inpt Clinical Care Cardiac Coronary Artery Bypass Graft (CABG): Prolonged Intubation N/A 0129 164 P P

Inpt Care Coordination Utilization Heart Failure Admission Rate 277 P P


Hematology: Chronic Lymphocytic Leukemia (CLL): Baseline Flow

CytometryN/A 0379 070

P P

Otpt Clinical Care Heme/OncHematology: Multiple Myeloma: Treatment with Bisphosphonates N/A 0380 069

P P


Hematology: Myelodysplastic Syndrome (MDS) and Acute

Leukemia: Baseline Cytogenetic Testing Performed on Bone MarrowN/A 0377 067

P P


Hematology: Myelodysplastic Syndrome (MDS): Documentation of

Iron Stores in Patients Receiving Erythropoietin TherapyN/A 0378 068

P P

Otpt Clinical Care Pediatrics Hemoglobin A1c (HbA1c) Testing for Pediatric Patients 60 P

Otpt Clinical Care Diabetes Hemoglobin A1c Test for Pediatric Patients 148v4 N/A 365 P P


Hepatitis C: Discussion and Shared Decision Making Surrounding

Treatment OptionsN/A N/A 390

P P

Otpt Population Health Infection Control Hepatitis C: Hepatitis A Vaccination N/A 0399 183 P P


Hepatitis C: Hepatitis C Virus (HCV) Genotype Testing Prior to

TreatmentN/A 0396 085

P P


Hepatitis C: Hepatitis C Virus (HCV) Ribonucleic Acid (RNA)

Testing Between 4-12 Weeks After Initiation of TreatmentN/A 0398 087

P P


Hepatitis C: Ribonucleic Acid (RNA) Testing Before Initiating

TreatmentN/A 0395 084

P P


Hepatitis C: Screening for Hepatocellular Carcinoma (HCC) in

Patients with CirrhosisN/A N/A 401

P P P

Inpt Safety OB/GYN High-Risk Deliveries NA NA P

Otpt Population Health Infection Control HIV Medical Visit Frequency N/A 2079 340 P P P

Otpt Clinical Care Infection Control HIV Viral Load Suppression N/A 2082 338 P P P P

Otpt Clinical Care Infection Control HIV/AIDS: Medical Visit 62v4 N/A 368 P P P

Otpt Clinical Care Infection ControlHIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis 52v4 0405 160

P P P

Otpt Clinical Care Infection Control HIV/AIDS: RNA Control for Patients with HIV 77v4 N/A 381 P P


HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia,

Gonorrhea, and SyphilisN/A 0409 205

P P P

Inpt

Care Coordination

Utilization

Hospital 30-day all-cause risk- standardized readmission rate

(RSRR) following acute myocardial infarction (AMI) hospitalization

505

P P P P

Inpt Care Coordination Utilization

Hospital 30-day, all-cause, risk- standardized mortality rate (RSMR)

following heart failure (HF) hospitalization for patients 18 and older

229

P P


Hospital 30-day, all-cause, risk- standardized mortality rate

(RSMR) following acute myocardial infarction (AMI) hospitalization

for patients 18 and older

230

P P

Inpt

Care Coordination

Utilization

Hospital 30-day, all-cause, risk- standardized readmission rate

(RSRR) following heart failure hospitalization

330

P P P P

Page7 of 24









From PQRS File


Quality Indicators

Behavioral

Health Homes

CMS-AHIP

ACO

CMS-AHIP

PCMHDSRIP HER

Medicaid/

CHIP

Health

Home

HEDIS Leapfrog

NJ Innovation

Institute PTN

Project


CHIP

NJ Medicaid ACO

DemoPCPI PQRS

Performance

Based Incentive

Program

SIM


Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate

(RSMR) Following Coronary Artery Bypass Graft (CABG) Surgery

2558

P

Inpt

Care Coordination

Utilization

Hospital 30-day, all-cause, unplanned, risk-standardized readmission

rate (RSRR) following coronary artery bypass graft (CABG) surgery

2515

P P

Inpt Clinical Care Cardiac Coronary Artery Bypass Graft (CABG): Stroke N/A 0131 166 P P

Inpt

Care Coordination Ortho Hospital-level 30-day, all-cause risk- standardized readmission rate

(RSRR) following elective primary total hip arthroplasty (THA)

and/or total knee arthroplasty (TKA)

1551

P P

Inpt Safety Ortho

Hospital-level risk-standardized complication rate (RSCR) following

elective primary total hip arthroplasty (THA) and/or total knee

arthroplasty (TKA)

1550

P

Inpt Clinical Care CardiacCoronary Artery Bypass Graft (CABG): Surgical Re-Exploration N/A 0115 168

P P


Coronary Artery Bypass Graft (CABG): Use of Internal Mammary

Artery (IMA) in Patients with Isolated CABG SurgeryN/A 0134 043

P P


Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme

(ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy --

Diabetes or Left Ventricular Systolic Dysfunction (LVEF < 40%)

N/A 0066 118

P P P P P

Otpt Clinical Care Prevention/ScreeningHuman Papillomavirus Vaccine for Female Adolescents (HPV) 1959

P P P P

Otpt Clinical Care Cardiac Coronary Artery Disease (CAD): Antiplatelet Therapy N/A 0067 006 P P P

Otpt Population Health Psych Identification of Alcohol & Other Drug Services NA NA P P

Both Inpt and OtptClinical Care Heme/Onc

Image Confirmation of Successful Excision of Image–Localized

Breast LesionN/A N/A 262

P P

Otpt Population Health Pediatrics Immunizations for Adolescents N/A 1407 394 P P P P P P

Inpt Clinical Care OB/GYN Incidence of Episiotomy 470 P P


Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus

(HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor)

Therapy

N/A N/A 275

P P

Otpt Clinical Care GI

Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid

Related Iatrogenic Injury – Bone Loss AssessmentN/A N/A 271

P P P


Inflammatory Bowel Disease (IBD): Preventive Care: Corticosteroid

Sparing TherapyN/A N/A 270

P P


Inflammatory Bowel Disease (IBD): Testing for Latent Tuberculosis

(TB) Before Initiating Anti-TNF (Tumor Necrosis Factor) TherapyN/A N/A 274

P P P


Coronary Artery Disease (CAD): Beta-Blocker Therapy – Prior

Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction

(LVEF < 40%)

145v4 0070 007

P P P P


Initial Antibiotic Selection for Community-Acquired Pneumonia

(CAP) in Immunocompetent Patient147

P


Initiation and Engagement of Alcohol and Other Drug Dependence

Treatment137v4 4, 2152 305, 431

P P P P P P


Initiation and Engagement of Alcohol and Other Drug Dependence

TreatmentNA NA

P P

Otpt Care Coordination Psych Integrating behavioral and physical health NA NA P

Both Clinical Care Cardiac Coronary Artery Disease (CAD): Symptom Management N/A N/A 242 P P

Inpt Clinical Care Cardiac Door to Puncture Time for Endovascular Stroke Treatment N/A N/A 413 P P

ER Clinical Care Cardiac

Emergency Medicine: 12-Lead Electrocardiogram (ECG) Performed

for Non-Traumatic Chest PainN/A 0090 054

P P

Page8 of 24









From PQRS File


Quality Indicators

Behavioral

Health Homes

CMS-AHIP

ACO

CMS-AHIP

PCMHDSRIP HER

Medicaid/

CHIP

Health

Home

HEDIS Leapfrog

NJ Innovation

Institute PTN

Project


CHIP

NJ Medicaid ACO

DemoPCPI PQRS

Performance

Based Incentive

Program

SIM


KRAS gene mutation testing performed for patients with metastatic

colorectal cancer who receive anti-epidermal growth factor receptor

monoclonal antibody therapy

1859

P

Otpt Clinical Care Prevention/Screening

Lead Screening Members age 12–23 months during the measurement

yearNA NA

P P


Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor

or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular

Systolic Dysfunction (LVSD)

135v4 0081 005

P P P P

Inpt Care Coordination Utilization Length of Stay for Common Acute Conditions NA NA P

Inpt Clinical Care OB/GYN Live Births Weighing Less Than 2,500 Grams (LBW) 1382 P

Both Inpt and OtptClinical Care Heme/Onc Lung Cancer Reporting (Biopsy/Cytology Specimens) N/A N/A 395 P P

Both Inpt and OtptClinical Care Heme/Onc Lung Cancer Reporting (Resection Specimens) N/A N/A 396 P P


Management of ADHD in primary care for school-age children and

adolescents. 107

Both Inpt and OtptSafety Safety Managing Serious Errors NA NA P

Otpt Population Health OB/GYN Maternal Depression Screening 82v3 1401 372 P P

Inpt Clinical Care OB/GYNMaternity Care: Post-Partum Follow-Up and Care Coordination N/A N/A 336

P P P

Otpt Clinical Care Smoking

Medical Assistance with Smoking and Tobacco Use Cessation

(MSC)27

P P

Otpt Clinical Care Asthma Medication Management for People with Asthma 1799 P P P P P P P

Both Inpt and OtptCare Coordination Pharmacy Medication Reconciliation Post-Discharge (see NQF 554) N/A 0097 046 P P P P P

Both Inpt and OtptPopulation Health Pharmacy Medication Reconciliation Post-Discharge (see NQF 97) 554

Both Inpt and OtptClinical Care Heme/Onc Melanoma Reporting N/A N/A 397 P P

Otpt Clinical Care Heme/Onc Melanoma: Continuity of Care – Recall System N/A 0650 137 P P

Both Inpt and OtptCare Coordination Heme/Onc Melanoma: Coordination of Care N/A N/A 138 P P

Otpt Safety Heme/Onc Melanoma: Overutilization of Imaging Studies in Melanoma N/A 0562 224 P P

Otpt Safety Prevention/Screening

Non-recommended Cervical Cancer Screening in Adolescent Females

(The percentage of women under the age of 21 who were screened

unnecessarily for cervical cancer.)

N/A N/A N/A

P P


Nuclear Medicine: Correlation with Existing Imaging Studies for All

Patients Undergoing Bone ScintigraphyN/A N/A 147

P P

Otpt Population Health Psych Obesity rates for persons with serious mental illness (SMI) NA NA

Otpt Clinical Care Heme/Onc Oncology: Medical and Radiation – Pain Intensity Quantified 157v4 0384 143 P P

Otpt Clinical Care Heme/Onc Oncology: Medical and Radiation – Plan of Care for Pain N/A 0383 144 P P

Otpt Clinical Care Heme/Onc Oncology: Radiation Dose Limits to Normal Tissues N/A 0382 156 P P

Otpt Clinical Care Prevention/ScreeningOne-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk N/A N/A 400

P P P


Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular

Systolic Dysfunction (LVSD)144v4 0083 008

P P P

Otpt Care Coordination Psych Opioid Therapy Follow-up Evaluation N/A N/A 408 P P

Otpt Clinical Care Asthma Optimal Asthma Control N/A N/A 398 P P P


Optimizing Patient Exposure to Ionizing Radiation: Appropriateness:

Follow-up CT Imaging for Incidentally Detected Pulmonary Nodules

According to Recommended Guidelines

N/A N/A 364

P P


Optimizing Patient Exposure to Ionizing Radiation: Computed

Tomography (CT) Images Available for Patient Follow-up and

Comparison Purposes

N/A N/A 362

P P


Optimizing Patient Exposure to Ionizing Radiation: Count of

Potential High Dose Radiation Imaging Studies: Computed

Tomography (CT) and Cardiac Nuclear Medicine Studies

N/A N/A 360

P P


Optimizing Patient Exposure to Ionizing Radiation: Reporting to a

Radiation Dose Index RegistryN/A N/A 361

P P

Page9 of 24









From PQRS File


Quality Indicators

Behavioral

Health Homes

CMS-AHIP

ACO

CMS-AHIP

PCMHDSRIP HER

Medicaid/

CHIP

Health

Home

HEDIS Leapfrog

NJ Innovation

Institute PTN

Project


CHIP

NJ Medicaid ACO

DemoPCPI PQRS

Performance

Based Incentive

Program

SIM


Optimizing Patient Exposure to Ionizing Radiation: Search for Prior

Computed Tomography (CT) Studies Through a Secure, Authorized,

Media-Free, Shared Archive

N/A N/A 363

P P


Optimizing Patient Exposure to Ionizing Radiation: Utilization of a

Standardized Nomenclature for Computed Tomography (CT) Imaging

Description

N/A N/A 359

P P

Otpt Clinical Care Ortho Osteoarthritis (OA): Function and Pain Assessment N/A N/A 109 P P

Otpt Clinical Care Ortho Osteoporosis Management in Women Who Had a Fracture N/A 0053 418 P P


Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50

Years and OlderN/A N/A 041

P P P


Overuse Of Neuroimaging For Patients With Primary Headache And

A Normal Neurological ExaminationN/A N/A 419

P P

Both Inpt and OtptPatient/Caregiver Experience Satisfaction PACIC Survey – measures patient engagement in care NA NA

Both Inpt and OtptCare Coordination Documentation Pain Assessment and Follow-Up N/A 0420 131 P P

Otpt Clinical Care Misc Pain Brought Under Control Within 48 Hours N/A N/A 342 P P

Inpt Clinical Care Surgical Pancreatic Resection NA NA P

Otpt Clinical Care NeuroParkinson’s Disease: Annual Parkinson’s Disease Diagnosis Review N/A N/A 289

P P

Otpt Clinical Care Neuro

Parkinson’s Disease: Cognitive Impairment or Dysfunction

AssessmentN/A N/A 291

P P


Parkinson’s Disease: Parkinson’s Disease Medical and Surgical

Treatment Options ReviewedN/A N/A 294

P P


Parkinson’s Disease: Psychiatric Disorders or Disturbances

AssessmentN/A N/A 290

P P

Otpt Clinical Care Neuro Parkinson’s Disease: Querying about Sleep Disturbances N/A N/A 292 P P

Otpt Clinical Care Neuro Parkinson’s Disease: Rehabilitative Therapy Options N/A N/A 293 P P

Inpt Patient/Caregiver Experience Satisfaction

Patient Experience with Surgical Care Based on the Consumer

Assessment of Healthcare Providers and Systems (CAHPS®)

Surgical Care Survey

1741

P P

Inpt Safety SurgicalPatient-Centered Surgical Risk Assessment and Communication N/A N/A 358

P P

Otpt Population Health Psych Patients Discharged on Multiple Antipsychotic Medications 552 P

Both Inpt and OtptPatient/Caregiver Experience Satisfaction Patients Rating of Doctor NA NA P

Otpt Population Health Psych Patients reporting abstinence after treatment for addiction (Future)NA NA


Patients with breast cancer and negative or undocumented human

epidermal growth factor receptor 2 (HER2) status who are spared

treatment with trastuzumab

1857

P

Inpt Clinical Care OB/GYN

PC-01 Elective Delivery

(Patients with elective vaginal

deliveries or elective cesarean sections at >= 37 and < 39 weeks of

gestation completed)

469

335

P P P P P P


PC-02 Cesarean Section

(Nulliparous women with a term, singleton baby in a vertex position

delivered by cesarean section)

471

P P


PC-03 Antenatal Steroids

(Patients at risk of preterm delivery at >=24 and <32 weeks gestation

receiving antenatal steroids prior to delivering preterm newborns)

476

P P P

Otpt Clinical Care OB/GYN PC-05 Exclusive Breast Milk Feeding and the subset measure 480 P

Otpt Clinical Care Neph Pediatric Kidney Disease: Adequacy of Volume Management: N/A N/A 327 P P


Pediatric Kidney Disease: ESRD Patients Receiving Dialysis:

Hemoglobin Level < 10 g/DlN/A 1667 328

P P

Otpt Clinical Care Pediatrics Pediatric Symptom Checklist 722

Otpt Clinical Care OB/GYN

Pelvic Organ Prolapse: Preoperative Assessment of Occult Stress

Urinary Incontinence N/A N/A 428

P P

Page10 of 24









From PQRS File


Quality Indicators

Behavioral

Health Homes

CMS-AHIP

ACO

CMS-AHIP

PCMHDSRIP HER

Medicaid/

CHIP

Health

Home

HEDIS Leapfrog

NJ Innovation

Institute PTN

Project


CHIP

NJ Medicaid ACO

DemoPCPI PQRS

Performance

Based Incentive

Program

SIM


Pelvic Organ Prolapse: Preoperative Screening for Uterine

Malignancy N/A N/A 429

P P

Both Inpt and OtptSafety DocumentationPercent of PCPs for Successfully Qualify for EHR Incentive Payment NA NA

P


Percentage of behavioral health providers (CMHCs, SA providers)

offering screening, services, and/or referral to treatment for health

conditions

NA NA

P

Otpt Population Health Dental

Percentage of Eligibles Who Received Preventive Dental Services

(PDENT)NA NA

P P P


Percentage of health providers (FQHCs, CHCs, private practitioners)

offering screening, services, and/or referral to treatment for

behavioral health conditions

NA NA


Performing Cystoscopy at the Time of Hysterectomy for Pelvic Organ

Prolapse to Detect Lower Urinary Tract InjuryN/A 2063 422

P P

Inpt Clinical Care Neuro

Perioperative Anti-platelet Therapy for Patients Undergoing Carotid

EndarterectomyN/A 0465 423

P P

Inpt Clinical Care Infection Control

Perioperative Care: Discontinuation of Prophylactic Parenteral

Antibiotics (Non-Cardiac Procedures)N/A 0271 022

P P


Perioperative Care: Selection of Prophylactic Antibiotic – First OR

Second Generation CephalosporinN/A 0268 021

P P

Inpt Clinical Care Surgical Perioperative Temperature Management N/A 2681 424 P P

Otpt Clinical Care GI Photodocumentation of Cecal Intubation N/A N/A 425 P P

Inpt Care Coordination Utilization Plan All-Cause Readmission Rate NA NA P

Inpt Care Coordination Utilization Plan All-Cause Readmissions (PCR) 1768 P P P P

Otpt Population Health Prevention/Screening Pneumococcal Immunization (PPV 23) 1653 P P

Otpt Clinical Care Prevention/Screening Pneumonia Vaccination Status for Older Adults 127v4 0043 111 P P


Population reporting knowledge of appropriate alcohol consumption

amounts (Future)NA NA

P

Inpt Clinical Care Surgical

Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post

Anesthesia Care Unit (PACU): N/A N/A 426

P P


Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for

Direct Transfer of Care from Procedure Room to Intensive Care Unit

(ICU)

N/A N/A 427

P P

Inpt Patient/Caregiver Experience Cardiac

Heart Failure Counseling regarding Implantable Cardioverter-

Defibrillator (ICD) Implantation for Patients with Left Ventricular

Systolic Dysfunction on Combination Medical TherapyP


PQI #05 Chronic Obstructive Pulmonary Disease (COPD) or Asthma

in Older Adults Admission RateNA NA

P

Inpt Care Coordination Utilization PQI #07 Hypertension Admission Rate NA NA P

Inpt Care Coordination Utilization PQI #10 Dehydration Admission Rate NA NA P

Inpt Care Coordination Utilization PQI #11 Bacterial Pneumonia Admission Rate NA NA P

Inpt Care Coordination Infection Control PQI #12 Urinary Tract Infection Admission Rate NA NA P P

Inpt Care Coordination Utilization PQI #13 Angina without Procedure Admission Rate NA NA P

Otpt Care Coordination Diabetes PQI #14 Uncontrolled Diabetes Admission Rate NA NA P

Otpt Safety Diabetes

PQI #16 Rate of Lower-Extremity Amputation Among Patients With

DiabetesNA NA

P

Otpt Population Health OB/GYN Pregnant Women that had HBsAg Testing 158v4 N/A 369 P P

Otpt Population Health OB/GYN Prenatal & Postpartum Care: Postpartum Care Rate (PPC) 1517 P P P P P P P

Both Inpt and OtptClinical Care Heme/Onc Preoperative Diagnosis of Breast Cancer N/A N/A 263 P P

Otpt Clinical Care Infection Control Prescription of HIV Antiretroviral Therapy N/A 2083 339 P P

Inpt Population Health OB/GYN Pre-Term Births N/A P

Otpt Population Health Psych Prevalence of alcohol and drug dependence NA NA P

Both Inpt and OtptPopulation Health Pharmacy Prevalence of prescription drug abuse/misuse by age (Future) NA NA

Otpt Population Health Psych Prevalence of suicide attempts NA NA

Page11 of 24









From PQRS File


Quality Indicators

Behavioral

Health Homes

CMS-AHIP

ACO

CMS-AHIP

PCMHDSRIP HER

Medicaid/

CHIP

Health

Home

HEDIS Leapfrog

NJ Innovation

Institute PTN

Project


CHIP

NJ Medicaid ACO

DemoPCPI PQRS

Performance

Based Incentive

Program

SIM

Otpt Population Health Smoking

Prevalence of tobacco use by age and by behavioral health condition

(Future)NA NA

Inpt Care Coordination Utilization Preventable Hospitalizations NA NA P


Prevention of Central Venous Catheter (CVC)-Related Bloodstream

InfectionsN/A N/A 076

P P


Prevention of Post-Operative Nausea and Vomiting (PONV) –

Combination TherapyN/A N/A 430

P P


Prevention: Dental Sealants for 6–9 Year-Old Children at Elevated

Caries Risk (SEAL)*2508

P

Both Inpt and OtptPopulation Health Documentation

Preventive Care and Screening: Body Mass Index (BMI) Screening

and Follow-Up Plan69v4 0421 128

P P P P P P P P


Preventive Care and Screening: Cholesterol – Fasting Low Density

Lipoprotein (LDL-C) Test Performed AND Risk-Stratified Fasting

LDL-C

61v5 &

64v5N/A 316

P P P

Otpt Population Health Prevention/Screening Preventive Care and Screening: Influenza Immunization 147v5 0041 110 P P


Preventive Care and Screening: Screening for Clinical Depression

and Follow-Up Plan2v5 0418 134

P P P P P P P


Preventive Care and Screening: Screening for High Blood Pressure

and Follow-Up Documented22v4 N/A 317

P P P

Otpt Population Health Smoking

Preventive Care and Screening: Tobacco Use: Screening and

Cessation Intervention138v4 0028 226

P P P P P


Preventive Care and Screening: Unhealthy Alcohol Use: Screening &

Brief CounselingN/A 2152 431

P P P

Otpt Population Health Dental

Primary Caries Prevention Intervention as Offered by Primary Care

Providers, including Dentists74v5 N/A 379

P P

Otpt Clinical Care EyePrimary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation 143v4 0086 012

P P


Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular

Pressure (IOP) by 15% OR Documentation of a Plan of CareN/A 0563 141

P P


Heart Failure Left Ventricular Ejection Fraction (LVEF) Assessment

(Inpatient Setting) P

Inpt Clinical Care Infection ControlProphylactic Antibiotic Selection for Surgical Patients - Overall Rate 528

P


Prophylactic Antibiotics Discontinued Within 24 Hours After

Surgery End Time - Overall Rate529

P


Proportion of Patients Sustaining a Bladder Injury at the Time of any

Pelvic Organ Prolapse RepairN/A N/A 432

P P


Proportion of Patients Sustaining a Major Viscus Injury at the Time

of Any Pelvic Organ Prolapse RepairN/A N/A 433

P P


Proportion of Patients Sustaining A Ureter Injury at the Time of any

Pelvic Organ Prolapse RepairN/A N/A 434

P P


Prostate Cancer: Adjuvant Hormonal Therapy for High Risk or Very

High Risk Prostate CancerN/A 0390 104

P P


Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging

Low Risk Prostate Cancer Patients129v5 0389 102

P P

Inpt Care Coordination Utilization Provider visit within 7 days of Hospital Discharge NA NA P

Both Inpt and OtptClinical Care Pharmacy

Psoriasis: Clinical Response to Oral Systemic or Biologic

MedicationsN/A N/A 410

P P


Quality Of Life Assessment For Patients With Primary Headache

DisordersN/A N/A 435

P P


Quantitative Immunohistochemical (IHC) Evaluation of Human

Epidermal Growth Factor Receptor 2 Testing (HER2) for Breast

Cancer Patients

N/A 1855 251

P P P


Radiation Consideration for Adult CT: Utilization of Dose Lowering

TechniquesN/A N/A 436

P P

Page12 of 24









From PQRS File


Quality Indicators

Behavioral

Health Homes

CMS-AHIP

ACO

CMS-AHIP

PCMHDSRIP HER

Medicaid/

CHIP

Health

Home

HEDIS Leapfrog

NJ Innovation

Institute PTN

Project


CHIP

NJ Medicaid ACO

DemoPCPI PQRS

Performance

Based Incentive

Program

SIM

Otpt Clinical Care Heme/Onc Radical Prostatectomy Pathology Reporting N/A 1853 250 P P

Otpt Safety Radiology

Radiology: Exposure Time Reported for Procedures Using

FluoroscopyN/A N/A 145

P P


Radiology: Inappropriate Use of “Probably Benign” Assessment

Category in Mammography ScreeningN/A 0508 146

P P

Otpt Population Health Prevention/Screening Radiology: Reminder System for Screening Mammograms N/A 0509 225 P P

Otpt Clinical Care Prevention/Screening Radiology: Stenosis Measurement in Carotid Imaging Reports N/A 0507 195 P P


Heart Failure Left Ventricular Ejection Fraction (LVEF) Assessment

(Outpatient Setting) P


Rate of Carotid Artery Stenting (CAS) for Asymptomatic Patients,

Without Major Complications (Discharged to Home by Post-

Operative Day #2)

N/A N/A 344

P P


Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients,

without Major Complications (Discharged to Home by Post-

Operative Day #2)

N/A N/A 260

P P

Both Inpt and OtptPatient/Caregiver Experience Cardiac Heart Failure Patient Self-Care Education P


Rate of Endovascular Aneurysm Repair (EVAR) of Small or

Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA)

without Major Complications (Discharged to Home by Post-

Operative Day #2)

N/A N/A 259

P P P


Rate of Open Repair of Small or Moderate Non-Ruptured Abdominal

Aortic Aneurysms (AAA) without Major Complications (Discharged

to Home by Post-Operative Day #7)

N/A N/A 258

P P P


Rate of Postoperative Stroke or Death in Asymptomatic Patients

Undergoing Carotid Artery Stenting (CAS)N/A 1543 345

P P


Rate of Postoperative Stroke or Death in Asymptomatic Patients

Undergoing Carotid Endarterectomy (CEA)N/A 1540 346

P P

Otpt Care Coordination CardiacHeart Failure Post-Discharge Appointment for Heart Failure Patients

P

Inpt Efficiency and Cost Reduction Utilization Ratio of detox to outpatient admissions NA NA

Both Inpt and OtptCare Coordination Pharmacy

Reconciled Medication List Received by Discharged Patients

(Discharges from an Inpatient Facility to Home/Self Care or Any

Other Site of Care) (see NQF 97 and 554) 646 P

Inpt Safety Safety Reduce Hospital-Acquired Injuries NA NA P

Inpt Safety Safety Reduce Hospital-Acquired Pressure Ulcers NA NA P

Inpt

Care Coordination UtilizationReduction in unplanned 30 day readmissions per 1,000 population N/A N/A

P


Referral for Otologic Evaluation for Patients with Acute or Chronic

DizzinessN/A N/A 261

P P

Both Inpt and OtptPatient/Caregiver Experience Documentation Referrals/Connections to Social Supports (housing, food) NA NA P


Rehospitalization rates for persons with behavioral health conditions

(Future)NA NA

ER Care Coordination Utilization Return to ED within 7 days of Hospital Discharge NA NA P


Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at

Risk of Fetal Blood ExposureN/A N/A 255

P P


Rheumatoid Arthritis (RA): Assessment and Classification of Disease

PrognosisN/A N/A 179

P P


Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug

(DMARD) TherapyN/A 0054 108

P P

Otpt Clinical Care Ortho Rheumatoid Arthritis (RA): Functional Status Assessment N/A N/A 178 P P

Otpt Clinical Care Ortho Rheumatoid Arthritis (RA): Glucocorticoid Management N/A N/A 180 P P

Otpt Clinical Care OrthoRheumatoid Arthritis (RA): Periodic Assessment of Disease Activity N/A N/A 177

P P P

Otpt Clinical Care Ortho Rheumatoid Arthritis (RA): Tuberculosis Screening N/A N/A 176 P P

Page13 of 24









From PQRS File


Quality Indicators

Behavioral

Health Homes

CMS-AHIP

ACO

CMS-AHIP

PCMHDSRIP HER

Medicaid/

CHIP

Health

Home

HEDIS Leapfrog

NJ Innovation

Institute PTN

Project


CHIP

NJ Medicaid ACO

DemoPCPI PQRS

Performance

Based Incentive

Program

SIM

Inpt

Care Coordination Utilization Risk-Adjusted Coronary Artery Bypass Graft (CABG) Readmission

Rate (30-days)

2514

P P

Both Inpt and OtptClinical Care Cardiac Heart Failure Symptom and Activity Assessment P

Otpt Population Health Psych Risky behavior assessment or counseling by age 13 1406

Otpt Population Health Psych Risky behavior assessment or counseling by age 18 1507

Otpt Population Health Pediatrics RSV in Neonates <35 weeks NA NA P

Otpt Population Health Prevention/Screening Screening Colonoscopy Adenoma Detection Rate Measure N/A N/A 343 P P P

Otpt Care Coordination Psych Screening for Clinical Depression and Follow-Up Plan NA NA P P

Otpt Population Health Prevention/ScreeningScreening for Osteoporosis for Women Aged 65-85 Years of Age N/A 0046 039

P P


Seclusion and restraint rates in residential/inpatient treatment settings

(Future)NA NA

Both Inpt and OtptClinical Care Heme/Onc Sentinel Lymph Node Biopsy for Invasive Breast Cancer N/A N/A 264 P P

Otpt Patient/Caregiver Experience Misc Shared Decision Making NA NA P

Otpt Clinical Care sleep

Sleep Apnea: Assessment of Adherence to Positive Airway Pressure

TherapyN/A N/A 279

P P

Otpt Clinical Care sleep Sleep Apnea: Assessment of Sleep Symptoms N/A N/A 276 P P

Otpt Clinical Care sleep Sleep Apnea: Positive Airway Pressure Therapy Prescribed N/A N/A 278 P P

Otpt Clinical Care sleep Sleep Apnea: Severity Assessment at Initial Diagnosis N/A N/A 277 P P

Otpt Population Health Smoking Smoking rates for persons with serious mental illness NA NA

Inpt Safety Misc Specially trained doctors care for ICU patients NA NA P

Inpt Safety Pediatrics

Standardized adverse event ratio for children < 18 years of age

undergoing cardiac catheterization

715

P

Both Inpt and OtptClinical Care Cardiac Heart Failure Symptom Management P

Inpt Safety Cardiac

Hospital Risk-Standardized Complication Rate following

Implantation of Implantable Cardioverter-Defibrillator (ICD)

694

P

Both Inpt and OtptSafety Safety Steps to Avoid Harm NA NA P


Stroke and Stroke Rehabilitation: Discharged on Antithrombotic

TherapyN/A 0325 032

P P

Inpt Clinical Care Neuro Stroke and Stroke Rehabilitation: Thrombolytic Therapy N/A N/A 187 P P

Inpt Safety Infection Control Surgical Site Infection (SSI) N/A N/A 357 P P

Inpt Safety Cardiac

HRS-12: Cardiac Tamponade and/or Pericardiocentesis Following

Atrial Fibrillation AblationN/A 2474 392

P P

Inpt Safety Documentation

Timely Transmission of Transition Record (Discharges from an

Inpatient Facility to Home/Self Care or Any Other Site of Care)648

P P P

Otpt Population Health Smoking Tobacco Use and Help with Quitting Among Adolescents N/A N/A 402 P P

Inpt Clinical Care Ortho

Total Knee Replacement: Identification of Implanted Prosthesis in

Operative ReportN/A N/A 353

P P


Total Knee Replacement: Preoperative Antibiotic Infusion with

Proximal TourniquetN/A N/A 352

P P


Total Knee Replacement: Shared Decision-Making: Trial of

Conservative (Non-surgical) TherapyN/A N/A 350

P P


Total Knee Replacement: Venous Thromboembolic and

Cardiovascular Risk EvaluationN/A N/A 351

P P

Inpt Safety Documentation Transmission of Timely Transition Record NA NA P

Both Inpt and OtptPatient/Caregiver Experience Documentation Transportation NA NA P


Trastuzumab administered to patients with AJCC stage I (T1c) – III

and human epidermal growth factor receptor 2 (HER2) positive

breast cancer who receive adjuvant chemotherapy

1858

P


Tuberculosis Prevention for Psoriasis,Psoriatic Arthritis and

Rheumatoid Arthritis Patients on a Biological Immune Response

Modifier

N/A N/A 337

P P


Ultrasound Determination of Pregnancy Location for Pregnant

Patients with

Abdominal Pain

N/A 0651 254

P P

Page14 of 24









From PQRS File


Quality Indicators

Behavioral

Health Homes

CMS-AHIP

ACO

CMS-AHIP

PCMHDSRIP HER

Medicaid/

CHIP

Health

Home

HEDIS Leapfrog

NJ Innovation

Institute PTN

Project


CHIP

NJ Medicaid ACO

DemoPCPI PQRS

Performance

Based Incentive

Program

SIM

Inpt Care Coordination Diabetes Uncontrolled Diabetes Admission Rate 638 P

Otpt Population Health Psych Unhealthy Alcohol Use Screening N/A N/A P P

Inpt

Care Coordination Utilization Unplanned Hospital Readmission within 30 Days of Principal

ProcedureN/A N/A 356

P P P

Inpt Safety SurgicalUnplanned Reoperation within the 30 Day Postoperative Period N/A N/A 355

P P


Urinary catheter removed on Postoperative Day 1 (POD 1) or

Postoperative Day 2 (POD 2) with day of surgery being day zero453

P


Urinary Incontinence: Assessment of Presence or Absence of Urinary

Incontinence in Women Aged 65 Years and OlderN/A N/A 048

P P


Urinary Incontinence: Plan of Care for Urinary Incontinence in

Women Aged 65 Years and OlderN/A N/A 050

P P

Otpt Population Health Asthma Use of Appropriate Medications for Asthma 126v4 0036 311 P P P P

Otpt Clinical Care Elderly Use of High-Risk Medications in the Elderly 156v4 0022 238 P P

Otpt Clinical Care Radiology Use of Imaging Studies for Low Back Pain 166v5 0052 312 P P P P P

Otpt Clinical Care Psych Use of Opioids at High Dosage (OHD)* N/A N/A P


HRS-3: Implantable Cardioverter-Defibrillator (ICD) Complications

RateN/A N/A 348

P P

Inpt Safety Cardiac

HRS-9: Infection within 180 Days of Cardiac Implantable Electronic

Device (CIED) Implantation, Replacement, or Revision N/A N/A 393

P P

Otpt Population Health Pediatrics

Weight Assessment and Counseling for Nutrition and Physical

Activity for Children and Adolescents155v4 0024 239

P P P P P P P P

Otpt Clinical Care Pediatrics Well-Child Visits in the First 15 Months of Life 1392 P P P P P P

Otpt Population Health Pediatrics

Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life

(W34)1516

P P P P

Inpt Clinical Care ENT Acute otitis externa Pain Assessment P

Inpt Clinical Care ENT

Acute otitis externa Antihistamines or Decongestants – Avoidance of

Inappropriate Use P


Acute otitis externa Diagnostic Evaluation – Assessment of Tympanic

Membrane Mobility P

Inpt Clinical Care ENT Acute otitis externa Hearing Testing P


Acute otitis externa Systemic Corticosteroids – Avoidance of

Inappropriate Use P


Adult Sinusitis Accurate Diagnosis of Acute Sinusitis: Distinguishing

Viral Vs. Bacterial Sinusitis P


Adult Sinusitis Appropriate Diagnostic Testing for Chronic Sinusitis

(underuse) P


Adult Sinusitis Computerized Tomography for Acute Sinusitis

(overuse) P

Inpt Safety ENT

Adult Sinusitis More than One Computerized Tomography (CT) Scan

Within 90 Days for Chronic Sinusitis (overuse) P

Inpt Patient/Caregiver Experience ENT

Adult Sinusitis Patient-Reported Health Status Follow-up for Chronic

Sinusitis (Quality Improvement Only) P

Inpt Patient/Caregiver Experience ENT

Adult Sinusitis Patient-Reported Health Status at Time of Diagnosis

for Chronic Sinusitis (Quality Improvement Only) P

Inpt Clinical Care ENTAdult Sinusitis Plain Film Radiography for Acute Sinusitis (overuse)

P


Adult Sinusitis Premature Changing of Initial Antibiotic for Acute

Bacterial Sinusitis (overuse) P


Adult Sinusitis Watchful Waiting for Acute Bacterial Sinusitis: Initial

Observation Without Antibiotics for Patients With Mild Illness

(appropriate use) P

Otpt Clinical Care Misc Anesthesia/CC Perioperative temperature management P

Page15 of 24









From PQRS File


Quality Indicators

Behavioral

Health Homes

CMS-AHIP

ACO

CMS-AHIP

PCMHDSRIP HER

Medicaid/

CHIP

Health

Home

HEDIS Leapfrog

NJ Innovation

Institute PTN

Project


CHIP

NJ Medicaid ACO

DemoPCPI PQRS

Performance

Based Incentive

Program

SIM


Anesthesia/CC Prevention of catheter-related bloodstream infections

(CRBSI) – central venous catheter (CVC) insertion protocolP


Anesthesia/CC Prevention of ventilator-associated pneumonia – head

elevation P

Both Inpt and OtptClinical Care Pulmonary Asthma assessment P

Otpt Clinical Care Misc Atopic Dermatitis Disease Assessment P

Otpt Clinical Care Misc Atopic Dermatitis Moisture Care P

Otpt Clinical Care Misc Atopic Dermatitis Reevaluation of Treatment P


Atopic Dermatitis Topical Steroid Preparations and Anti-

Inflammatory Agents P

Otpt Clinical Care Cardiac Hypertension Blood Pressure Control P

Otpt Clinical Care Cardiac Hypertension: Improvement in Blood Pressure 65v5 N/A 373 P P P

Inpt Safety Cardiac

In-hospital Risk Adjusted Rate of Bleeding Events for Patients

Undergoing PCI

2459

P

Otpt Care Coordination Documentation

Care Transition Reconciled Medication List Received by Discharged

Patients P


Care Transition Transition Record with Specified Elements Received

by Discharged Patients (Emergency Department Discharges)P


Care Transition Transition Record with Specified Elements Received

by Discharged Patients (Inpatient Discharges) P

Both Inpt and OtptClinical Care Pulmonary COPD Assessment of oxygen saturation P

Both Inpt and OtptClinical Care Pulmonary COPD Assessment of pneumococcus immunization status P

Both Inpt and OtptClinical Care Pulmonary COPD Assessment of symptoms P

Both Inpt and OtptClinical Care Pulmonary COPD Influenza immunization administered P

Both Inpt and OtptClinical Care Pulmonary COPD Long term oxygen therapy P

Both Inpt and OtptPopulation Health Pulmonary COPD Pneumococcus immunization administered P

Both Inpt and OtptClinical Care PulmonaryCOPD Pulmonary rehabilitation: exercise training recommended

P

Both Inpt and OtptClinical Care Pulmonary COPD Recommendation of influenza immunization P

Both Inpt and OtptPopulation Health Pulmonary COPD Smoking assessment P

Both Inpt and OtptPopulation Health Pulmonary COPD Smoking cessation intervention P

Inpt Clinical Care Cardiac Intensive Care Unit Venous Thromboembolism Prophylaxis 372 P


Ischemic Vascular Disease (IVD): Complete Lipid Profile and LDL-

C Control (< 100 mg/dL)182v5 75 241

P P P P


Ischemic Vascular Disease (IVD): Use of Aspirin or Another

Antithrombotic164v4 0068 204

P P P P P

Otpt Clinical Care Cardiac Left Ventricular Ejection Fraction (LVEF) Assessment 79 P

Inpt Safety Cardiac

Operative Mortality Stratified by the Five STS-EACTS Mortality

Categories

733

P

Inpt Clinical Care Cardiac PCI Annual Hospital PCI Volume P

Inpt Clinical Care Cardiac PCI Annual Operator PCI Volume P

Both Inpt and OtptClinical Care Surgical

Chronic Wound Assessment of wound characteristics in patients

undergoing debridement P

Both Inpt and OtptClinical Care SurgicalChronic Wound Offloading (pressure relief) of diabetic foot ulcers

P

Both Inpt and OtptClinical Care Surgical Chronic Wound Patient education regarding diabetic foot care P


Chronic Wound Patient education regarding long term compression

therapy P


Chronic Wound Use of compression system in patients with venous

ulcers P


Chronic Wound Use of wet to dry dressings in patients with chronic

skin ulcers (overuse measure) P


Chronic Wound Use of wound surface culture technique in patients

with chronic skin ulcers (overuse measure) P

Page16 of 24









From PQRS File


Quality Indicators

Behavioral

Health Homes

CMS-AHIP

ACO

CMS-AHIP

PCMHDSRIP HER

Medicaid/

CHIP

Health

Home

HEDIS Leapfrog

NJ Innovation

Institute PTN

Project


CHIP

NJ Medicaid ACO

DemoPCPI PQRS

Performance

Based Incentive

Program

SIM

Both Inpt and OtptClinical Care Pulmonary CAP Assessment of co-morbid conditions P

Both Inpt and OtptClinical Care Pulmonary CAP Assessment of hydration status P

Both Inpt and OtptClinical Care Pulmonary CAP Assessment of influenza immunization status P

Both Inpt and OtptClinical Care Pulmonary CAP Assessment of mental status P

Both Inpt and OtptClinical Care Pulmonary CAP Assessment of oxygen saturation P

Both Inpt and OtptClinical Care Pulmonary CAP Chest radiograph P

Both Inpt and OtptClinical Care Pulmonary CAP Level of care rationale P

Both Inpt and OtptPopulation Health Pulmonary CAP Smoking assessment P

Both Inpt and OtptPopulation Health Pulmonary CAP Smoking cessation recommendation P

Both Inpt and OtptClinical Care Pulmonary CAP Vital signs P

Both Inpt and OtptClinical Care Neuro Dementia Care Caregiver Education and Support P

Both Inpt and OtptClinical Care Neuro Dementia Care Cognitive Assessment P

Both Inpt and OtptClinical Care Neuro Dementia Care Counseling Regarding Safety Concerns P

Both Inpt and OtptClinical Care Neuro Dementia Care Counseling regarding Risks of Driving P

Both Inpt and OtptClinical Care Neuro Dementia Care Functional Status Assessment P

Both Inpt and OtptClinical Care Neuro Dementia Care Management of Neuropsychiatric Symptoms P

Both Inpt and OtptClinical Care Neuro Dementia Care Neuropsychiatric Symptom Assessment P

Both Inpt and OtptCare Coordination Neuro

Dementia Care Palliative Care Counseling and Advance Care

Planning P

Both Inpt and OtptClinical Care Neuro Dementia Care Screening for Depressive Symptoms P

Both Inpt and OtptClinical Care Neuro Dementia Care Staging of Dementia P

Both Inpt and OtptClinical Care Diabetes

Diabetes Measure #1a: Estimated Glomerular Filtration Rate

(eGFR) & Urine Albumin Result (Paired) P

Both Inpt and OtptClinical Care Diabetes Diabetes Measure #1b: Nephrologist Consultation (Paired) P


Diabetes Measure #2a: Diabetes Self-Management

Education/Training (DSME/T) Program Attendance Within 12

Months of New Diagnosis (Paired) P


Diabetes Measure #2b: Diabetes Self-Management

Education/Training (DSME/T) Program Attendance Within 6 Months

Before or 6 Months After the Start of Insulin Therapy (Paired)P

ed Clinical Care Misc

Emergency 12-Lead electrocardiogram performed for non-traumatic

chest pain P

ed Clinical Care Misc Emergency 12-Lead electrocardiogram performed for syncope P

ed Clinical Care Misc Emergency Aspirin at arrival for AMI P


Emergency Assessment of mental status for community-acquired

bacterial pneumonia P


Emergency Assessment of oxygen saturation for community-acquired

bacterial pneumonia P

ed Clinical Care Misc Emergency Care coordination for PCI (QI) P


Emergency Fibrinolytic therapy ordered within 20 minutes of 12-

Lead ECG performed for AMI (QI) P

ed Clinical Care MiscEmergency Vital signs for community-acquired bacterial pneumonia

P


Endoscopy Colonoscopy Interval for Patients with a History of

Adenomatous Polyps- Avoidance of Inappropriate Use P

Otpt Clinical Care GI Endoscopy Comprehensive Colonoscopy Documentation P


Eye Care Age-related Macular Degeneration (AMD): Counseling on

Antioxidant Supplements P


Eye Care Age-related Macular Degeneration: Antioxidant

Supplement Prescribed/Recommended P


Eye Care Cataracts: 20/40 or Better Visual Acuity within 90 Days

Following Cataract Surgery P


Eye Care Cataracts: Complications within 30 Days Following

Cataract Surgery P

Page17 of 24









From PQRS File


Quality Indicators

Behavioral

Health Homes

CMS-AHIP

ACO

CMS-AHIP

PCMHDSRIP HER

Medicaid/

CHIP

Health

Home

HEDIS Leapfrog

NJ Innovation

Institute PTN

Project


CHIP

NJ Medicaid ACO

DemoPCPI PQRS

Performance

Based Incentive

Program

SIM


Eye Care Cataracts: Comprehensive Pre-operative Assessment for

Cataract Surgery with Intraocular (IOL) PlacementP


Eye Care Cataracts: Method of Intraocular Lens Power Calculation

and Pre-surgical Dilated Fundus Evaluation P


Eye Care Diabetic Retinopathy: Communication with the Physician

Managing the Ongoing Diabetes Care P


Eye Care Diabetic Retinopathy: Documentation of Presence or

Absence of Macular Edema and Level of Severity of RetinopathyP


Eye Care Dilated Macular Examination, Cataracts: Assessment of

Visual Functional Status P


Eye Care Primary Open-Angle Glaucoma (POAG): Counseling on

Glaucoma P


Eye Care Primary Open-Angle Glaucoma (POAG): Optic Nerve

Evaluation P


Eye Care Primary Open-Angle Glaucoma (POAG): Reduction of

Intraocular Pressure by 15% or Documentation of a Plan of CareP

Otpt Clinical Care GI GERD Assessment for alarm symptoms P

Otpt Clinical Care GI GERD Barium swallow – inappropriate use P

Otpt Clinical Care GI GERD Biopsy for Barrett’s esophagus P


GERD Chronic Medication therapy – assessment of GERD

symptoms P

Otpt Clinical Care GI GERD Upper Endoscopy for patients with alarm symptoms P

Otpt Care Coordination Elderly Geriatrics Advance care plan P

Otpt Clinical Care Elderly

Geriatrics Assessment of presence or absence of urinary incontinence

in women aged 65 years and older P


Geriatrics Characterization of urinary incontinence in women aged 65

years and older P

Otpt Clinical Care Elderly Geriatrics Medication reconciliation P

Otpt Clinical Care Elderly Geriatrics Plan of Care for Falls P


Geriatrics Plan of care for urinary incontinence in women aged 65

years and older P

Otpt Clinical Care Elderly Geriatrics Risk Assessment for Falls P

Otpt Clinical Care Elderly Geriatrics Screening for future fall risk P


Geriatrics Urinary incontinence – medication overuse in women aged

65 years and older (QI) P

Inpt Clinical Care Cardiac PCI Appropriate Indication for Elective PCI P

Inpt Clinical Care Cardiac PCI Assessment of Candidacy for Dual Antiplatelet Therapy P

Inpt Clinical Care Cardiac PCI Cardiac Rehabilitation Patient Referral P

Inpt Clinical Care Cardiac PCI Comprehensive Documentation of Indications for PCI P


PCI Documentation of Pre-Procedural Glomerular Filtration Rate

(GFR) and Contrast Dose Used During the Procedure P

Inpt Clinical Care Cardiac PCI Post-Procedural Optimal Medical Therapy Composite P

Inpt Clinical Care Cardiac PCI Radiation Dose Documented P

Inpt Population Health Cardiac PCI Regional or National PCI Registry Participation P


PCI Use of Embolic Protection Devices in the Treatment of

Saphenous Vein Bypass Graft Disease P

Otpt Clinical Care Heme/OncHematology Chronic lymphocytic leukemia: Baseline flow cytometry

P


Hematology MDS: Documentation of iron stores in patients receiving

erythropoietin therapy P

Otpt Clinical Care Heme/OncHematology Multiple myeloma: Treatment with bisphosphonates

P

Page18 of 24









From PQRS File


Quality Indicators

Behavioral

Health Homes

CMS-AHIP

ACO

CMS-AHIP

PCMHDSRIP HER

Medicaid/

CHIP

Health

Home

HEDIS Leapfrog

NJ Innovation

Institute PTN

Project


CHIP

NJ Medicaid ACO

DemoPCPI PQRS

Performance

Based Incentive

Program

SIM


Hematology Myelodysplastic syndrome (MDS) and acute leukemias:

Baseline cytogenetic testing performed on bone marrowP


Hepatitis Annual HCV Screening for Patients who are Active

Injection Drug Users P

Otpt Clinical Care Infection Control Hepatitis Confirmation of Hepatitis C Viremia P

Otpt Patient/Caregiver Experience Infection Control Hepatitis Counseling Regarding Risk of Alcohol Consumption P


Hepatitis Discontinuation of Antiviral Therapy for Inadequate Viral

Response P

Otpt Patient/Caregiver Experience Infection Control

Hepatitis Discussion and Shared Decision Making Surrounding

Treatment Options P

Otpt Clinical Care Infection Control Hepatitis HCV Genotype Testing Prior to Treatment (Paired) P


Hepatitis HCV RNA Testing Between 4-12 Weeks After Initiation of

Treatment P

Otpt population Health Infection Control Hepatitis Hepatitis A Vaccination (Paired Measure) P

Otpt population Health Infection Control Hepatitis Hepatitis B Vaccination (Paired Measure) P


Hepatitis Hepatitis C RNA Testing Before Initiating Treatment

(Paired Measure) P

Otpt Clinical Care Infection Control Hepatitis QI only: Sustained Virological Response (SVR) P

Otpt Care Coordination Infection Control

Hepatitis Referral to Treatment for Patients Identified with HCV

Infection P

Otpt Population Health Infection ControlHepatitis Screening for HCC in Patients with Hepatitis C Cirrhosis

P

Otpt Population Health Infection Control Hepatitis Screening for HCV for Patients at High Risk P


HIV Adolescent and Adult Patients with HIV/AIDS who are

Prescribed Potent Antiretroviral Therapy P

Otpt Clinical Care Infection Control HIV CD4+ Cell Count or CD4+ Percentage Performed P

Otpt Clinical Care Infection ControlHIV RNA Control After Six Months of Potent Antiretroviral Therapy

P

Otpt Population Health Infection Control HIV Hepatitis B Vaccination P

Otpt Population Health Infection Control HIV Influenza Immunization P

Otpt Population Health Infection Control HIV Other Infectious Diseases – Hepatitis B Screening P

Otpt Population Health Infection Control HIV Other Infectious Diseases – Hepatitis C Screening P

Otpt Population Health Infection Control HIV Pneumococcal Vaccine P

Otpt Clinical Care Infection Control HIV Pneumocystis jiroveci pneumonia (PCP) prophylaxis P

Otpt Clinical Care Infection Control HIV Screening for High Risk Sexual Behaviors P

Otpt Clinical Care Infection Control HIV Screening for Injection Drug Use P


HIV Sexually Transmitted Diseases – Chlamydia and Gonorrhea

Screenings P

Otpt Clinical Care Infection Control HIV Sexually Transmitted Diseases – Syphilis Screening P

Otpt Clinical Care Infection Control HIV Tuberculosis (TB) Screening P


Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis

(When Indicated in ALL Patients)N/A 0239 023

P P

Otpt Clinical Care Neph Kidney Disease Adult Adequacy of Volume management P

Otpt Care Coordination Neph Kidney Disease Adult Advance Care Planning P

Otpt Care Coordination Neph Kidney Disease Adult Advance Directives Completed P


Kidney Disease Adult Angiotensin-Converting Enzyme (ACE)

Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy P

Otpt Clinical Care Neph Kidney Disease Adult Arteriovenous Fistula Rate P

Otpt Clinical Care Neph Kidney Disease Adult Blood pressure management P

Otpt Clinical Care NephKidney Disease Adult Catheter Use at Initiation of Hemodialysis

P

Otpt Clinical Care Neph Kidney Disease Adult Catheter Use for >= 90 days P


Kidney Disease Adult Kidney Disease Adult ESRD Patients

Receiving Dialysis: Hemoglobin Level <10g/dL P

Otpt Clinical Care Neph Kidney Disease Adult Hemodialysis Adequacy: Solute P

Page19 of 24









From PQRS File


Quality Indicators

Behavioral

Health Homes

CMS-AHIP

ACO

CMS-AHIP

PCMHDSRIP HER

Medicaid/

CHIP

Health

Home

HEDIS Leapfrog

NJ Innovation

Institute PTN

Project


CHIP

NJ Medicaid ACO

DemoPCPI PQRS

Performance

Based Incentive

Program

SIM

Otpt Clinical Care Neph Kidney Disease Adult Influenza Immunization P

Otpt Clinical Care Neph Kidney Disease Adult Laboratory Testing (Lipid Profile) P


Kidney Disease Adult Patients on Erythropoiesis Stimulating Agent

(ESA)-Hemoglobin Level >12.0 g/dL P

Otpt Clinical Care Neph Kidney Disease Adult Peritoneal Dialysis Adequacy: Solute P

Otpt Care Coordination Neph Kidney Disease Adult Referral to Hospice P

Otpt Care Coordination Neph Kidney Disease Adult Referral to Nephrologist P

Otpt Care Coordination Neph Kidney Disease Adult Transplant Referral P

Otpt Clinical Care Neph Kidney Disease Peds Adequacy of Volume management P

Otpt Care Coordination Neph Kidney Disease Peds Discussion of Advance Care Planning P


Kidney Disease Peds ESRD Patients Receiving Dialysis:

Hemoglobin Level <10g/dL P

Otpt population Health Neph Kidney Disease Peds Influenza Immunization P


Depression Adult Comprehensive Depression Evaluation: Diagnosis

and Severity P


Depression Coordination of Care of Patients with Specific Comorbid

Conditions P


Depression Adult Depression Care Follow Up: Assessment of

Response to Treatment P


Depression Adult Depression Care Follow Up: Three Visits in 90

Days following Diagnosis P

Otpt Patient/Caregiver Experience Psych Depression Adult Patient Education P

Otpt Clinical Care Psych Depression Adult Suicide Risk Assessment P

Otpt Clinical Care Psych Depression Adult Treatment for Depression P

Otpt Care Coordination Psych Depression Peds Follow-Up Care P

Otpt Clinical Care Psych Depression Peds Interview of Adolescent or Child P

Otpt Clinical Care Psych Depression Peds Medications Considered P

Otpt Clinical Care Psych Depression Peds Psychotherapy P

Otpt Clinical Care Psych Depression Peds Suicide Risk Assessment P

Otpt Clinical Care OB/GynMaternity Care BMI Assessment and Recommended Weight Gain

P

Otpt Clinical Care OB/Gyn Maternity Care Behavioral Health Risk Assessment P

Inpt Clinical Care OB/Gyn

Maternity Care Care Coordination: Prenatal Record Present at time

of Delivery P

Inpt Clinical Care OB/GynMaternity Care Cesarean Delivery for Low-Risk Nulliparous Women

P

Inpt Clinical Care OB/Gyn Maternity Care Elective Delivery Before 39 Weeks P

Inpt Clinical Care OB/Gyn Maternity Care Episiotomy P

Otpt Clinical Care OB/Gyn Maternity Care Establishment of Gestational Age P

Otpt Clinical Care OB/Gyn

Maternity Care Post-Partum Follow-up for Depression, Breast

Feeding, Glucose Screening for Gestational Diabetes, and

Contraceptive Planning P

Otpt Population Health OB/Gyn Maternity Care Prenatal Care Screening P

Inpt Clinical Care OB/Gyn Maternity Care Spontaneous Labor and Birth P

Otpt Care Coordination Heme/Onc Melanoma Continuity of Care – Recall System P

Otpt Care Coordination Heme/Onc Melanoma Coordination of Care P

Otpt Care Coordination Heme/Onc Melanoma Follow-Up Aspects of Care P

Otpt Safety Heme/Onc Melanoma Overutilization of Imaging Studies in Melanoma P


Nuc Med Communication to Referring Physician of Patient’s

Potential Risk for Fracture for All Patients Undergoing Bone

Scintigraphy P


Nuc Med Correlation With Existing Imaging Studies for All Patients

Undergoing Bone Scintigraphy P

Otpt Clinical Care Sleep Sleep Apnea Adherence to Positive Airway Pressure Therapy P

Otpt Clinical Care Sleep Sleep Apnea Assessment of Sleep Symptoms P

Otpt Clinical Care Sleep Sleep Apnea Positive Airway Pressure Therapy Prescribed P

Page20 of 24









From PQRS File


Quality Indicators

Behavioral

Health Homes

CMS-AHIP

ACO

CMS-AHIP

PCMHDSRIP HER

Medicaid/

CHIP

Health

Home

HEDIS Leapfrog

NJ Innovation

Institute PTN

Project


CHIP

NJ Medicaid ACO

DemoPCPI PQRS

Performance

Based Incentive

Program

SIM

Otpt Clinical Care Sleep Sleep Apnea Severity Assessment at Initial Diagnosis P

Otpt Clinical Care Heme/Onc Cancer Stage Documented P


Cancer Chemotherapy for Stage IIIA through IIIC Colon Cancer

Patients P


Cancer Hormonal Therapy for Stage IC through IIIC, ER/PR Positive

Breast Cancer P


Cancer Pain Intensity Quantified-Medical Oncology and Radiation

Oncology P

Otpt Clinical Care Heme/Onc Cancer Pathology Report (QI) P

Otpt Clinical Care Heme/Onc Cancer Plan for Chemotherapy Documented P

Otpt Care Coordination Heme/Onc

Cancer Plan of Care for Pain-Medical Oncology and Radiation

Oncology P

Otpt Safety Heme/Onc Cancer Radiation Dose Limits to Normal Tissues P

Otpt Clinical Care Heme/OncCancer Treatment Summary Communication – Radiation Oncology

P

Otpt Care Coordination Heme/Onc

Cancer Treatment Summary Documented and Communicated–

Medical Oncology (QI) P


Ionizing Radiation Appropriateness: Follow-up CT Imaging for

Incidental Pulmonary Nodules According to Recommended

Guidelines P


Ionizing Radiation CT Images Available for Patient Follow-Up and

Comparison Purposes P


Ionizing Radiation Count of Potential High Dose Radiation Imaging

Studies: CT Studies and Cardiac Nuclear Medicine StudiesP


Ionizing Radiation Equipment Evaluation for Pediatric CT Imaging

Protocols P

Otpt Safety RadiologyIonizing Radiation Reporting to a Radiation Dose Index Registry

P


Ionizing Radiation Search for Prior CT Studies through a Secure,

Authorized, Media-free, Shared Archive P

Otpt Safety Radiology Ionizing Radiation Utilization of Pediatric CT Imaging Protocols P


Ionizing Radiation Utilization of a Standardized Nomenclature for

CT Imaging Description P

Otpt Clinical Care Rheuma Osteoarthritis Anti-inflammatory/analgesic therapy P

Otpt Clinical Care Rheuma

Osteoarthritis Assessment for use of anti-inflammatory or analgesic

over the counter (OTC) medications P

Otpt Clinical Care Rheuma Osteoarthritis Function and pain assessment P

Otpt Clinical Care Rheuma Osteoarthritis Gastrointestinal prophylaxis P


Osteoarthritis Non-steroidal anti-inflammatory drug (NSAID) risk

assessment P

Otpt Clinical Care Rheuma Osteoarthritis Physical examination of the involved joint P

Otpt Clinical Care Rheuma Osteoarthritis Therapeutic exercise for the involved joint P


Osteoporosis Communication with the Physician Managing On-going

Care Post Fracture of Hip, Spine or Distal Radius for Men and

Women Aged 50 Years and Older P


Osteoporosis Counseling for Vitamin D and Calcium Intake and

Exercise for Men and Women P

Otpt Clinical Care RheumaOsteoporosis Glucocorticosteroids and Other Secondary Causes (QI)

P


Osteoporosis Management Following Fracture of Hip, Spine or Distal

Radius for Men and Women Aged 50 Years and Older P


Osteoporosis Pharmacologic Therapy for Men and Women Aged 50

Years and Older P


Osteoporosis Screening or Therapy for Osteoporosis for Women

Aged 65 Years and Older P

Page21 of 24









From PQRS File


Quality Indicators

Behavioral

Health Homes

CMS-AHIP

ACO

CMS-AHIP

PCMHDSRIP HER

Medicaid/

CHIP

Health

Home

HEDIS Leapfrog

NJ Innovation

Institute PTN

Project


CHIP

NJ Medicaid ACO

DemoPCPI PQRS

Performance

Based Incentive

Program

SIM

Otpt Clinical Care Infection ControlOP Parenteral Antimicrobial Therapy Laboratory testing – CBC (QI)

P


OP Parenteral Antimicrobial Therapy Laboratory testing – creatinine

or GFR (QI) P


OP Parenteral Antimicrobial Therapy Maintenance visit – history

(QI) P


OP Parenteral Antimicrobial Therapy Maintenance visit – physical

examination (QI) P


OP Parenteral Antimicrobial Therapy Plan of care documentation at

initial visit (QI) P

Otpt Care Coordination Palliative Palliative Care Advance care planning P

Otpt Clinical Care Palliative Palliative Care Dyspnea screening and management P


Pathology Breast cancer resection pathology reporting – pT category

and pN category with histologic grade P


Pathology Colorectal cancer resection pathology reporting – pT

category and pN category with histologic grade P

Otpt Clinical Care GI Ped Acute Gastroenteritis Documentation of hydration status P

Otpt Patient/Caregiver Experience GI Ped Acute Gastroenteritis Education P


Ped Acute Gastroenteritis Recommendation of appropriate oral

rehydration solution P

Otpt Clinical Care GI Ped Acute Gastroenteritis Weight measurement P

Otpt Clinical Care Cardiac Persistent Beta Blocker Treatment After a Heart Attack N/A 0071 N/A P


Post-Procedural Optimal Medical Therapy Composite (Percutaneous

Coronary Intervention)N/A 2452 399

P P

Inpt Clinical Care Cardiac Primary PCI received within 90minutes of hospital arrival 163 P


Rate of Open Repair of Ascending Abdominal Aortic Aneurysms

(AAA) Where Patients Are Discharged Alive N/A 1523 417

P P P


Rate of Endovascular Aneurysm Repair (EVAR) of Small or

Moderate Non-Ruptured Abdominal Aortic Aneurysms (AAA) Who

Die While in Hospital

N/A 1534 347

P P


Rate of Surgical Conversion from Lower Extremity Endovascular

Revasculatization Procedure N/A N/A 437

P P

Inpt Clinical Care Cardiac Risk-Adjusted Operative Mortality for CABG 119

Inpt Clinical Care CardiacStatin Therapy at Discharge after Lower Extremity Bypass (LEB) N/A 1519 257

P P


Statin Therapy for the Prevention and Treatment of Cardiovascular

DiseaseN/A N/A 438

P P


Therapy with aspirin, P2Y12 inhibitor, and statin at discharge

following PCI in eligible patients

964

P

Inpt Clinical Care CardiacVaricose Vein Treatment with Saphenous Ablation: Outcome Survey N/A N/A 420

P P


Periop Care Discontinuation of Prophylactic Antibiotics (Cardiac

Procedures) P


Periop Care Discontinuation of Prophylactic Antibiotics (Non-

Cardiac Procedures) P


Periop Care Selection of Prophylactic Antibiotic -- First or Second

Generation Cephalosporin P


Periop Care Timing of Prophylactic Antibiotics – Administering

Physician P

Inpt Clinical Care SurgicalPeriop Care Timing of Prophylactic Antibiotics – Ordering Physician

P

Inpt Clinical Care Surgical Periop Care Venous Thromboembolism (VTE) Prophylaxis P

Otpt Population Health Prevention/Screening Screening Cervical Cancer Screening P

Otpt Population Health Prevention/Screening Screening Obesity Screening P

Otpt Population Health Prevention/Screening Screening Pneumococcal Immunization P

Otpt Population Health Prevention/Screening Screening Tobacco Use: Screening & Cessation Intervention P

Page22 of 24









From PQRS File


Quality Indicators

Behavioral

Health Homes

CMS-AHIP

ACO

CMS-AHIP

PCMHDSRIP HER

Medicaid/

CHIP

Health

Home

HEDIS Leapfrog

NJ Innovation

Institute PTN

Project


CHIP

NJ Medicaid ACO

DemoPCPI PQRS

Performance

Based Incentive

Program

SIM

Otpt Population Health Prevention/Screening Screening Unhealthy Alcohol Use: Screening P

Otpt Population Health Prevention/ScreeningScreening Unhealthy Alcohol Use: Screening & Brief Counseling

P


Prostate Cancer Adjuvant Hormonal Therapy for High-Risk Prostate

Cancer Patients P


Prostate Cancer Avoidance of Overuse Measure – Bone Scan for

Staging Low-Risk Prostate Cancer Patients P

Otpt Clinical Care Heme/Onc Prostate Cancer Initial Evaluation P

Otpt Clinical Care Heme/Onc Prostate Cancer Initial Evaluation, New Diagnoses P


Prostate Cancer Treatment Options for Patients with Clinically

Localized Disease P

Both Inpt and OtptSafety Radiology Radiology CT radiation dose reduction P


Radiology Communication of suspicious findings from the diagnostic

mammogram to the patient P


Radiology Communication of suspicious findings from the diagnostic

mammogram to the practice managing ongoing care P

Otpt Safety RadiologyRadiology Exposure time reported for procedures using fluoroscopy

P


Radiology Inappropriate use of "probably benign" assessment

category in mammography screening P

Otpt Clinical Care Radiology Radiology Mammography assessment category data collection P

Otpt Care Coordination Radiology Radiology Reminder system for mammograms P

Otpt Clinical Care Radiology Radiology Stenosis measurement in carotid imaging reports P

Otpt Clinical Care Rheuma RA Assessment and Classification of Disease Prognosis P

Otpt Clinical Care Rheuma RA Functional Status Assessment P

Otpt Clinical Care Rheuma RA Glucocorticoid Management P

Otpt Clinical Care Rheuma RA Periodic Assessment of Disease Activity P

Otpt Clinical Care Rheuma RA Tuberculosis Screening P

Inpt Clinical Care Cardiac Venous Thromboembolism Prophylaxis 371 P

Otpt Clinical Care Neuro Stroke Blood Pressure Management P


Stroke Computed Tomography (CT) or Magnetic Resonance Imaging

(MRI) Reports P

Otpt Clinical Care Neuro Stroke Discharged on Antithrombotic Therapy P

Otpt Clinical Care NeuroStroke Imaging for Transient Ischemic Attack or Ischemic Stroke

P

Otpt Clinical Care Neuro Stroke Lipid Management P

Otpt Clinical Care Neuro Stroke Patient/Caregiver Nutritional Preferences P

Otpt Safety Neuro

Stroke Potentially Avoidable Harmful Events: Fall with Fracture or

Acute Subdural Hematoma (QI only) P

Otpt Safety Neuro

Stroke Potentially Avoidable Harmful Events: Stage III or Greater

Decubiti (QI only) P

Otpt Safety Neuro

Stroke Potentially Avoidable Harmful Events: Urinary Tract Infection

(QI only) P

Otpt Care Coordination Neuro Stroke Rehabilitation Services Ordered P

Otpt Clinical Care Neuro Stroke Screening for Dysphagia P


Stroke Tissue Plasminogen Activator (t-PA) Considered (Paired

Measure) P


Stroke Tissue Plasminogen Activator (t-PA) Initiated (Paired

Measure) P


Stroke Venous Thromboembolism Prophylaxis (VTE) for Ischemic

Stroke or Intracranial Hemorrhage P

Inpt Clinical Care Psych

Substance Abuse Counseling Regarding Psychosocial and

Pharmacologic Treatment Options for Opioid Addiction P


Substance Abuse Counseling regarding psychosocial and

pharmacologic treatment options for alcohol dependence P

Page23 of 24









From PQRS File


Quality Indicators

Behavioral

Health Homes

CMS-AHIP

ACO

CMS-AHIP

PCMHDSRIP HER

Medicaid/

CHIP

Health

Home

HEDIS Leapfrog

NJ Innovation

Institute PTN

Project


CHIP

NJ Medicaid ACO

DemoPCPI PQRS

Performance

Based Incentive

Program

SIM


Substance Abuse Screening for depression among patients with

substance abuse or dependence P

Page24 of 24

Documents

New Jersey Quality Metrics Alignment Quality Metrics from ......New Jersey Quality Metrics Alignment CMS – AHIP PCMH = CMS – American Health Insurance Plans Patient Centered Medical