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M1338 Patients who had follow-up assessment 30 to 180 days after the index assessment who did not demonstrate positive improvement or maintenance of functioning scores during the performance period
BackM1003Tb screening performed and results interpreted within twelve months prior to initiation of first-time biologic and/or immune response modifier therapy→M1004Documentation of medical reason for not screening for tb or interpreting results (i.e., patient positive for tb and documentation of past treatment; patient who has recently completed a course of anti-tb therapy)→M1005Tb screening not performed or results not interpreted, reason not given→M1006Disease activity not assessed, reason not given→M1007>=50% of total number of a patient's outpatient ra encounters assessed→M1008<50% of total number of a patient's outpatient ra encounters assessed→M1009Discharge/discontinuation of the episode of care documented in the medical record→M1010Discharge/discontinuation of the episode of care documented in the medical record→M1011Discharge/discontinuation of the episode of care documented in the medical record→M1012Discharge/discontinuation of the episode of care documented in the medical record→M1013Discharge/discontinuation of the episode of care documented in the medical record→M1014Discharge/discontinuation of the episode of care documented in the medical record→M1016Female patients unable to bear children→M1018Patients with an active diagnosis or history of cancer (except basal cell and squamous cell skin carcinoma), patients who are heavy tobacco smokers, lung cancer screening patients→M1019Adolescent patients 12 to 17 years of age with major depression or dysthymia who reached remission at twelve months as demonstrated by a twelve month (+/-60 days) phq-9 or phq-9m score of less than 5→M1020Adolescent patients 12 to 17 years of age with major depression or dysthymia who did not reach remission at twelve months as demonstrated by a twelve month (+/-60 days) phq-9 or phq-9m score of less than 5. either phq-9 or phq-9m score was not assessed or is greater than or equal to 5→M1021Patient had only urgent care visits during the performance period→M1027Imaging of the head (ct or mri) was obtained→M1028Documentation of patients with primary headache diagnosis and imaging other than ct or mri obtained→M1029Imaging of the head (ct or mri) was not obtained, reason not given→M1032Adults currently taking pharmacotherapy for oud→M1034Adults who have at least 180 days of continuous pharmacotherapy with a medication prescribed for oud without a gap of more than seven days→M1035Adults who are deliberately phased out of medication assisted treatment (mat) prior to 180 days of continuous treatment→M1036Adults who have not had at least 180 days of continuous pharmacotherapy with a medication prescribed for oud without a gap of more than seven days→M1037Patients with a diagnosis of lumbar spine region cancer at the time of the procedure→M1038Patients with a diagnosis of lumbar spine region fracture at the time of the procedure→M1039Patients with a diagnosis of lumbar spine region infection at the time of the procedure→M1040Patients with a diagnosis of lumbar idiopathic or congenital scoliosis→M1041Patient had cancer, acute fracture or infection related to the lumbar spine or patient had neuromuscular, idiopathic or congenital lumbar scoliosis→M1043Functional status was not measured by the oswestry disability index (odi version 2.1a) at one year (9 to 15 months) postoperatively→M1045Functional status measured by the oxford knee score (oks) at one year (9 to 15 months) postoperatively was greater than or equal to 37 or knee injury and osteoarthritis outcome score joint replacement (koos, jr.) was greater than or equal to 71→M1046Functional status measured by the oxford knee score (oks) at one year (9 to 15 months) postoperatively was less than 37 or the knee injury and osteoarthritis outcome score joint replacement (koos, jr.) was less than 71 postoperatively→M1049Functional status was not measured by the oswestry disability index (odi version 2.1a) at three months (6 - 20 weeks) postoperatively→M1051Patient had cancer, acute fracture or infection related to the lumbar spine or patient had neuromuscular, idiopathic or congenital lumbar scoliosis→M1052Leg pain was not measured by the visual analog scale (vas) or numeric pain scale at one year (9 to 15 months) postoperatively→M1054Patient had only urgent care visits during the performance period→M1055Aspirin or another antiplatelet therapy used→M1056Prescribed anticoagulant medication during the performance period, history of gi bleeding, history of intracranial bleeding, bleeding disorder and specific provider documented reasons: allergy to aspirin or anti-platelets, use of non-steroidal anti-inflammatory agents, drug-drug interaction, uncontrolled hypertension > 180/110 mmhg or gastroesophageal reflux disease→M1057Aspirin or another antiplatelet therapy not used, reason not given→M1058Patient was a permanent nursing home resident at any time during the performance period→M1059Patient was in hospice or receiving palliative care at any time during the performance period→M1060Patient died prior to the end of the performance period→M1067Hospice services for patient provided any time during the measurement period→M1068Adults who are not ambulatory→M1069Patient screened for future fall risk→M1070Patient not screened for future fall risk, reason not given→M1106The start of an episode of care documented in the medical record→M1107Documentation stating patient has a diagnosis of a degenerative neurological condition such as als, ms, or parkinson's diagnosed at any time before or during the episode of care→M1108Ongoing care not clinically indicated because the patient needed a home program only, referral to another provider or facility, or consultation only, as documented in the medical record→M1109Ongoing care not medically possible because the patient was discharged early due to specific medical events, documented in the medical record, such as the patient became hospitalized or scheduled for surgery→M1110Ongoing care not possible because the patient self-discharged early (e.g., financial or insurance reasons, transportation problems, or reason unknown)→M1111The start of an episode of care documented in the medical record→M1112Documentation stating patient has a diagnosis of a degenerative neurological condition such as als, ms, or parkinson's diagnosed at any time before or during the episode of care→M1113Ongoing care not clinically indicated because the patient needed a home program only, referral to another provider or facility, or consultation only, as documented in the medical record→M1114Ongoing care not medically possible because the patient was discharged early due to specific medical events, documented in the medical record, such as the patient became hospitalized or scheduled for surgery→M1115Ongoing care not possible because the patient self-discharged early (e.g., financial or insurance reasons, transportation problems, or reason unknown)→M1116The start of an episode of care documented in the medical record→M1117Documentation stating patient has a diagnosis of a degenerative neurological condition such as als, ms, or parkinson's diagnosed at any time before or during the episode of care→M1118Ongoing care not clinically indicated because the patient needed a home program only, referral to another provider or facility, or consultation only, as documented in the medical record→M1119Ongoing care not medically possible because the patient was discharged early due to specific medical events, documented in the medical record, such as the patient became hospitalized or scheduled for surgery→M1120Ongoing care not possible because the patient self-discharged early (e.g., financial or insurance reasons, transportation problems, or reason unknown)→M1121The start of an episode of care documented in the medical record→M1122Documentation stating patient has a diagnosis of a degenerative neurological condition such as als, ms, or parkinson's diagnosed at any time before or during the episode of care→M1123Ongoing care not clinically indicated because the patient needed a home program only, referral to another provider or facility, or consultation only, as documented in the medical record→M1124Ongoing care not medically possible because the patient was discharged early due to specific medical events, documented in the medical record, such as the patient became hospitalized or scheduled for surgery→M1125Ongoing care not possible because the patient self-discharged early (e.g., financial or insurance reasons, transportation problems, or reason unknown)→M1126The start of an episode of care documented in the medical record→M1127Documentation stating patient has a diagnosis of a degenerative neurological condition such as als, ms, or parkinson's diagnosed at any time before or during the episode of care→M1128Ongoing care not clinically indicated because the patient needed a home program only, referral to another provider or facility, or consultation only, as documented in the medical record→M1129Ongoing care not medically possible because the patient was discharged early due to specific medical events, documented in the medical record, such as the patient became hospitalized or scheduled for surgery→M1130Ongoing care not possible because the patient self-discharged early (e.g., financial or insurance reasons, transportation problems, or reason unknown)→M1131Documentation stating patient has a diagnosis of a degenerative neurological condition such as als, ms, or parkinson's diagnosed at any time before or during the episode of care→M1132Ongoing care not clinically indicated because the patient needed a home program only, referral to another provider or facility, or consultation only, as documented in the medical record→M1133Ongoing care not medically possible because the patient was discharged early due to specific medical events, documented in the medical record, such as the patient became hospitalized or scheduled for surgery→M1134Ongoing care not possible because the patient self-discharged early (e.g., financial or insurance reasons, transportation problems, or reason unknown)→M1135The start of an episode of care documented in the medical record→M1141Functional status was not measured by the oxford knee score (oks) or the knee injury and osteoarthritis outcome score joint replacement (koos, jr.) at one year (9 to 15 months) postoperatively→M1142Emergent cases→M1143Initiated episode of rehabilitation therapy, medical, or chiropractic care for neck impairment→M1146Ongoing care not clinically indicated because the patient needed a home program only, referral to another provider or facility, or consultation only, as documented in the medical record→M1147Ongoing care not medically possible because the patient was discharged early due to specific medical events, documented in the medical record, such as the patient became hospitalized or scheduled for surgery→M1148Ongoing care not possible because the patient self-discharged early (e.g., financial or insurance reasons, transportation problems, or reason unknown)→M1149Patient unable to complete the neck fs prom at initial evaluation and/or discharge due to blindness, illiteracy, severe mental incapacity or language incompatibility, and an adequate proxy is not available→M1150Current or prior left ventricular ejection fraction (lvef) less than or equal to 40% or documentation of moderately or severely depressed left ventricular systolic function→M1151Patients with a history of heart transplant or with a left ventricular assist device (lvad)→M1152Patients with a history of heart transplant or with a left ventricular assist device (lvad)→M1153Patient with diagnosis of osteoporosis on date of encounter→M1159Hospice services provided to patient any time during the measurement period→M1160Patient had anaphylaxis due to the meningococcal vaccine any time on or before the patient's 13th birthday→M1161Patient had anaphylaxis due to the tetanus, diphtheria or pertussis vaccine any time on or before the patient's 13th birthday→M1162Patient had encephalitis due to the tetanus, diphtheria or pertussis vaccine any time on or before the patient's 13th birthday→M1163Patient had anaphylaxis due to the hpv vaccine any time on or before the patient's 13th birthday→M1164Patients with dementia any time during the patient's history through the end of the measurement period→M1165Patients who use hospice services any time during the measurement period→M1166Pathology report for tissue specimens produced from wide local excisions or re-excisions→M1167In hospice or using hospice services during the measurement period→M1168Patient received an influenza vaccine on or between july 1 of the year prior to the measurement period and june 30 of the measurement period→M1169Documentation of medical reason(s) for not administering influenza vaccine (e.g., prior anaphylaxis due to the influenza vaccine)→M1170Patient did not receive an influenza vaccine on or between july 1 of the year prior to the measurement period and june 30 of the measurement period→M1171Patient received at least one td vaccine or one tdap vaccine between nine years prior to the encounter and the end of the measurement period→M1172Documentation of medical reason(s) for not administering td or tdap vaccine (e.g., prior anaphylaxis due to the td or tdap vaccine or history of encephalopathy within seven days after a previous dose of a td-containing vaccine)→M1173Patient did not receive at least one td vaccine or one tdap vaccine between nine years prior to the encounter and the end of the measurement period→M1174Patient received at least two doses of the herpes zoster recombinant vaccine (at least 28 days apart) on october 20, 2017, through the end of the measurement period→M1175Documentation of medical reason(s) for not administering zoster vaccine (e.g., prior anaphylaxis due to the zoster vaccine)→M1176Patient did not receive two doses of the herpes zoster recombinant vaccine (at least 28 days apart) on october 20, 2017, through the end of the measurement period→M1177Patient received any pneumococcal conjugate or polysaccharide vaccine on or after their 19th birthday and before the end of the measurement period→M1178Documentation of medical reason(s) for not administering pneumococcal vaccine (e.g., prior anaphylaxis due to the pneumococcal vaccine)→M1179Patient did not receive any pneumococcal conjugate or polysaccharide vaccine, on or after their 19th birthday and before or during measurement period→M1180Patients on immune checkpoint inhibitor therapy→M1181Grade 2 or above diarrhea and/or grade 2 or above colitis→M1182Patients not eligible due to pre-existing inflammatory bowel disease (ibd) (e.g., ulcerative colitis, crohn's disease)→M1183Documentation of immune checkpoint inhibitor therapy held and corticosteroids or immunosuppressants prescribed or administered→M1184Documentation of medical reason(s) for not prescribing or administering corticosteroid or immunosuppressant treatment (e.g., allergy, intolerance, infectious etiology, pancreatic insufficiency, hyperthyroidism, prior bowel surgical interventions, celiac disease, receiving other medication, awaiting diagnostic workup results for alternative etiologies, other medical reasons/contraindication)→M1185Documentation of immune checkpoint inhibitor therapy not held and/or corticosteroids or immunosuppressants prescribed or administered was not performed, reason not given→M1186Patients who have an order for or are receiving hospice or palliative care→M1187Patients with a diagnosis of end stage renal disease (esrd)→M1188Patients with a diagnosis of chronic kidney disease (ckd) stage 5→M1189Documentation of a kidney health evaluation defined by an estimated glomerular filtration rate (egfr) and urine albumin-creatinine ratio (uacr) performed→M1190Documentation of a kidney health evaluation was not performed or defined by an estimated glomerular filtration rate (egfr) and urine albumin-creatinine ratio (uacr)→M1191Hospice services provided to patient any time during the measurement period→M1192Patients with an existing diagnosis of squamous cell carcinoma of the esophagus→M1193Surgical pathology reports that contain impression or conclusion of or recommendation for testing of mmr by immunohistochemistry, msi by dna-based testing status, or both→M1194Documentation of medical reason(s) surgical pathology reports did not contain impression or conclusion of or recommendation for testing of mmr by immunohistochemistry, msi by dna-based testing status, or both tests were not included (e.g., patient will not be treated with checkpoint inhibitor therapy, no residual carcinoma is present in the sample [tissue exhausted or status post neoadjuvant treatment], insufficient tumor for testing)→M1195Surgical pathology reports that do not contain impression or conclusion of or recommendation for testing of mmr by immunohistochemistry, msi by dna-based testing status, or both, reason not given→M1196Initial (index visit) numeric rating scale (nrs), visual rating scale (vrs), or itchyquant assessment score of greater than or equal to 4→M1197Itch severity assessment score is reduced by 3 or more points from the initial (index) assessment score to the follow-up visit score→M1198Itch severity assessment score was not reduced by at least 3 points from initial (index) score to the follow-up visit score or assessment was not completed during the follow-up encounter→M1199Patients receiving rrt→M1200Ace inhibitor (ace-i) or arb therapy prescribed during the measurement period→M1201Documentation of medical reason(s) for not prescribing ace inhibitor (ace-i) or arb therapy during the measurement period (e.g., pregnancy, history of angioedema to ace-i, other allergy to ace-i and arb, hyperkalemia or history of hyperkalemia while on ace-i or arb therapy, acute kidney injury due to ace-i or arb therapy), other medical reasons)→M1202Documentation of patient reason(s) for not prescribing ace inhibitor or arb therapy during the measurement period, (e.g., patient declined, other patient reasons)→M1203Ace inhibitor or arb therapy not prescribed during the measurement period, reason not given→M1204Initial (index visit) numeric rating scale (nrs), visual rating scale (vrs), or itchyquant assessment score of greater than or equal to 4→M1205Itch severity assessment score is reduced by 3 or more points from the initial (index) assessment score to the follow-up visit score→M1206Itch severity assessment score was not reduced by at least 3 points from initial (index) score to the follow-up visit score or assessment was not completed during the follow-up encounter→M1207Patient is screened for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety→M1208Patient is not screened for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety→M1209At least two orders for high-risk medications from the same drug class, (table 4), without appropriate diagnoses→M1210At least two orders for high-risk medications from the same drug class, (table 4), not ordered→M1211Most recent glycemic status assessment (hba1c or gmi) level > 9.0%→M1212Glycemic status assessment (hba1c or gmi) level is missing, or was not performed during the measurement period→M1213No history of spirometry results with confirmed airflow obstruction (fev1/fvc < 70%) and present spirometry is >= 70%→M1214Spirometry results with confirmed airflow obstruction (fev1/fvc < 70%) documented and reviewed→M1215Documentation of medical reason(s) for not documenting and reviewing spirometry results (e.g., patients with dementia or tracheostomy)→M1216No spirometry results with confirmed airflow obstruction (fev1/fvc < 70%) documented and/or no spirometry performed with results documented during the encounter→M1217Documentation of system reason(s) for not documenting and reviewing spirometry results (e.g., spirometry equipment not available at the time of the encounter)→M1218Patient has copd symptoms (e.g., dyspnea, cough/sputum, wheezing)→M1220Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist or artificial intelligence (ai) interpretation documented and reviewed; with evidence of retinopathy→M1221Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist or artificial intelligence (ai) interpretation documented and reviewed; without evidence of retinopathy→M1222Glaucoma plan of care not documented, reason not otherwise specified→M1223Glaucoma plan of care documented→M1224Intraocular pressure (iop) reduced by a value less than 20% from the pre-intervention level→M1225Intraocular pressure (iop) reduced by a value of greater than or equal to 20% from the pre-intervention level→M1226Iop measurement not documented, reason not otherwise specified→M1227Evidence-based therapy was prescribed→M1228Patient, who has a reactive hcv antibody test, and has a follow up hcv viral test that detected hcv viremia, has hcv treatment initiated within 3 months of the reactive hcv antibody test→M1229Patient, who has a reactive hcv antibody test, and has a follow up hcv viral test that detected hcv viremia, is referred within 1 month of the reactive hcv antibody test to a clinician who treats hcv infection→M1230Patient has a reactive hcv antibody test and does not have a follow up hcv viral test, or patient has a reactive hcv antibody test and has a follow up hcv viral test that detects hcv viremia and is not referred to a clinician who treats hcv infection within 1 month and does not have hcv treatment initiated within 3 months of the reactive hcv antibody test, reason not given→M1231Patient receives hcv antibody test with nonreactive result→M1232Patient receives hcv antibody test with reactive result→M1233Patient does not receive hcv antibody test or patient does receive hcv antibody test but results not documented, reason not given→M1234Patient has a reactive hcv antibody test, and has a follow up hcv viral test that does not detect hcv viremia→M1235Documentation or patient report of hcv antibody test or hcv rna test which occurred prior to the performance period→M1236Baseline mrs > 2→M1237Patient reason for not screening for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety (e.g., patient declined or other patient reasons)→M1238Documentation that administration of second recombinant zoster vaccine could not occur during the performance period due to the recommended 2-6 month interval between doses (i.e, first dose received after october 31)→M1239Patient did not respond to the question of patient felt heard and understood by this provider and team→M1240Patient did not respond to the question of patient felt this provider and team put my best interests first when making recommendations about my care→M1241Patient did not respond to the question of patient felt this provider and team saw me as a person, not just someone with a medical problem→M1242Patient did not respond to the question of patient felt this provider and team understood what is important to me in my life→M1243Patient provided a response other than "completely true" for the question of patient felt heard and understood by this provider and team→M1244Patient provided a response other than "completely true" for the question of patient felt this provider and team put my best interests first when making recommendations about my care→M1245Patient provided a response other than "completely true" for the question of patient felt this provider and team saw me as a person, not just someone with a medical problem→M1246Patient provided a response other than "completely true" for the question of patient felt this provider and team understood what is important to me in my life→M1247Patient responded "completely true" for the question of patient felt this provider and team put my best interests first when making recommendations about my care→M1248Patient responded "completely true" for the question of patient felt this provider and team saw me as a person, not just someone with a medical problem→M1249Patient responded "completely true" for the question of patient felt this provider and team understood what is important to me in my life→M1250Patient responded as "completely true" for the question of patient felt heard and understood by this provider and team→M1251Patients for whom a proxy completed the entire hu survey on their behalf for any reason (no patient involvement)→M1252Patients who did not complete at least one of the four patient experience hu survey items and return the hu survey within 60 days of the ambulatory palliative care visit→M1253Patients who respond on the patient experience hu survey that they did not receive care by the listed ambulatory palliative care provider in the last 60 days (disavowal)→M1254Patients who were deceased when the hu survey reached them→M1255Patients who have another reason for visiting the clinic [not prenatal or postpartum care] and have a positive pregnancy test but have not established the clinic as an ob provider (e.g., plan to terminate the pregnancy or seek prenatal services elsewhere)→M1256Prior history of known cvd→M1257Cvd risk assessment not performed or incomplete (e.g., cvd risk assessment was not documented), reason not otherwise specified→M1258Cvd risk assessment performed, have a documented calculated risk score→M1259Patient status documented within the first year of initiating dialysis→M1260Patient status not documented within the first year of initiating dialysis→M1261Patients that were on the kidney or kidney-pancreas waitlist prior to initiation of dialysis→M1262Patients who had a transplant prior to initiation of dialysis→M1263Patients in hospice on their initiation of dialysis date or during the month of evaluation→M1265Cms medical evidence form 2728 for dialysis patients: initial form completed→M1266Patients admitted to a skilled nursing facility (snf)→M1267Patients not observed in active status on any kidney or kidney-pancreas transplant waitlist as of the last day of each month during the measurement period→M1268Patients observed in active status on any kidney or kidney-pancreas transplant waitlist as of the last day of each month during the measurement period→M1269Receiving esrd mcp dialysis services by the provider on the last day of the reporting month→M1270Patients not on any kidney or kidney-pancreas transplant waitlist as of the last day of each month during the measurement period→M1271Patients with dementia at any time prior to or during the month→M1272Patients observed on any kidney or kidney-pancreas transplant waitlist as of the last day of each month during the measurement period→M1273Patients who were admitted to a skilled nursing facility (snf) within one year of dialysis initiation according to the cms-2728 form→M1274Patients who were admitted to a skilled nursing facility (snf) during the month of evaluation were excluded from that month→M1275Patients determined to be in hospice were excluded from month of evaluation and the remainder of reporting period→M1276Bmi documented outside normal parameters, no follow-up plan documented, no reason given→M1277Colorectal cancer screening results documented and reviewed→M1278Elevated or hypertensive blood pressure reading documented, and the indicated follow-up is documented→M1279Elevated or hypertensive blood pressure reading documented, indicated follow-up not documented, reason not given→M1280Women who had a bilateral mastectomy or who have a history of a bilateral mastectomy or for whom there is evidence of a right and a left unilateral mastectomy→M1281Blood pressure reading not documented, reason not given→M1282Patient screened for tobacco use and identified as a tobacco non-user→M1283Patient screened for tobacco use and identified as a tobacco user→M1284Patients age 66 or older in institutional special needs plans (snp) or residing in long term care with pos code 32, 33, 34, 54, or 56 for more than 90 consecutive days during the measurement period→M1285Screening, diagnostic, film, digital or digital breast tomosynthesis (3d) mammography results were not documented and reviewed, reason not otherwise specified→M1286Bmi is documented as being outside of normal parameters, follow-up plan is not completed for documented medical reason→M1287Bmi is documented below normal parameters and a follow-up plan is documented→M1288Documented reason for not screening or recommending a follow-up for high blood pressure→M1289Patient identified as tobacco user did not receive tobacco cessation intervention during the measurement period or in the six months prior to the measurement period (counseling and/or pharmacotherapy)→M1290Patient not eligible due to active diagnosis of hypertension→M1291Patients 66 years of age and older with at least one claim/encounter for frailty during the measurement period and a dispensed medication for dementia during the measurement period or the year prior to the measurement period→M1292Patients 66 years of age and older with at least one claim/encounter for frailty during the measurement period and an advanced illness diagnosis during the measurement period or the year prior to the measurement period→M1293Bmi is documented above normal parameters and a follow-up plan is documented→M1294Normal blood pressure reading documented, follow-up not required→M1295Patients with a diagnosis or past history of total colectomy or colorectal cancer→M1296Bmi is documented within normal parameters and no follow-up plan is required→M1297Bmi not documented due to medical reason or patient refusal of height or weight measurement→M1298Documentation of patient pregnancy anytime during the measurement period prior to and including the current encounter→M1299Influenza immunization administered or previously received→M1300Influenza immunization was not administered for reasons documented by clinician (e.g., patient allergy or other medical reasons, patient declined or other patient reasons, vaccine not available or other system reasons)→M1301Patient identified as a tobacco user received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period (counseling and/or pharmacotherapy)→M1302Screening, diagnostic, film digital or digital breast tomosynthesis (3d) mammography results documented and reviewed→M1303Hospice services provided to patient any time during the measurement period→M1304Patient did not receive any pneumococcal conjugate or polysaccharide vaccine on or after their 19th birthday and before the end of the measurement period→M1305Patient received any pneumococcal conjugate or polysaccharide vaccine on or after their 19th birthday and before the end of the measurement period→M1306Patient had anaphylaxis due to the pneumococcal vaccine any time during or before the measurement period→M1307Documentation stating the patient has received or is currently receiving palliative or hospice care→M1308Influenza immunization was not administered, reason not given→M1309Palliative care services provided to patient any time during the measurement period→M1310Patient screened for tobacco use and received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period (counseling, pharmacotherapy, or both), if identified as a tobacco user→M1311Anaphylaxis due to the vaccine on or before the date of the encounter→M1312Patient not screened for tobacco use→M1313Tobacco screening not performed or tobacco cessation intervention not provided during the measurement period or in the six months prior to the measurement period→M1314Bmi not documented and no reason is given→M1315Colorectal cancer screening results were not documented and reviewed; reason not otherwise specified→M1316Current tobacco non-user→M1317Patients who are counseled on connection with a csp and explicitly opt out→M1318Patients who did not have documented contact with a csp for at least one of their screened positive hrsns within 60 days after screening or documentation that there was no contact with a csp→M1319Patients who had documented contact with a csp for at least one of their screened positive hrsns within 60 days after screening→M1320Patients who screened positive for at least 1 of the 5 hrsns→M1321Patients who were not seen within 7 weeks following the date of injection for follow up or who did not have a documented iop or no plan of care documented if the iop was >25 mm hg→M1322Patients seen within 7 weeks following the date of injection and are screened for elevated intraocular pressure (iop) with tonometry with documented iop =<25 mm hg for injected eye→M1323Patients seen within 7 weeks following the date of injection and are screened for elevated intraocular pressure (iop) with tonometry with documented iop >25 mm hg and a plan of care was documented→M1324Patients who had an intravitreal or periocular corticosteroid injection (e.g., triamcinolone, preservative-free triamcinolone, dexamethasone, dexamethasone intravitreal implant, or fluocinolone intravitreal implant)→M1325Patients who were not seen for reasons documented by clinician for patient or medical reasons (e.g., inadequate time for follow-up, patients who received a prior intravitreal or periocular steroid injection within the last six (6) months and had a subsequent iop evaluation with iop <25mm hg within seven (7) weeks of treatment)→M1326Patients with a diagnosis of hypotony→M1327Patients who were not appropriately evaluated during the initial exam and/or who were not re-evaluated within 8 weeks→M1328Patients with a diagnosis of acute vitreous hemorrhage→M1329Patients with a post-operative encounter of the eye with the acute pvd within 2 weeks before the initial encounter or 8 weeks after initial acute pvd encounter→M1330Documentation of patient reason(s) for not having a follow up exam (e.g., inadequate time for follow up)→M1331Patients who were appropriately evaluated during the initial exam and were re-evaluated no later than 8 weeks from initial exam→M1332Patients who were not appropriately evaluated during the initial exam and/or who were not re-evaluated within 2 weeks→M1333Acute vitreous hemorrhage→M1334Patients with a post-operative encounter of the eye with the acute pvd within 2 weeks before the initial encounter or 2 weeks after initial acute pvd encounter→M1335Documentation of patient reason(s) for not having a follow up exam (e.g., inadequate time for follow up)→M1336Patients who were appropriately evaluated during the initial exam and were re-evaluated no later than 2 weeks→M1337Acute pvd→M1338Patients who had follow-up assessment 30 to 180 days after the index assessment who did not demonstrate positive improvement or maintenance of functioning scores during the performance period→M1339Patients who had follow-up assessment 30 to 180 days after the index assessment who demonstrated positive improvement or maintenance of functioning scores during the performance period→M1340Index assessment completed using the 12-item whodas 2.0 or sds during the denominator identification period→M1341Patients who did not have a follow-up assessment or did not have an assessment within 30 to 180 days after the index assessment during the performance period→M1342Patients who died during the performance period→M1343Patients who are at pam level 4 at baseline or patients who are flagged with extreme straight line response sets on the pam or with excessive missing responses→M1344Patients who did not have a baseline pam score and/or a second score within 4 to 12 months of baseline pam score→M1345Patients who had a baseline pam score and a second score within 4 to 12 month of baseline pam score→M1346Patients who did not have a net increase in pam score of at least 6 points within a 4 to 12 month period→M1347Patients who achieved a net increase in pam score of at least 3 points in a 4 to 12 month period (passing)→M1348Patients who achieved a net increase in pam score of at least 6-points in a 4 to 12 month period (excellent)→M1349Patients who did not have a net increase in pam score of at least 3 points within a 4 to 12 month period→M1350Patients who had a completed suicide safety plan initiated, reviewed or updated in collaboration with their clinician (concurrent or within 24 hours) of the index clinical encounter→M1351Patients who had a suicide safety plan initiated, reviewed, or updated and reviewed and updated in collaboration with the patient and their clinician concurrent or within 24 hours of clinical encounter and within 120 days after initiation→M1352Suicidal ideation and/or behavior symptoms based on the c-ssrs or equivalent assessment→M1353Patients who did not have a completed suicide safety plan initiated, reviewed or updated in collaboration with their clinician (concurrent or within 24 hours) of the index clinical encounter→M1354Patients who did not have a suicide safety plan initiated, reviewed, or updated or reviewed and updated in collaboration with the patient and their clinician concurrent or within 24 hours of clinical encounter and within 120 days after initiation→M1355Suicide risk based on their clinician's evaluation or a clinician-rated tool→M1356Patients who died during the measurement period→M1357Patients who had a reduction in suicidal ideation and/or behavior upon follow-up assessment within 120 days of index assessment→M1358Patients who did not have a reduction in suicidal ideation and/or behavior upon follow-up assessment within 120 days of index assessment→M1359Index assessment during the denominator period when the suicidal ideation and/or behavior symptoms or increased suicide risk by clinician determination occurs and a non-zero c-ssrs score is obtained→M1360Suicidal ideation and/or behavior symptoms based on the c-ssrs→M1361Suicide risk based on their clinician's evaluation or a clinician-rated tool→M1362Patients who died during the measurement period→M1363Patients who did not have a follow-up assessment within 120 days of the index assessment→M1364Calculated 10-year ascvd risk score of >= 20 percent during the performance period→M1365Patient encounter during the performance period with hospice and palliative care specialty code 17→M1366Focusing on women's health mips value pathway→M1367Quality care for the treatment of ear, nose, and throat disorders mips value pathway→M1368Prevention and treatment of infectious disorders including hepatitis c and hiv mips value pathway→M1369Quality care in mental health and substance use disorders mips value pathway→M1370Rehabilitative support for musculoskeletal care mips value pathway→M1371Most recent glycemic status assessment (hba1c or gmi) level < 7.0%→M1372Most recent glycemic status assessment (hba1c or gmi) level >= 7.0% and < 8.0%→M1373Most recent glycemic status assessment (hba1c or gmi) level >= 8.0% and <= 9.0%→M1374An additional encounter with an ra diagnosis during the performance period or prior performance period that is at least 90 days before or after an encounter with an ra diagnosis during the performance period→M1375An additional encounter with an ra diagnosis during the performance period or prior performance period that is at least 90 days before or after an encounter with an ra diagnosis during the performance period→M1376An additional encounter with an ra diagnosis during the performance period or prior performance period that is at least 90 days before or after an encounter with an ra diagnosis during the performance period→M1377Recommended follow-up interval for repeat colonoscopy of 10 years documented in colonoscopy report and communicated with patient→M1378Documentation of medical reason(s) for not recommending a 10 year follow-up interval (e.g., inadequate prep, familial or personal history of colonic polyps, patient had no adenoma and age is >= 66 years old, or life expectancy < 10 years, other medical reasons)→M1379A 10 year follow-up interval for colonoscopy not recommended, reason not otherwise specified→M1380Filled at least two prescriptions during the performance period for any combination of the qualifying oral antipsychotic medications listed under "denominator note" or the long-acting injectable antipsychotic medications listed under "denominator note"→M1381Patients with secondary stroke (e.g., a subsequent stroke that may occur with vasospasm in the setting of subarachnoid hemorrhage) within 5 days of the initial procedure→M1382Patient encounter during the performance period with place of service code 11→M1383Acute pvd→M1384Patients who died during the performance period→M1385Documentation of patient reasons for patients who were not seen for the second pam survey (e.g., less than four months between baseline pam assessment and follow-up→M1386Patients with an excisional surgery for melanoma or melanoma in situ in the past 5 years with an initial ajcc staging of 0, i, or ii at the start of the performance period→M1387Patients who died during the performance period→M1388Patients with documentation of an exam performed for recurrence of melanoma→M1390Patients who do not have a documented exam performed for recurrence of melanoma or no documentation within the performance period→M1391All patients who were diagnosed with recurrent melanoma during the current performance period→M1392Documentation of patient reasons for no examination, i.e., refusal of examination or lost to follow-up (documentation must include information that the clinician was unable to reach the patient by phone, mail or secure electronic mail - at least one method must be documented)→M1393Patients who were not diagnosed with recurrent melanoma during the current performance period→M1394Stages i-iii breast cancer→M1395Patients receiving an initial chemotherapy regimen with a defined duration with the eligible clinician or group→M1396Patients on a therapeutic clinical trial→M1397Patients with recurrence/disease progression→M1398Patients with baseline and follow-up promis surveys documented in the medical record→M1399Patients who leave the practice during the follow-up period→M1400Patients who died during the follow-up period→M1401Stages i-iii breast cancer→M1402Patients receiving an initial chemotherapy regimen with a defined duration with the eligible clinician or group→M1403Patients with baseline and follow-up promis surveys documented in the medical record→M1404Patients on a therapeutic clinical trial→M1405Patients with recurrence/disease progression→M1406Patients who leave the practice during the follow-up period→M1407Patients who died during the follow-up period→M1408Patients who have germline brca testing completed before diagnosis of epithelial ovarian, fallopian tube, or primary peritoneal cancer→M1409Patients who received germline testing for brca1 and brca2 or genetic counseling completed within 6 months of diagnosis→M1410Patients who did not have germline testing for brca1 and brca2 or genetic counseling completed within 6 months of diagnosis→M1411Currently on first-line immune checkpoint inhibitors without chemotherapy→M1412Patients with metastatic nsclc with epidermal growth factor receptor (egfr) mutations, alk genomic tumor aberrations, or other targetable genomic abnormalities with approved first-line targeted therapy, such as nsclc with ros1 rearrangement, braf v600e mutation, ntrk 1/2/3 gene fusion, met ex14 skipping mutation, and ret rearrangement→M1413Patients who had a positive pd-l1 biomarker expression test result prior to the initiation of first-line immune checkpoint inhibitor therapy→M1414Documentation of medical reason(s) for not performing the pd-l1 biomarker expression test prior to initiation of first-line immune checkpoint inhibitor therapy (e.g., patient is in an urgent or emergent situation where delay of treatment would jeopardize the patient's health status; other medical reasons/contraindication)→M1415Patients who did not have a positive pd-l1 biomarker expression test result prior to the initiation of first-line immune checkpoint inhibitor therapy→M1416Patient received hospice services any time during the performance period→M1417Patients who are up to date on their covid-19 vaccinations as defined by cdc recommendations on current vaccination→M1418Patients who are not up to date on their covid-19 vaccinations as defined by cdc recommendations on current vaccination because of a medical contraindication documented by clinician→M1419Patients who are not up to date on their covid-19 vaccinations as defined by cdc recommendations on current vaccination→M1420Complete ophthalmologic care mips value pathway→M1421Dermatological care mips value pathway→M1422Gastroenterology care mips value pathway→M1423Optimal care for patients with urologic conditions mips value pathway→M1424Pulmonology care mips value pathway→M1425Surgical care mips value pathway→M1426Encounters conducted via telehealth→M1427Documentation of medical reason(s) for performing a bone scan (including documented pain related to prostate cancer, salvage therapy, other medical reasons)→M1428Patients who have bilateral absence of eyes any time during the patient's history through the end of the measurement period→M1429Retinal exam finding with evidence of retinopathy in left, right or both eyes with severity level documented→M1430Retinal exam finding without evidence of retinopathy in both eyes with severity level documented (in measurement year or in the prior year)→M1431Encounters conducted via telehealth→M1432Encounters conducted via telehealth→M1433Patient on oral chemotherapy on or within 30 days before denominator eligible encounter→M1434Patient on oral chemotherapy on or within 30 days after denominator eligible encounter→M1435Patient on oral chemotherapy during the performance period→M1436Encounters conducted via telehealth→M1437Encounters conducted via telehealth→M1438Time last known well to hospital arrival less than or equal to 3.5 hours (<= 210 minutes)→M1439Significant ocular conditions that impact the visual outcome of surgery→M1440Encounters conducted via telehealth→M1441Encounter corresponds to initial diagnosis of sleep apnea or first contact with sleep apnea diagnosed patient→M1442Encounters conducted via telehealth→M1443Encounters conducted via telehealth→M1444Delivery at < 39 weeks of gestation→M1445Postpartum care visit before or at 12 weeks of giving birth→M1446Patients who died any time prior to the end of the measure assessment period→M1447Patients with an active diagnosis of bipolar disorder any time prior to the end of the measure assessment period→M1448Patients with an active diagnosis of personality disorder any time prior to the end of the measure assessment period→M1449Patients with an active diagnosis of schizophrenia or psychotic disorder any time prior to the end of the measure assessment period→M1450Patients who received hospice or palliative care service any time during denominator identification period or the measure assessment period→M1451Patients with an active diagnosis of pervasive developmental disorder any time prior to the end of the measure assessment period→M1452Patient ever had a diagnosis of dementia→M1453Patients with a pre-operative visual acuity better than 20/40→M1454New cied→M1455Replaced or revised cied→M1456Patient had a heart transplant→M1457Patient had a diagnosis of asthma with any contact during the current or prior performance period or had asthma present on an active problem list any time during the performance period→M1458Patient died prior to the end of the performance period→M1459Patient was in hospice or receiving palliative care services at any time during the performance period→M1460Diagnosis for chronic obstructive pulmonary disease, emphysema, cystic fibrosis, or acute respiratory failure→M1461Patient diagnosis for chronic hepatitis c→M1462Patients with clinical indications for imaging of the head→M1463Documentation of at least two attempts to follow up with patient within 180 days of treatment→M1464No documentation of at least two attempts to follow up with patient within 180 days of treatment→M1465Patient follow up more than 180 days after treatment→M1466Patient had a lumbar fusion on the same date as the discectomy/laminectomy procedure→M1467Patients with an existing diagnosis of lynch syndrome→M1468Patient received recommended doses of hepatitis b vaccination based on age→M1469Patient has a history of hepatitis b illness or received a hepatitis b surface antigen, hepatitis b surface antibody, or total antibody to hepatitis b core antigen test with a positive result any time before or during the measurement period→M1470Documentation of medical reason(s) for not administering hepatitis b vaccine (e.g., prior anaphylaxis due to the hepatitis b vaccine)→M1471Documentation that patient is a medicare fee-for-service beneficiary and without additional supplementary insurance coverage for whom hep b vaccination is not reimbursable under current medicare part b coverage rules→M1472Patient did not receive recommended doses of hepatitis b vaccination based on age→M1473Patient situations, at any point during the denominator identification period, where the patient's functional capacity or motivation (or lack thereof) to improve may impact the accuracy of results of validated tools, such as delirium, dementia, intellectual disabilities, and pervasive and specific development disorders→M1474Patients with diagnosis of dementia→M1475Patients with diagnosis of huntington's disease→M1476Patients with diagnosis of cognitive impairment or alzheimer's disease→M1477Diagnosis of delirium→M1478Psychoactive substance abuse→M1479Patients whose functional capacity or motivation (or lack thereof) to improve may impact the accuracy of results of validated tools such as delirium, dementia, intellectual disabilities, and pervasive and specific development disorders→M1480Patients whose functional capacity or motivation (or lack thereof) to improve may impact the accuracy of results of validated tools such as delirium, dementia, intellectual disabilities, and pervasive and specific development disorders→M1481Patients receiving hospice or palliative care or who died during the measurement period→M1482Positive/detectable hepatitis c virus quantitative or qualitative rna test result during the denominator identification period→M1483Patients who achieve sustained virological response as identified by an hcv rna test (cpt 87522) or (cpt 87521) with a negative/undetectable hcv rna result that occurred 20 weeks to 12 months after the first positive/detectable hcv rna test result within the denominator identification period→M1484Patients who did not have a repeat hcv rna labs performed for medical reasons documented by clinician (e.g., patient with limited life expectancy, delay in treatment of hcv related to treatment of hiv, hbv, hepatocellular carcinoma, decompensated cirrhosis)→M1485Patients who did not achieve sustained virological response as identified by an hcv rna test (cpt 87522) or (cpt 87521) with a negative/undetectable hcv rna result that occurred 20 weeks to 12 months after the first positive/detectable hcv rna test result within the denominator identification period→M1486Patients admitted to a skilled nursing facility (snf) during the period of evaluation→M1487Patients in hospice in the year before or during the period of evaluation→M1488Patients with a diagnosis for dementia in the year before or during the period of evaluation→M1489Patient status documented→M1490Patient status not documented→M1491Receiving esrd mcp dialysis services by the provider during the performance period→M1492Patients who did not report a fall→M1493Documentation of falls not performed due to medical reasons (e.g., syncope, vertigo and related disorders, restless leg syndrome, tourette syndrome/tic disorder, back pain, concussion/mild traumatic brain injury (mtbi), cervical dystonia, or epilepsy)→M1494Patients that reported a fall since the last visit→M1495Patients that reported a fall occurred who had a plan of care for falls documented or patients that did not report a fall→M1496Patients that had a fall who did not have a plan of care for falls documented or do not have documentation of being assessed for falls→M1497Documentation of falls not performed due to medical reasons (e.g., syncope, vertigo and related disorders, restless leg syndrome, tourette syndrome/tic disorder, back pain, concussion/mild traumatic brain injury (mtbi), cervical dystonia, or epilepsy)→M1498Diagnostic radiology mips value pathway→M1499Interventional radiology mips value pathway→M1500Neuropsychology mips value pathway→M1501Pathology mips value pathway→M1502Podiatry mips value pathway→M1503Vascular surgery mips value pathway→
Procedure codeCODABLE
M1338
Patients who had follow-up assessment 30 to 180 days after the index assessment who did not demonstrate positive improvement or maintenance of functioning scores during the performance period
- Part
- HCPCS Level II
- M
- Medical Services
- M1
- M1003–M1503
Source
CMS — ICD-10-PCS FY2026, HCPCS Level II october 2026, Procedure Codes 2026.