Measure Name

Denominator

Numerator

Diabetes Measures

Hemoglobin A1c (HgA1c) Test

Patients aged 18-75 with a diagnosis of diabetes who had two face-to-face encounters* with different dates of service - one visit during the measurement period and the other visit in the measurement period or within two years prior to the end of the measurement period.

Denominator patients who had at least one HgA1c test within one year prior to the end of the measurement period.

Poor Control of HgA1c

Patients aged 18-75 with a diagnosis of diabetes who had two face-to-face encounters* with different dates of service - one visit during the measurement period and the other visit in the measurement period or within two years prior to the end of the measurement period.

Denominator patients who did not have at least one HgA1c test within one year prior to the end of the measurement period or who’s last HgA1c test was > 9%.

Control of Hga1c

Patients aged 18-75 with a diagnosis of diabetes who had two face-to-face encounters* with different dates of service - one visit during the measurement period and the other visit in the measurement period or within two years prior to the end of the measurement period.

Denominator patients who had at least one HgA1c test within one year prior to the end of the measurement period and who’s last HgA1c test was < 8%.

Retinal Eye Exams

Patients aged 18-75 with a diagnosis of diabetes who had two face-to-face encounters* with different dates of service - one visit during the measurement period and the other visit in the measurement period or within two years prior to the end of the measurement period.

Denominator patients who received a retinal eye exam from an ophthalmologist or optometrist within one year prior to the end of the measurement period.

Foot Exams

Patients aged 18-75 with a diagnosis of diabetes who had two face-to-face encounters* with different dates of service - one visit during the measurement period and the other visit in the measurement period or within two years prior to the end of the measurement period.

Denominator patients who received at least one LEAP or diabetic/sensory foot exam during the measurement period or within one year prior to the end of the measurement period.

Diabetes Blood Pressure Control (<140/90)

Patients aged 18-75 with a diagnosis of diabetes who had two face-to-face encounters* with different dates of service - one visit during the measurement period and the other visit in the measurement period or within two years prior to the end of the measurement period.

Denominator patients whose blood pressure at their last encounter was equal to or <140/90.

Hypertension Measures

Blood Pressure Measurement

Patients aged 18-85 with a diagnosis of hypertension who had two face-to-face encounters* with different dates of service—one during the measurement period and the other in the measurement period or within two years prior to the end of the measurement period.

Denominator patients who had a blood pressure measurement taken at their last encounter

Blood Pressure Control

Patients aged 18-85 with a diagnosis of hypertension who had two face-to-face encounters* with different dates of service - one visit during the measurement period and the other visit in the measurement period or within two years prior to the end of the measurement period.

Of the denominator patients:

• Adults 18–59 years of age whose blood pressure was <140/90 mm Hg.
• Adults 60–85 years of age, with a diagnosis of diabetes, whose blood pressure was <140/90 mm Hg.
• Adults 60–85 years of age, without a diagnosis of diabetes, whose blood pressure was <150/90 mm Hg.

Cancer Screening

Breast Cancer Screening 40+ years

Women aged 40-74 who had two face-to-face encounters* with different dates of service - one visit during the measurement period and the other visit in the measurement period or within two years prior to the end of the measurement period.

Denominator patients who received a mammogram within two years prior to the end of the reporting period.

Breast Cancer Screening 50+ years

Women aged 50 to 74 who had two face-to-face encounters* with different dates of service - one visit during the measurement period and the other visit in the measurement period or within two years prior to the end of the measurement period.

Denominator patients who received a mammogram within two years prior to the end of the reporting period.

Cervical Cancer Screening

Women aged 21-64 as of the end of the measurement period who had two face-to-face encounters* with different dates of service - one visit during the measurement period and the other visit in the measurement period or within two years prior to the end of the measurement period.

Of the denominator patients

• Women aged 21 -64 with cervical cytology performed within the last 3 years
• Women aged 30-64 who had cervical high risk hrHPV testing performed within the last 3 years
• Women 30-64 years of age who had cervical cytology/high risk hrHPV cotesting within the last 5 years

Colorectal Cancer Screening

Men and women aged 45-75 as of the end of the measurement period who had two face-to-face encounters* with different dates of service - one visit during the measurement period and the other visit in the measurement period or within two years prior to the end of the measurement period.

Denominator patients who received one of the following tests:

• Colonoscopy during the measurement period or within 10 years of the end of the measurement period.
• Flexible sigmoidoscopy during the measurement period or within 5 years of the end of the measurement period.
• Fecal occult blood or FIT test within 12 months of the end of the measurement period.

Vaccinations

Pneumococcal vaccination

Patients aged 65 or older who had two face-to-face encounters with different dates of service – one visit during the measurement period and the other visit in the measurement period or within two years prior to the end of the measurement period.

Denominator patients who have had a pneumococcal vaccination at any point prior to their most recent encounter. 

Behavioral Health

Primary Care Visit Depression Screening 

Completed primary care visit (PCV) encounters during the measurement period.

Denominator encounters with a documented PHQ-9 or PHQ-2.

Active Patient Depression Screening 

Patients as of the end of the measurement period who had two face-to-face encounters* (PCV or SCV) with different dates of service - one visit during the measurement period and the other visit in the measurement period or within two years prior to the end of the measurement period.

Denominator patients who had at least one documented PHQ2 or PHQ9 at any type of visit in the 15 months prior to the end of the measurement period.

Behavioral Health Follow Up After Positive Depression Screen 

Patients as of the end of the measurement period who had two face-to-face encounters* (PCV or SCV) with different dates of service - one visit during the measurement period and the other visit in the measurement period or within two years prior to the end of the measurement period.

And have a completed PCV visit in the three months prior to the beginning of the measurement period with a positive PHQ screen (PHQ>9 OR PHQ-2>0). 

Denominator patients who receive any BH visit (excluding phone visits) within two months of the positive PHQ screen.

Depression Symptom Reduction 

Percentage of patients with clinically significant symptoms of depression with a demonstrated decrease in depression symptoms within six months of initial Behavioral Health evaluation (2 measures: Most recent score and best score)

Patients as of the end of the measurement period who had two face-to-face encounters* (PCV or SCV) with different dates of service - one visit during the measurement period and the other visit in the measurement period or within two years prior to the end of the measurement period.

And who have Behavioral Health evaluation (CPT Code 90791 or 90792) in the six months prior to the beginning of the measurement period with a PHQ ≥10. This is the baseline score. 

And at least one additional PHQ9 score at any type of visit before the end of the measurement period.

Denominator patients whose: 

Measure 1: Most recent PHQ-9 score at any visit in the measurement period is either ≤9 OR a decrease of ≥50% from the baseline score. 

Measure 2: Lowest recorded PHQ-9 score at any visit after the baseline score is either ≤9 OR a decrease of ≥ 50% from the baseline score.