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1 | Measure Title | Measure ID | Collection Type | Measure Type | High Priority | Average Performance Rate | Measure has a Benchmark | Performance Range 1 | Performance Range 2 | Performance Range 3 | Performance Range 4 | Performance Range 5 | Performance Range 6 | Performance Range 7 | Performance Range 8 | Performance Range 9 | Performance Range 10 | Topped Out | Seven Point Cap | Reason for No Benchmarks | ||||||
2 | Hepatitis B Safety Screening | ACR10 | QCDR Measure | Process | Yes | 56.87 | Yes | 3.23 - 32.80 | 32.81 - 39.99 | 40.00 - 49.05 | 49.06 - 54.25 | 54.26 - 58.89 | 58.90 - 64.48 | 64.49 - 68.93 | 68.94 - 72.92 | 72.93 - 77.41 | >= 77.42 | No | No | N/A | ||||||
3 | Disease Activity Measurement for Patients with PsA | ACR12 | QCDR Measure | Process | No | 80.05 | Yes | 3.57 - 46.35 | 46.36 - 66.12 | 66.13 - 80.90 | 80.91 - 83.39 | 83.40 - 90.02 | 90.03 - 92.82 | 92.83 - 95.54 | 95.55 - 97.37 | 97.38 - 99.01 | >= 99.02 | No | No | N/A | ||||||
4 | Gout: Serum Urate Target | ACR14 | QCDR Measure | Intermediate Outcome | Yes | 60.19 | Yes | 24.64 - 43.92 | 43.93 - 49.77 | 49.78 - 53.56 | 53.57 - 58.50 | 58.51 - 61.35 | 61.36 - 63.05 | 63.06 - 66.66 | 66.67 - 70.36 | 70.37 - 75.13 | >= 75.14 | No | No | N/A | ||||||
5 | Safe Hydroxychloroquine Dosing | ACR15 | QCDR Measure | Process | Yes | 69.88 | Yes | 12.20 - 47.35 | 47.36 - 60.18 | 60.19 - 67.15 | 67.16 - 69.46 | 69.47 - 72.77 | 72.78 - 75.17 | 75.18 - 78.78 | 78.79 - 81.79 | 81.80 - 87.03 | >= 87.04 | No | No | N/A | ||||||
6 | Rheumatoid Arthritis Patients with Low Disease Activity or Remission | ACR16 | QCDR Measure | Intermediate Outcome | Yes | -- | No | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | N/A | N/A | Insufficient volume of data submitted in PY 2023 to establish historical benchmark. | ||||||
7 | Methotrexate to Biologic Adherence to Treatment Pathway for Patients with Rheumatoid Arthritis | ACR17 | QCDR Measure | Process | Yes | -- | No | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | N/A | N/A | Measure added in PY 2025; subject to 7-point scoring floor if data completeness is met. | ||||||
8 | Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older | 024 | MIPS CQM | Process | Yes | 80.87 | Yes | 1.69 - 34.18 | 34.19 - 57.62 | 57.63 - 77.14 | 77.15 - 92.49 | 92.50 - 95.82 | 95.83 - 99.88 | 99.89 - 99.99 | -- | -- | 100 | No | No | N/A | ||||||
9 | Screening for Osteoporosis for Women Aged 65-85 Years of Age | 039 | MIPS CQM | Process | No | 54.79 | Yes | 0.38 - 4.45 | 4.46 - 19.45 | 19.46 - 36.18 | 36.19 - 48.41 | 48.42 - 58.06 | 58.07 - 68.70 | 68.71 - 77.82 | 77.83 - 86.80 | 86.81 - 96.97 | >= 96.98 | No | No | N/A | ||||||
10 | Advance Care Plan | 047 | MIPS CQM | Process | Yes | 82.58 | Yes | 0.34 - 30.26 | 30.27 - 67.77 | 67.78 - 85.87 | 85.88 - 94.95 | 94.96 - 98.75 | 98.76 - 99.84 | 99.85 - 99.99 | -- | -- | 100 | Yes | No | N/A | ||||||
11 | Documentation of Current Medications in the Medical Record | 130 | MIPS CQM | Process | Yes | 91.38 | Yes | 4.13 - 70.81 | 70.82 - 94.19 | 94.20 - 98.37 | 98.38 - 99.67 | 99.68 - 99.98 | 99.99 - 99.99 | -- | -- | -- | 100 | Yes | Yes | N/A | ||||||
12 | Documentation of Current Medications in the Medical Record | 130 | eCQM | Process | Yes | 86.93 | Yes | 3.40 - 60.63 | 60.64 - 80.57 | 80.58 - 88.71 | 88.72 - 92.94 | 92.95 - 95.65 | 95.66 - 97.44 | 97.45 - 98.60 | 98.61 - 99.45 | 99.46 - 99.90 | >= 99.91 | Yes | Yes | N/A | ||||||
13 | Preventive Care and Screening: Screening for Depression and Follow-Up Plan | 134 | MIPS CQM | Process | No | 89.24 | Yes | 0.08 - 61.67 | 61.68 - 84.49 | 84.50 - 97.70 | 97.71 - 99.77 | 99.78 - 99.99 | -- | -- | -- | -- | 100 | Yes | Yes | N/A | ||||||
14 | Preventive Care and Screening: Screening for Depression and Follow-Up Plan | 134 | eCQM | Process | No | 48.51 | No | 0.09 - 4.95 | 4.96 - 15.05 | 15.06 - 24.73 | 24.74 - 35.27 | 35.28 - 45.94 | 45.95 - 58.10 | 58.11 - 71.38 | 71.39 - 84.22 | 84.23 - 94.98 | >= 94.99 | No | No | N/A | ||||||
15 | Falls: Plan of Care | 155 | MIPS CQM | Process | Yes | 96.07 | Yes | 25.00 - 91.08 | 91.09 - 99.43 | 99.44 - 99.99 | -- | -- | -- | -- | -- | -- | 100 | Yes | Yes | N/A | ||||||
16 | Tuberculosis Screening Prior to First Course of Biologic and/or Immune Response Modifier Therapy | 176 | MIPS CQM | Process | No | 87.21 | Yes | 5.26 - 51.27 | 51.28 - 80.16 | 80.17 - 90.47 | 90.48 - 95.82 | 95.83 - 99.99 | -- | -- | -- | -- | 100 | Yes | Yes | N/A | ||||||
17 | Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity | 177 | MIPS CQM | Process | No | 91.94 | Yes | 17.14 - 74.47 | 74.48 - 90.12 | 90.13 - 95.00 | 95.01 - 97.77 | 97.78 - 99.33 | 99.34 - 99.99 | -- | -- | -- | 100 | Yes | Yes | N/A | ||||||
18 | Rheumatoid Arthritis (RA): Functional Status Assessment | 178 | MIPS CQM | Process | No | 90.83 | Yes | 9.59 - 72.99 | 73.00 - 90.81 | 90.82 - 95.78 | 95.79 - 98.25 | 98.26 - 99.61 | 99.62 - 99.99 | -- | -- | -- | 100 | Yes | Yes | N/A | ||||||
19 | Rheumatoid Arthritis (RA): Glucocorticoid Management | 180 | MIPS CQM | Process | No | 91.87 | Yes | 0.17 - 75.19 | 75.20 - 88.69 | 88.70 - 92.13 | 92.14 - 98.04 | 98.05 - 99.99 | -- | -- | -- | -- | 100 | Yes | Yes | N/A | ||||||
20 | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | 226 | MIPS CQM | Process | No | 80.27 | Yes | 3.12 - 28.56 | 28.57 - 58.27 | 58.28 - 77.77 | 77.78 - 89.79 | 89.80 - 96.50 | 96.51 - 99.55 | 99.56 - 99.99 | -- | -- | 100 | Yes | No | N/A | ||||||
21 | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | 226 | eCQM | Process | No | 63.13 | Yes | 3.23 - 16.38 | 16.39 - 28.58 | 28.59 - 42.04 | 42.05 - 55.25 | 55.26 - 67.73 | 67.74 - 80.90 | 80.91 - 90.61 | 90.62 - 97.13 | 97.14 - 99.99 | 100 | No | No | N/A | ||||||
22 | Controlling High Blood Pressure | 236 | MIPS CQM | Intermediate Outcome | Yes | 72.82 | Yes | 1.00 - 9.99 | 10.00 - 19.99 | 20.00 - 29.99 | 30.00 - 39.99 | 40.00 - 49.99 | 50.00 - 59.99 | 60.00 - 69.99 | 70.00 - 79.99 | 80.00 - 89.99 | >= 90.00 | No | No | N/A | ||||||
23 | Controlling High Blood Pressure | 236 | eCQM | Intermediate Outcome | Yes | 66.23 | Yes | 5.56 - 45.70 | 45.71 - 55.16 | 55.17 - 61.15 | 61.16 - 65.31 | 65.32 - 68.73 | 68.74 - 71.93 | 71.94 - 75.30 | 75.31 - 79.30 | 79.31 - 84.73 | >= 84.74 | No | No | Measure was suppressed in PY 2022 (baseline period); data isn't available for historical benchmarking. | ||||||
24 | Use of High-Risk Medications in Older Adults | 238 | MIPS CQM | Process | Yes | 0.3 | Yes | 5.97 - 0.01 | -- | -- | -- | -- | -- | -- | -- | -- | 0 | Yes | No | N/A | ||||||
25 | Use of High-Risk Medications in Older Adults | 238 | eCQM | Process | Yes | 4.51 | Yes | 30.03 - 15.44 | 15.43 - 9.44 | 9.43 - 4.31 | 4.30 - 1.68 | 1.67 - 0.53 | 0.52 - 0.10 | 0.09 - 0.01 | -- | -- | 0 | Yes | No | N/A | ||||||
26 | Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 317 | MIPS CQM | Process | No | 68.66 | Yes | 0.12 - 14.22 | 14.23 - 28.15 | 28.16 - 41.52 | 41.53 - 66.92 | 66.93 - 89.39 | 89.40 - 97.17 | 97.18 - 99.81 | 99.82 - 99.99 | -- | 100 | No | No | N/A | ||||||
27 | Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented | 317 | eCQM | Process | No | 27.1 | Yes | 0.05 - 4.33 | 4.34 - 14.37 | 14.38 - 18.88 | 18.89 - 22.50 | 22.51 - 25.38 | 25.39 - 28.46 | 28.47 - 31.88 | 31.89 - 36.16 | 36.17 - 44.95 | >= 44.96 | No | No | N/A | ||||||
28 | Falls: Screening for Future Fall Risk | 318 | eCQM | Process | Yes | 64.1 | Yes | 0.15 - 6.21 | 6.22 - 25.72 | 25.73 - 43.95 | 43.96 - 60.90 | 60.91 - 75.95 | 75.96 - 86.30 | 86.31 - 93.91 | 93.92 - 98.06 | 98.07 - 99.65 | >= 99.66 | No | No | N/A | ||||||
29 | Closing the Referral Loop: Receipt of Specialist Report | 374 | MIPS CQM | Process | Yes | 89.33 | Yes | 3.26 - 54.70 | 54.71 - 88.78 | 88.79 - 97.74 | 97.75 - 99.99 | -- | -- | -- | -- | -- | 100 | Yes | No | N/A | ||||||
30 | Closing the Referral Loop: Receipt of Specialist Report | 374 | eCQM | Process | Yes | 46.69 | Yes | 0.65 - 6.92 | 6.93 - 17.38 | 17.39 - 26.78 | 26.79 - 34.83 | 34.84 - 43.30 | 43.31 - 51.99 | 52.00 - 61.53 | 61.54 - 78.16 | 78.17 - 95.23 | >= 95.24 | No | No | N/A | ||||||
31 | Screening for Social Drivers of Health | 487 | MIPS CQM | Process | Yes | 43.32 | Yes | 0.03 - 0.12 | 0.13 - 0.24 | 0.25 - 0.80 | 0.81 - 7.28 | 7.29 - 18.74 | 18.75 - 61.89 | 61.90 - 99.08 | 99.09 - 99.99 | -- | 100 | No | No | N/A | ||||||
32 | Adult Immunization Status | 493 | MIPS CQM | Process | No | 23.7 | Yes | 0.02 - 0.23 | 0.24 - 2.27 | 2.28 - 7.42 | 7.43 - 13.20 | 13.21 - 18.75 | 18.76 - 24.96 | 24.97 - 31.87 | 31.88 - 37.38 | 37.39 - 53.11 | >= 53.12 | No | No | N/A | ||||||
33 | Connection to Community Service Provider | 498 | MIPS CQM | Process | Yes | -- | No | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | N/A | N/A | Measure added in PY 2024; subject to 5-point scoring floor if data completeness is met. | ||||||
34 | Gains in Patient Activation Measure (PAM) Scores at 12 Months | 503 | MIPS CQM | Patient-Reported Outcome-Based Performance Measure (PRO-PM) | Yes | -- | No | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | N/A | N/A | Measure added in PY 2024; subject to 5-point scoring floor if data completeness is met. | ||||||
35 | Adult COVID-19 Vaccination Status | 508 | MIPS CQM | Process | No | -- | No | -- | -- | -- | -- | -- | -- | -- | -- | -- | -- | N/A | N/A | Measure added in PY 2025; subject to 7-point scoring floor if data completeness is met. | ||||||
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