PCMH Standardized Measurement

Starting the 2024 reporting year, NCQA is requiring standardized measures for PCMH QI 01, QI 02, AR QI 1, AR QI 2, BH 17 and AR BH. As a part of standardized measures reporting, practices will be required to submit the previous calendar year’s data (Jan 1 – Dec 31) unless otherwise specified in the measure description. Standardized measures are measures which are validated by a measure steward and have specific parameters for reporting. For PCMH, practices should utilize the specifications of electronic clinical quality measures (eCQMs) which were designed to be applied at the practice or clinician level of reporting. Specifications for these measures can be found at the eCQI Resource Center’s website.

PCMH Supported Measures


MeasureCMS eCQM #Measure Steward
Influenza ImmunizationCMS 147NCQA
Pneumococcal Vaccination Status for Older AdultsCMS 127NCQA
Childhood Immunization Status: Combination 10 (CIS)CMS 117NCQA


MeasureCMS eCQM #Measure Steward
Cervical Cancer ScreeningCMS 124NCQA
Colorectal Cancer ScreeningCMS 130NCQA
Breast Cancer ScreeningCMS 125NCQA
Body Mass Index Screening and Follow-Up PlanCMS 69CMS
Tobacco Use: Screening and Cessation InterventionCMS 138NCQA
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up DocumentedCMS 22CMS
HIV ScreeningCMS 349CDC
Weight Assessment and Counseling for Nutrition and Physical Activity for Children/AdolescentsCMS 155NCQA
Chlamydia Screening in WomenCMS 153NCQA
Fall: Screening for Future Fall RiskCMS 139NCQA

Behavioral Health

MeasureCMS eCQM #Measure Steward
Follow-Up Care for Children Prescribed ADHD Medication (ADD)CMS 136NCQA
Screening for Depression and Follow-Up PlanCMS 2CMS
Initiation and Engagement of Substance Use Disorder TreatmentCMS 137NCQA
Adult Major Depressive Disorder (MDD): Suicide Risk AssessmentCMS 161Mathematica
Depression Remission at Twelve MonthsCMS 159MN Community Measurement
Anti-depressant Medication ManagementCMS 128NCQA
Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk AssessmentCMS 177Mathematica


Chronic or Acute Care

MeasureCMS eCQM #Measure Steward
Controlling High Blood PressureCMS 165NCQA
Diabetes HbA1C Poor Control (>9%)CMS 122NCQA
Diabetes Eye ExamCMS 131NCQA
Statin Therapy for the Prevention and Treatment of Cardiovascular DiseaseCMS 347CMS
Dementia: Cognitive AssessmentCMS 149American Academy of Neurology


Care Coordination

MeasureCMS eCQM #Measure Steward
Closing the Referral LoopCMS 50CMS
Documentation of Current Medications in the Medical RecordCMS 68CMS


Health Care Costs

MeasureCMS eCQM #Measure Steward
Appropriate Testing for PharyngitisCMS 146NCQA
Appropriate Treatment for Upper Respiratory Infection (URI)CMS 154NCQA


Reporting Exceptions

In 2024, standardized measures reporting will be required for all practices seeking or renewing their recognition status. NCQA will allow exceptions to standardized measures reporting and will permit practices to submit custom measures in a few unique cases:

  • Pediatric practices will be permitted to submit a custom measure for the chronic or acute component in QI 01 as there are currently no approved standardized measures for chronic or acute care for pediatric populations.
  • In the event that no measures within a measure category are relevant to your patient population, please submit a case detailing why. Also include the measure name and the numerator and denominator descriptions of the custom measure the practice would like to submit for consideration.

As a part of standardized measures reporting, practices will be required to submit a full calendar year’s data (Jan 1 – Dec 31) unless otherwise specified in the measure description. NCQA recognizes that there can be unique challenges to obtaining a full calendar year of data if a practice were to change vendors mid-year. In such instances, NCQA may grant an exception to full calendar year reporting.

Please note that exceptions to standardized measures for 2024 reporting will be granted on a case-by-case basis. If a practice meets the exception criteria outlined above or faces other barriers that prevent the reporting of standardized measures, then they are asked to submit a PCS ticket through MyNCQA for consideration.

Custom Measures

The following are examples of acceptable custom measures for pediatric populations:

Chronic or Acute
Nutrition consultation to obese patients
Physical activity consultation to obese patients
Asthma controller medications for persistent asthma
Influenza prevention in asthma patients
The Asthma Control Test (ACT)
Asthma self-management plan
ADHD medication management and monitoring
Treatment of an ear infection with antibiotic therapy
Diagnosis of UTI and follow-up care
Diagnosis of acute bronchitis and follow-up care


The following resource may be used to explore measure specifications.

eCQI Resource Center: A resource website from The Office of the National Coordinator for Health Information Technology. Contains the most current resources to support electronic clinical quality improvement (eCQI).

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