Mastering the Top 5 Ambulatory Quality Measures: A Practical Guide for QPP Success

Understanding and mastering your quality measure performance is crucial for healthcare providers aiming to succeed in the Quality Payment Program (QPP). In this guide, we're examining the five most commonly reported ambulatory measures, complete with specifications, practical tips, and real-world strategies for improvement. These measures also represent the core of preventive care and chronic disease management. Master these, and you'll build a foundation for both clinical excellence and QPP success. 

Why These Five Measures Dominate 

As we looked through reporting patterns and talked with our in-house quality experts, five measures consistently emerged as the most widely adopted in ambulatory care: 

1. Depression Screening and Follow-Up Plan (CMS134) 
2. Diabetes: Glycemic Status Assessment Greater Than 9% (CMS122) 
3. Controlling High Blood Pressure (CMS165) 
4. Breast Cancer Screening (CMS125) 
5. Colorectal Cancer Screening (CMS130)

Why are these measures so prevalent? There are a few key reasons. First, many of these measures involve screenings that can be conducted in various settings, making them versatile and applicable to a wide range of providers. The MIPS reporting framework under the QPP has a fundamental flaw, according to CMS, in that it requires reporting at the TIN level. As a result, those responsible for TIN submissions often choose measures that are most applicable to the majority of providers within their TIN. 

Second, these measures are relatively straightforward. Many gaps in performance can be identified and addressed during routine visits, making them easier to manage and report. 

Last, MSSP ACOs are required to report under the APP framework, which mandates the reporting of these specific measures. 

Important Note: All of these measures are specified as eCQMs, CQMs, and Medicare CQMs, giving you the flexibility to choose the measure type that best suits your group. However, breast and colorectal cancer screening measures can only be reported as eCQMs and CQMs through the MVP or APP pathways, not through traditional MIPS. Moving to MVP reporting not only restores these critical measures but also leverages their often high-performance rates, well-developed workflows, and enhances patient care 

Understanding Each Measure 

We will review each measure in detail below, covering the specification populations, how to succeed, the challenges, and our tips for success. Additionally, we will provide the top-performing deciles. Your performance rate determines which decile you fall into, and each decile corresponds to a specific number of points in the Quality category of QPP. For example, if you rank in Decile 7, you will earn 7 points toward your quality score.  

1. Depression Screening and Follow-Up Plan 

Depression screening casts the widest net of any measure we discuss. What catches practices off-guard isn't the clinical component; it's realizing that virtually every patient encounter triggers inclusion. Your orthopaedic surgeons, physical therapists, and specialists who may not screen for mental health suddenly impact your performance. That said, implementing the measure gives you a lot of agility to have established workflows even if your reporting framework shifts.  

The Specification 

This measure is used to track how well healthcare providers screen their adolescent and adult patients for depression. It also measures whether these providers offer appropriate follow-up care for patients who screen positive for depression. This is important because depression is a common mental health condition that can be treated effectively with early detection and the right care. 

Populations: 

• Initial Population: All patients aged 12 years and older at the beginning of the measurement period with at least one qualifying encounter during the measurement period 

• Denominator: Initial Population 

• Exclusions: Patients who have been diagnosed with bipolar disorder at any time prior to the qualifying encounter 

• Numerator: Patients screened for depression on the date of the encounter or up to 14 days prior to the date of the encounter using an age-appropriate standardized tool AND if positive, a follow-up plan is documented on the date of or up to two days after the date of the qualifying encounter or an active depression medication overlaps the date of the qualifying encounter 
• Success Criteria

• • Depression screening using a standardized tool (PHQ-2, PHQ-9, etc.). Any standardized screening tool can be used, which allows you to customize it to the provider type.  

• • If positive, documented follow-up plan within 2 days. There are many follow-up options including medication prescription, mental health referral, primary care referral, counseling/support group referral, among others. 
• Why It's Challenging

• • The volume alone makes this a challenge. There are so few exclusions, and the net is so wide (patients age 12 and up). We looked at one system of Medisolv’s who reported 375,000 eligible patients in six months. 

• •  As of 2024, patients with a current Depression diagnosis are no longer excluded from the Denominator. If a patient screens positive for depression and already has treatment in place, follow-up should be documented as "Continue Current Mental Health Treatment"  

• • It includes ALL eligible clinicians (specialists, therapists, etc.) 

• • The measure looks at the last screening, and it may or may not be the last encounter of the year. Whoever screens should ensure documenting follow-up to avoid overwriting a previously done correctly screening. ---A real balance of patient care, versus meeting measure logic:  

• • • Decile 7: 58.11 - 71.38% 

• • • Decile 8: 71.39 - 84.22% 

• • • Decile 9: 84.23 - 94.98% 

• • • Decile 10: ≥ 94.99% 

Build Universal Screening Competency 

Success requires expanding depression screening beyond primary care walls. Every billing provider needs both tools and training. Create laminated cards with PHQ-2 questions for exam rooms. Build quick-documentation pathways in your EHR. Increase patient portal usage and streamline documentation by building screening documentation through pre-registration paperwork. Just remember that any positive result must have action taken.  

Most importantly, reassure specialists that referring them back to primary care counts as appropriate follow-up. They don't need to become mental health experts overnight. 

Documentation and Mapping 

Ensure that follow-up plans are documented in discrete fields, not just in provider notes. This helps in maintaining clear and accessible records. Additionally, map the documentation to the appropriate codes to ensure proper measure calculation. Whether you are using paper or electronic screening methods, the results must be entered into the EHR for accurate calculation. 

Workflow Integration 

Build depression screening into routine workflows for all qualifying encounters. Leverage your EMR to drive this measure. Utilize health management tools and EMR rules. Consider triggering an alert if the screening hasn't been done within the timeline set by your organization's policy. Screening every patient, every time, can disrupt results and increase push back by clinicians. This ensures that screening is consistently performed and documented, improving overall compliance and patient care. 

Focus on High-Volume Specialists 

Rather than training every provider equally, identify your highest-volume specialists and start there. A physical therapy group seeing 100 patients weekly has more impact than a subspecialist seeing 20. Priority training for high-volume providers yields the fastest improvements. This measure has relatively low performance rates to get to Decile 7, which is a perfectly acceptable score.  

2. Diabetes: Glycemic Status Assessment Greater Than 9% 

This is an inverse measure where lower scores indicate better performance. You're essentially being graded on failure rates, measuring how many diabetic patients have poorly controlled blood sugar levels. It's a true outcome measure assessing disease control rather than process completion. 

The Specification 

This measure is used to assess the percentage of patients aged 18-75 who have diabetes and had a recent measurement of their glycemic status showing high levels (>9%) or did not have any measurement at all. This measure is important because it helps healthcare providers track their patients' diabetes control and management. 

• Populations: 

• • Initial Population: Patients 18-75 years of age by the end of the measurement period, with diabetes with a visit during the measurement period 

• • Denominator: Initial Population 
  • Exclusions:

• • • Hospice Care: Patients who are in hospice care. 

• • • Nursing Home Residents: Patients who are 66 years or older and have been living in a nursing home. 

• • • Frailty and Advanced Illness: Patients who are 66 years or older and have an indication of frailty, along with any of the following conditions: 

• • • • • Advanced illness diagnosis.  

• • • • • Taking dementia medications during the measurement period or the year prior. 

• • • Palliative Care: Patients who are receiving palliative care. 

• • Numerator: Patients whose most recent glycemic status assessment (HbA1c or GMI) (performed during the measurement period) is >9.0% or is missing.  

• Success Criteria: Most recent glycemic status assessment < 9.0%  
• Why It's Challenging

• • The measure categorizes missing assessments as failures, not just the results that are >9.0%.  

• • Outdated problem lists can create false-positive population qualifications. If a patient has an active diabetes diagnosis on the problem list, it may count the patient in this measure even if their diabetes condition is considered resolved.  

• • Just like the depression screening above, the most recent result counts. So, if your patient sees a specialist at the end of December (right during holiday cookie time), and their blood sugar is out of control, it will count against you. 

• • It's an outcome, not a process measure. It’s not enough to simply screen for the glycemic status assessment (HbA1c or GMI), your providers are responsible for ensuring your patient’s blood sugar levels are below 9.0%. 

• 2025 Benchmarks (inverse – lower is better):  

• • Decile 1: ≤ 5.56% 

• • Decile 2: 5.57 - 10.64% 

• • Decile 3: 10.65 - 16.79% 

• • Decile 4: 16.80 - 23.80% 

Continuous Glucose Monitoring (CGM) Now Applicable 

In 2025, CMS added GMI from continuous glucose monitors that patients wear at home. Patients using CGM generate constant data streams that can automatically satisfy measure requirements. There is no specified minimum date range (e.g., 7-day, 14-day, 30-day, 90-day, etc.) for reporting GMI values so you can determine the range. You can opt to map this new technology to your measure results.  

Make December Your Redemption Month 

Since only the most recent glycemic status assessment (HbA1c or GMI) counts, December becomes strategically critical. Create workflows to identify patients with borderline results from earlier in the year. Schedule them for late-year appointments and retests. A patient with 9.2% in March who achieves 8.8% in December moves from failure to success. 

Track the "Ghost Patients" 

Patients without results often represent your most vulnerable population, those who've disengaged from care. These automatic failures deserve special attention. Build reports identifying diabetics without current glycemic screenings. Implement proactive outreach, combining quality improvement with genuine clinical concern.

3. Controlling High Blood Pressure

This measure is very similar to the Diabetes measure above, except as a standard measure. Meaning, the higher the percentage of patients you have measured as “in control” of their blood pressure, the better. Again, the outcome matters in this instance. 

The Specification 

This measure checks if patients with high blood pressure are being well controlled. It looks at the blood pressure readings of patients aged 18-85 who have been diagnosed with high blood pressure and have had at least one visit to their doctor during the measurement period. The measure then compares these blood pressure readings to a target value. If the readings are below the target, it means the patient's high blood pressure is under control. 

• Populations: 

• • Initial Population: Patients 18-85 years of age by the end of the measurement period who had a visit during the measurement period and diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period 

• • Denominator: Initial Population 

• • Exclusions:  

• • • Hospice Care: Patients who are in hospice care. 

• • • End Stage Renal Disease (ESRD): Patients who have evidence of ESRD, are on dialysis, or have had a renal transplant before or during the measurement period.
    • Patients with a diagnosis of pregnancy during the measurement period. 

• • • Nursing Home Residents: Patients who are 66 years or older and are living in a nursing home. 

• • • Frailty and Advanced Illness: Patients who are 66 years or older and have an indication of frailty, along with any of the following conditions: 

• • • • An advanced illness diagnosis during the measurement period or the year prior. 

• • • • Taking dementia medications during the measurement period or the year prior. 

• • • Palliative Care: Patients who are receiving palliative care. 

• • Numerator: Patients whose most recent blood pressure is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement period 

• Success Criteria: Most recent BP < 140/90 mmHg 

• Why It's Challenging:  

• • A doctor’s visit can cause stress, and the patient may be rushing to the appointment. Both of these scenarios can elevate readings. 

• • One bad reading at the end of the year nullifies a year of control 

• 2025 Benchmarks:  

• • Decile 7: 71.94 - 75.30% 

• • Decile 8: 75.31 - 79.30% 

• • Decile 9: 79.31 - 84.73% 

• • Decile 10: ≥ 84.74% 

Normalize a Second Reading 

That patient who rushed from the parking lot with an elevated BP? That patient with white coat syndrome? They're not alone. Consider building a "recheck elevated BP" into your practice's workflow if the reading is high at the beginning of the appointment. This isn't gaming the system; it's recognizing that initial readings often don't reflect true control. 

Create Rapid Recheck Pathways 

Consider developing BP recheck appointment types. These could be quick 15-minute nurse visits solely for blood pressure measurements. These serve dual purposes: providing more accurate assessments for borderline patients and creating additional opportunities to capture controlled readings. Market these as "convenience appointments" that save patients from full office visits.

4. Breast Cancer Screening

Breast cancer is one of the most prevalent cancers among women, with approximately 3 million women living with breast cancer in the United States alone. Early detection of breast cancer significantly improves the likelihood of successful treatment and survival. Therefore, regular screening is crucial for timely detection and diagnosis of breast cancer.  

The Specification 

• Populations: 

• • Initial Population: There is a difference in the age range between the 2025 and 2026 versions of this measure, so it’s important to understand the following:  

• • • In 2025: Women 52-74 years of age by the end of the measurement period with a visit during the measurement period 

• • • In 2026: Includes women 42-74 years of age  

• • Denominator: Initial Population 

• • Exclusions:  

• • • Hospice Care: Patients who are in hospice care. 

• • • Bilateral Mastectomy: Women who have had a bilateral mastectomy (either a single bilateral procedure or two separate unilateral procedures) on or before the end of the measurement period. 

• • • Nursing Home Residents: Patients who are 66 years or older and are living in a nursing home. 

• • • Frailty and Advanced Illness: Patients who are 66 years or older and have an indication of frailty, along with any of the following conditions: 

• • • • An advanced illness diagnosis during the measurement period or the year prior. 

• • • • Taking dementia medications during the measurement period or the year prior. 

• • • Palliative Care: Patients who are receiving palliative care. 

• • Numerator: Women with one or more mammograms any time on or between October 1st, two years prior to the measurement period and the end of the measurement period. 

• • Also note: In 2026, this measure introduces two stratifications. You must report a total rate, and each of the following age strata: 

• • • Stratum 1: Patients age 42-51 by the end of the measurement period 

• • • Stratum 2: Patients age 52-74 by the end of the measurement period 

• Success Criteria: Mammogram within 27 months before measurement period end 

• Why It's Challenging:  

• • Screening often occurs at external facilities 

• • 27-month window is non-intuitive 

• 2025 Benchmarks:  

• • Decile 7: 68.22 - 73.36% 

• • Decile 8: 73.37 - 78.89% 

• • Decile 9: 78.90 - 85.58% 

• • Decile 10: ≥ 85.59% 

Partner with Imaging Centers 

Work with your common imaging centers to establish data feeds. If electronic integration isn't possible, create workflows for systematic result retrieval. Assign specific staff to contact imaging centers monthly for patient result batches. 

Leverage your EHR 

Use health maintenance routines in your EHR to track patients that need to be screened.  

5. Colorectal Cancer Screening

Colorectal cancer represents eight percent of all new cancer cases in the United States. The Colorectal Cancer Screening measure assesses the percentage of adults aged 45-75 who have appropriate screenings for colorectal cancer. The measure emphasizes the importance of early detection and prevention of colorectal cancer.  

The Specification 

• Populations: 

• • Initial Population: Patients 46-75 years of age by the end of the measurement period with a visit during the measurement period 

• • Denominator: Initial Population 

• • Exclusions:  

• • • Hospice Care: Patients who are in hospice care. 

• • • Total Colectomy or Colorectal Cancer: Patients who have had a diagnosis or history of total colectomy or colorectal cancer. 

• • • Nursing Home Residents: Patients who are 66 years or older and are living in a nursing home. 

• • • Frailty and Advanced Illness: Patients who are 66 years or older and have an indication of frailty, along with any of the following conditions: 

• • • • An advanced illness diagnosis during the measurement period or the year prior. 

• • • • Taking dementia medications during the measurement period or the year prior. 

• • • Palliative Care: Patients who are receiving palliative care. 

• • Numerator: Patients with one or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria:  

• • • Fecal occult blood test (FOBT) during the measurement period 

• • • Stool DNA (sDNA) with FIT test during the measurement period or the two years prior to the measurement period 

• • • Flexible sigmoidoscopy during the measurement period or the four years prior to the measurement period 

• • • CT Colonography during the measurement period or the four years prior to the measurement period 

• • • Colonoscopy during the measurement period or the nine years prior to the measurement period 

• Success Criteria (any of these):  

• • Annual FOBT 

• • Stool DNA test (within 3 years) 

• • Flexible sigmoidoscopy (within 5 years) 

• • CT colonography (within 5 years) 

• • Colonoscopy (within 10 years) 

• Why It's Challenging:  

• • Multiple valid methods with different intervals make it hard to track whether a patient has successfully met the measure 

• • Patients often can't recall exact procedure dates 

• • External procedure documentation is common 

• • Tracking complexity increases with options 

• 2025 Benchmarks:  

• • Decile 7: 60.33 - 67.15% 

• • Decile 8: 67.16 - 73.81% 

• • Decile 9: 73.82 - 83.54% 

• • Decile 10: ≥ 83.55% 

Embrace the Full Menu 

Many practices default to colonoscopy promotion, missing opportunities with screening-resistant patients. Create educational materials showcasing all options. That patient refusing a colonoscopy might be more willing to complete annual stool testing. Train providers to present choices, not mandates. "We have several effective screening options, let's find what works for you" beats "You need a colonoscopy." 

Build Method-Specific Tracking 

Generic "colorectal screening" fields create confusion. Build discrete documentation for each screening type with associated date fields. Create reports sorted by method and due date. This granular tracking prevents marking patients compliant based on outdated procedures. 

Leverage Annual Options for Engagement 

Annual FOBT, while requiring yearly completion, offers unique advantages. It keeps patients engaged with preventive care, provides regular touchpoints, and suits those avoiding procedures. Create systems supporting annual FOBT: automated reminders, mailed kits, and simple result documentation. Some practices achieve better overall screening rates through robust FOBT programs rather than procedure-focused approaches. 

Universal Measure Success Strategies 

Maximize Annual Wellness Visits 

The Annual Wellness Visit represents your single best opportunity to impact all five measures simultaneously. Generate reports for scheduled AWV patients that highlight gaps across all five measures. Build templates that prompt systematic review of depression screening, diabetes control, blood pressure, and cancer screening status. Train providers to view AWVs as quality optimization opportunities. One well-executed visit can improve multiple measure performances. 

Gap Identification 

In an ideal world, real-time intelligence could help you identify opportunities before patients arrive. A daily report showing tomorrow's appointments cross-referenced against care gaps, could help your team focus on what specifically needs to be completed for the patients.  Utilize the EMR's health management tools to track screening due dates.  

Expand Beyond Primary Care 

Perhaps the biggest paradigm shift involves recognizing these aren't just primary care measures; they're practice-wide responsibilities. Every eligible clinician billing under your TIN impacts performance. This includes specialists who've never considered themselves part of quality measurement. 

Success requires education. Many specialists simply don't know they're included. Create simple reference materials showing the measure requirements and their role in meeting those requirements. Build streamlined workflows acknowledging time constraints. Emphasize that appropriate referrals count; they don’t have to manage conditions outside their expertise. 

Master your Documentation  

If you are capturing these measures as eCQMs, documentation matters. The most detailed progress notes mean nothing if the data isn't captured in discrete fields. Ensure you understand every required data element for the measure and that the documentation is mapped in your EHR so that the data can be evaluated. 

Read more: Implementing New eCQMs: A Strategic Guide 

Play Strategic Calendar Games 

Understanding measure specifications reveals timing opportunities. The "most recent" rules for glycemic status assessment and blood pressure make December strategically critical.  

Build quality improvement into your annual calendar. Schedule diabetics with borderline control for November/December appointments. Create October campaigns for cancer screening updates. Use September for problem list cleanup. This strategic care delivery will maximize both clinical outcomes and measure performance. 

Building Your Path Forward 

Excellence in quality measurement doesn't happen through heroic individual efforts; it requires systematic infrastructure making the right thing the easy thing. High-performing practices build interconnected systems where quality improvement becomes automatic rather than arduous. 

Imagine a practice where scheduling systems talk to quality databases, identifying gaps before appointments. Where EHR alerts guide appropriate screenings without disrupting workflow. Where every team member understands their role in comprehensive care delivery. This isn't a fantasy. It's what a focused effort can build. 

Start with an honest assessment. Which measure causes the most pain? Where do workflows break down? What documentation consistently goes missing? Pick your biggest failure point and systematically address it. Build momentum through sequential improvements rather than attempting a wholesale transformation. Encourage growth of a cross-functional quality team, including registration, billing, providers, nursing staff, and IT. All play an important role in impacting performance! 

Remember, these measures weren't created to torture practices. Each represents evidence-based care proven to improve outcomes. Depression screenings can help identify and provide timely intervention. Diabetes control prevents amputations. Blood pressure management lowers the risk of heart attacks and stroke. Cancer screening saves lives. When you excel at these measures, you’re systematically delivering care that matters. 

That's why this work matters.