This step-by-step guide provides instructions for completing APM Performance Pathway (APP) Quality measure templates and is intended to support accurate reporting and standardized submission.
Instructions Applicable to All Templates
Provider Information
The following columns collect identifying information for the individual provider.
Provider Last Name – Column A
Optional. Enter the provider’s last name as it appears in Medicare enrollment records.Provider First Name – Column B
Optional. Enter the provider’s first name as it appears in Medicare enrollment records.Individual NPI – Column C
Required. Enter the provider’s 10-digit individual National Provider Identifier (NPI).TIN – Column D
Required. Enter the 9-digit billing Tax Identification Number (TIN) for the practice.
ACO Information
The following column collects identifying information for the Accountable Care Organization (ACO).
Entity ID – Column E
Optional. Enter the ACO Entity ID.
Patient Demographic Information
The following columns collect identifying information for the patient.
Patient Last Name – Column F
Required. Enter the patient’s last name.Patient First Name – Column G
Required. Enter the patient’s first name.Patient Middle – Initial Column H
Optional. Enter the patient’s middle initial.Date of Birth – Column I
Required. Enter the patient’s date of birth.Gender – Column J
Required. Enter the patient’s gender.-
Medical Record Number (MRN) – Column K
Optional. ZIP Code – Column L
Optional. Enter the patient’s 5-digit ZIP Code.
Visit Information
The following columns collect information related to the patient visit.
-
Visit Date – Column M
Required. Enter the date of the eligible patient visit. The date must fall between 01/01/2025 and 12/31/2025. -
Insurance (FFS Medicare) – Column N
Optional. List 'Yes' if Medicare Fee-for-Service; 'Other' if other insurance. -
Medicare Beneficiary Identifier (MBI) – Column O
N/A.
Measure #1 – Diabetes: Glycemic Status Assessment (>9%)
The following columns are used to report data for this measure.
HgA1c (%) – Column P
Enter the patient’s most recent A1c value OR Glycemic Mgt Indicator (GMI) value.
Date of last HgA1c – Column Q
Enter the date of the most recent A1c or OR Glycemic Mgt Indicator (GMI) test (must be between 1/1/25-12/31/25).
Reporting Status - Column R
N/A
Diabetes, Ages 18–75, No Exclusions – Column S
-
Required. Indicate whether the patient meets the eligibility requirements for this measure. If the patient does not meet all criteria, do not include the patient in the template. Enter “Yes” if:
The patient is 18–75 years of age, AND
Has a diagnosis of diabetes, AND
Had an encounter during the performance period, AND
Does not meet any denominator exclusions
*Refer to the CMS Measure Specifications for applicable diagnosis codes and denominator exclusions: Measure #1 – Diabetes: Glycemic Status Assessment (>9%)
Measure #112 – Breast Cancer Screening
The following columns are used to report data for this measure.
Mammogram – Column P
Enter Performed* or Not Performed (*use exact wording).
NOTE: Performed = mammogram within 27 months prior to performance period end (cutoff date 10/1/2023); otherwise Not Performed.
Date of Last Mammogram – Column Q
Enter the date of the last mammogram.
Women 41 to 74 years of age, no exclusions – Column R
Required. Indicate if patients meets eligibility requirements for measure. If the patient does not meet all criteria, do not include the patient in the template.
Enter "Yes" if:The patient is female, age 41-74 AND
Does not meet any of the denominator exclusions
*Refer to the CMS Measure Specifications for specific codes and denominator exclusions: Measure #112 – Breast Cancer Screening
Measure #134 – Depression Screening and Follow-Up Plan
The following columns are used to report data for this measure.
Clinical depression screening – Column P
-
Enter Documentation of Screening for Depression and Follow-Up Plan as one of the following (*use exact wording):
Positive screen, follow-up plan documented
Negative screen
Screening not done, documented patient or medical reason
Positive screen, follow-up plan not done
Not Done
12+ patient, no bipolar diagnosis – Column Q
-
Indicate if patients meets eligibility requirements for this measure. If the patient does not meet all criteria, do not include the patient in the template.
Enter "Yes" if:
- Patient is age 12 and older AND
- Patient had an eligible encounter during the performance period AND
- Patient does not have diagnosis of bipolar disorder
*Refer to the CMS Measure Specifications for specific codes and denominator exclusions: Measure #134 – Depression Screening and Follow-Up Plan
Measure #236 – Controlling High Blood Pressure
The following columns are used to report data for this measure.
Date of last BP – Column P
- Enter the date of the most recent blood pressure reading.
Systolic BP – Column Q
- Enter the most recent systolic blood pressure value.
Diastolic BP – Column R
- Enter the most recent diastolic blood pressure value.
Blood pressure is adequately controlled – Column S
-
Review the most recent documented blood pressure.
Enter one of the following (*use exact wording):
Done
Not Done
Blood pressure not documented
Note:
Done = systolic is < 140 mmHg and diastolic is < 90 mmHg.
Not Done = systolic is ≥ 140 mmHg and diastolic is ≥ 90 mmHg.
Blood pressure not documented = no blood pressure values are documented.
Hypertension, ages 18-85, no exclusions – Column T
-
Indicate if patients meets eligibility requirements for this measure. If the patient does not meet all criteria, do not include the patient in the template.
Enter "Yes" if:
- Patient is age 18-85 AND
- Has diagnosis of hypertension AND
- Had an encounter during performance period AND
- Does not meet any of the denominator exclusions
*Refer to the CMS Measure Specifications for specific codes and denominator exclusions: Measure #236 – Controlling High Blood Pressure