Below are details for the quality measures supported by HASA TurboMACRA. To download the full specification pages from CMS, visit https://qpp.cms.gov/resources/education.  


Quality Measure #001: Diabetes: Hemoglobin A1C (HbA1c) Poor Control (>9%) – National Quality Strategy Domain: Effective Clinical Care

Description:

Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period

Instructions:

This measure is to be reported a minimum of once per performance period for patients with diabetes seen during the performance period. The most recent quality-data code submitted will be used for performance calculation. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

Measure Reporting:

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data.

 

Denominator:

Patients 18 - 75 years of age with diabetes with a visit during the measurement period

Denominator Criteria (Eligible Cases):

Patients 18-75 years of age on date of encounter

AND

Diagnosis for diabetes (ICD-10-CM): E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, E10.319, E10.3211, E10.3212, E10.3213, E10.3219, E10.3291, E10.3292, E10.3293, E10.3299, E10.3311, E10.3312, E10.3313, E10.3319, E10.3391, E10.3392, E10.3393, E10.3399, E10.3411, E10.3412, E10.3413, E10.3419, E10.3491, E10.3492, E10.3493, E10.3499, E10.3511, E10.3512, E10.3513, E10.3519, E10.3521, E10.3522, E10.3523, E10.3529, E10.3531, E10.3532, E10.3533, E10.3539, E10.3541, E10.3542, E10.3543, E10.3549, E10.3551, E10.3552, E10.3553, E10.3559, E10.3591, E10.3592, E10.3593, E10.3599, E10.36, E10.37X1, E10.37X2, E10.37X3, E10.37X9, E10.39, E10.40, E10.41, E10.42, E10.43, E10.44, E10.49, E10.51, E10.52, E10.59, E10.610, E10.618, E10.620, E10.621, E10.622, E10.628, E10.630, E10.638, E10.641, E10.649, E10.65, E10.69, E10.8, E10.9, E11.00, E11.01, E11.21, E11.22, E11.29, E11.311, E11.319, E11.3211, E11.3212, E11.3213, E11.3219, E11.3291, E11.3292, E11.3293, E11.3299, E11.3311, E11.3312, E11.3313, E11.3319, E11.3391, E11.3392, E11.3393, E11.3399, E11.3411, E11.3412, E11.3413, E11.3419, E11.3491, E11.3492, E11.3493, E11.3499, E11.3511, E11.3512, E11.3513, E11.3519, E11.3521, E11.3522, E11.3523, E11.3529, E11.3531, E11.3532, E11.3533, E11.3539, E11.3541, E11.3542, E11.3543, E11.3549, E11.3551, E11.3552, E11.3553, E11.3559, E11.3591, E11.3592, E11.3593, E11.3599, E11.36, E11.37X1, E11.37X2, E11.37X3, E11.37X9, E11.39, E11.40, E11.41, E11.42, E11.43, E11.44, E11.49, E11.51, E11.52, E11.59, E11.610, E11.618, E11.620, E11.621, E11.622, E11.628, E11.630, E11.638, E11.641, E11.649, E11.65, E11.69, E11.8, E11.9, E13.00, E13.01, E13.10, E13.11, E13.21, E13.22, E13.29, E13.311, E13.319, E13.3211, E13.3212, E13.3213, E13.3219, E13.3291, E13.3292, E13.3293, E13.3299, E13.3311, E13.3312, E13.3313, E13.3319 E13.3391, E13.3392, E13.3393, E13.3399, E13.3411, E13.3412, E13.3413, E13.3419, E13.3491, E13.3492, E13.3493, E13.3499, E13.3511, E13.3512, E13.3513, E13.3519, E13.3521, E13.3522, E13.3523, E13.3529, E13.3531, E13.3532, E13.3533, E13.3539, E13.3541, E13.3542, E13.3543, E13.3549, E13.3551, E13.3552, E13.3553, E13.3559, E13.3591, E13.3592, E13.3593, E13.3599, E13.36, E13.37X1, E13.37X2, E13.37X3, E13.37X9, E13.39, E13.40, E13.41, E13.42, E13.43, E13.44, E13.49, E13.51, E13.52, E13.59, E13.610, E13.618, E13.620, E13.621, E13.622, E13.628, E13.630, E13.638, E13.641, E13.649, E13.65, E13.69, E13.8, E13.9, O24.011, O24.012, O24.013, O24.019, O24.02, O24.03, O24.111, O24.112, O24.113, O24.119, O24.12, O24.13, O24.311, O24.312, O24.313, O24.319, O24.32, O24.33, O24.811, O24.812, O24.813, O24.819, O24.82, O24.83

AND

Patient encounter during performance period (CPT or HCPCS): 97802, 97803, 97804, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99281, 99282, 99283, 99284, 99285, 99291, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0270, G0271, G0402, G0438, G0439

AND NOT

Denominator Exclusion: Hospice services to patient any time during the measurement period (G9687)

 

Numerator:

Patient whose most recent HbA1c level (performed during the measurement period) is >9.0%

Numerator Instructions:

INVERSE MEASURE - A lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Reporting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control. Patient is numerator compliant if most recent HbA1c level >9% or is missing a result or if an HbA1c test was not done during the measurement year. Ranges and thresholds do not meet criteria for this indicator. A distinct numeric result is required for numerator compliance.

 

Numerator Options:

Performance Met: Most recent hemoglobin A1c level >9.0% (3046F)

OR

Performance Met: Hemoglobin A1c level was not performed during the measurement period (6046F w/ 8P)

OR

Performance Not Met: Most recent hemoglobin A1c (HbA1c) level <7.0% (3044F)

OR

Performance Not Met: Most recent hemoglobin A1c (HbA1c) level 7.0-9.0% (3045F)

 


Quality Measure #005: Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) - National Quality Strategy Domain: Effective Clinical Care

Description:

Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge

Instructions:

This measure is to be reported for all heart failure patients a minimum of once per performance period when seen in the outpatient setting AND reported at each hospital discharge (99238* and 99239*) during the performance period.

*NOTE: When reporting CPT code 99238 and 99239, it is recommended the measure be reported each time the code is submitted for hospital discharge. This measure is intended to reflect the quality of services provided for patients with HF and decreased left ventricular systolic function. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. Only patients who had at least two denominator eligible visits during the performance period will be counted for Reporting Criteria 1. 

Measure Reporting:

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data.

THERE ARE TWO REPORTING CRITERIA FOR THIS MEASURE:

1) Patients who are 18 years and older with a diagnosis of HF with a current or prior LVEF < 40% seen in the outpatient setting with two denominator eligible visits

OR

2) Patients who are 18 years and older with a diagnosis of HF with a current or prior LVEF < 40% and discharged from hospital

 

REPORTING CRITERIA 1: ALL PATIENTS WITH A DIAGNOSIS OF HF ASSESSED DURING AN OUTPATIENT ENCOUNTER

Denominator (Reporting Criteria 1):

All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF < 40%

DENOMINATOR NOTE: LVEF < 40% corresponds to qualitative documentation of moderate dysfunction or severe dysfunction. The LVSD may be determined by quantitative or qualitative assessment, which may be current or historical. Examples of a quantitative or qualitative assessment may include an echocardiogram: 1) that provides a numerical value of LVSD or 2) that uses descriptive terms such as moderately or severely depressed left ventricular systolic function. Any current or prior ejection fraction study documenting LVSD can be used to identify patients.

To meet the denominator criteria, a patient must have an active diagnosis of heart failure at the time of the encounter which is used to qualify for the denominator and evaluate the numerator.

The encounter used to evaluate the numerator counts as 1 of the 2 encounters required for denominator inclusion. If the patient meets the heart failure diagnosis criterion, the diagnosis needs to be active only at the encounter being evaluated for the numerator action.

*Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for registry-based measures. 

Denominator Criteria (Eligible Cases) 1:

Patients aged ≥ 18 years on date of encounter

AND

Diagnosis for heart failure (ICD-10-CM): I11.0, I13.0, I13.2, I50.1, I50.20, I50.21, I50.22, I50.23, I50.30, I50.31, I50.32, I50.33, I50.40, I50.41, I50.42, I50.43, I50.9 

AND

Patient encounter during performance period – to be used for numerator evaluation (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241*, 99242*, 99243*, 99244*, 99245*, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350 

WITHOUT

Telehealth Modifier (GQ, GT)

AND

At least one additional patient encounter during performance period (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241*, 99242*, 99243*, 99244*, 99245*, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350 

WITHOUT

Telehealth Modifier (GQ, GT)

AND

Left ventricular ejection fraction (LVEF) less than 40% or documentation of moderately or severely depressed left ventricular systolic function (3021F) 

 

Numerator (Reporting Criteria 1):

Patients who were prescribed ACE inhibitor or ARB therapy within a 12 month period when seen in the outpatient setting 

Definition: Prescribed – Outpatient setting: prescription given to the patient for ACE inhibitor or ARB therapy at one or more visits in the measurement period OR patient already taking ACE inhibitor or ARB therapy as documented in current medication list.

NUMERATOR NOTE: To meet the intent of the measure, the numerator quality action must be performed at the encounter at which the active diagnosis of heart failure is documented.

 

Numerator Options:

Performance Met: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) therapy prescribed or currently being taken (4010F) 

OR

Denominator Exception: Documentation of medical reason(s) for not prescribing ACE inhibitor or ARB therapy (eg, hypotensive patients who are at immediate risk of cardiogenic shock, hospitalized patients who have experienced marked azotemia, allergy, intolerance, other medical reasons) (4010F with 1P)

OR

Denominator Exception: Documentation of patient reason(s) for not prescribing ACE inhibitor or ARB therapy (eg, patient declined, other patient reasons) (4010F with 2P)

OR

Denominator Exception: Documentation of system reason(s) for not prescribing ACE inhibitor or ARB therapy (eg, other system reasons) (4010F with 3P)

OR

Performance Not Met: Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy was not prescribed, reason not otherwise specified (4010F with 8P) 

 

REPORTING CRITERIA 2: ALL PATIENTS WITH A DIAGNOSIS OF HF AND DISCHARGED FROM HOSPITAL

Denominator (Reporting Criteria 2):

All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF < 40% 

DENOMINATOR NOTE: LVEF < 40% corresponds to qualitative documentation of moderate dysfunction or severe dysfunction. The LVSD may be determined by quantitative or qualitative assessment, which may be current or historical. Examples of a quantitative or qualitative assessment may include an echocardiogram: 1) that provides a numerical value of LVSD or 2) that uses descriptive terms such as moderately or severely depressed left ventricular systolic function. Any current or prior ejection fraction study documenting LVSD can be used to identify patients.

Denominator Critera (Eligible Cases) 2:

Patients aged ≥ 18 years on date of encounter 

AND

Diagnosis for heart failure (ICD-10-CM): I11.0, I13.0, I13.2, I50.1, I50.20, I50.21, I50.22, I50.23, I50.30, I50.31, I50.32, I50.33, I50.40, I50.41, I50.42, I50.43, I50.9 

AND

Patient encounter during performance period (CPT): 99238, 99239

AND

Left ventricular ejection fraction (LVEF) less than 40% or documentation of moderately or severely depressed left ventricular systolic function (3021F) 

 

Numerator (Reporting Criteria 2):

Patients who were prescribed ACE inhibitor or ARB therapy at hospital discharge 

Definition: Prescribed – Inpatient setting: prescription given to the patient for ACE inhibitor or ARB therapy at discharge OR ACE inhibitor or ARB therapy to be continued after discharge as documented in the discharge medication list.

NUMERATOR NOTE: To meet the intent of the measure, the numerator quality action must be performed at the each denominator eligible discharge.

Numerator Options:

Performance Met: Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) therapy prescribed or currently being taken (4010F) 

OR

Denominator Exception: Documentation of medical reason(s) for not prescribing ACE inhibitor or ARB therapy (eg, hypotensive patients who are at immediate risk of cardiogenic shock, hospitalized patients who have experienced marked azotemia, allergy, intolerance, other medical reasons) (4010F with 1P)

OR

Denominator Exception: Documentation of patient reason(s) for not prescribing ACE inhibitor or ARB therapy (eg, patient declined, other patient reasons) (4010F with 2P) 

OR

Denominator Exception: Documentation of system reason(s) for not prescribing ACE inhibitor or ARB therapy (eg, other system reasons) (4010F with 3P) 

OR

Performance Not Met: Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy was not prescribed, reason not otherwise specified (4010F with 8P)


Quality Measure #006: Coronary Artery Disease (CAD): Antiplatelet Therapy - National Quality Strategy Domain: Effective Clinical Care

Description:

Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12 month period who were prescribed aspirin or clopidogrel 

Instructions:

This measure is to be reported a minimum of once per performance period for all patients with CAD seen during the performance period. This measure may be reported by eligible clinicians who perform the quality actions described in the measure for the primary management of patients with CAD based on the services provided and themeasurespecific denominator coding. 

Measure Reporting:

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data.

 

Denominator:

All patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period 

Denominator Criteria (Eligible Cases):

Patients aged ≥ 18 years on date of encounter 

AND

Diagnosis for coronary artery disease (ICD-10-CM): I20.0, I20.1, I20.8, I20.9, I21.01, I21.02, I21.09, I21.11, I21.19, I21.21, I21.29, I21.3, I21.4, I22.0, I22.1, I22.2, I22.8, I22.9, I24.0, I24.1, I24.8, I24.9, I25.10, I25.110, I25.111, I25.118, I25.119, I25.2, I25.5, I25.6, I25.700, I25.701, I25.708, I25.709, I25.710, I25.711, I25.718, I25.719, I25.720, I25.721, I25.728, I25.729, I25.730, I25.731, I25.738, I25.739, I25.750,I25.751, I25.758, I25.759, I25.760, I25.761, I25.768, I25.769, I25.790, I25.791, I25.798, I25.799, I25.810, I25.811, I25.812, I25.82, I25.83, I25.89, I25.9, Z95.1, Z95.5, Z98.61 

AND

Patient encounter during the performance period (CPT): 99201, 99202, 99203, 99204, 99205,99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349,99350 

WITHOUT

Telehealth Modifier: GQ, GT

 

Numerator:

Patients who were prescribed aspirin or clopidogrel 

Definition: Prescribed - May include prescription given to the patient for aspirin or clopidogrel at one or more visits in the measurement period OR patient already taking aspirin or clopidogrel as documented incurrent medication list

Numerator Options:

Performance Met: Aspirin or clopidogrel prescribed (4086F)

OR

Denominator Exception: Documentation of medical reason(s) for not prescribing aspirin or clopidogrel (eg, allergy, intolerance, receiving other thienopyridine therapy, receiving warfarin therapy, bleeding coagulation disorders, other medical reasons) (4086F with 1P)

OR

Denominator Exception: Documentation of patient reason(s) for not prescribing aspirin or clopidogrel (eg, patient declined, other patient reasons) (4086F with 2P)

OR

Denominator Exception: Documentation of system reason(s) for not prescribing aspirin or clopidogrel (eg, lack of drug availability, other reasons attributable to the health care system) (4086F with 3P) 

OR

Performance Not Met: Aspirin or clopidogrel was not prescribed, reason not otherwise specified (4086F with 8P)


Quality Measure #007: Coronary Artery Disease (CAD): Beta-Blocker Therapy - Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfuntion (LVEF<40%) - National Quality Strategy Domain: Effective Clinical Care

Description:

Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have a prior MI or a current or prior LVEF < 40% who were prescribed beta-blocker therapy

Instructions:

This measure is to be reported a minimum of once per performance period for all patients with a diagnosis of CAD seen during the performance period. Only patients who had at least two denominator eligible visits during the performance period will be counted for Reporting Criteria 1 and Reporting Criteria 2 of this measure. This measure may be reported by eligible clinicians who perform the quality actions described in the measure for the primary management of patients with CAD based on the services provided and the measure-specific denominator coding.

This measure will be calculated with 2 performance rates:

1) Percentage of patients with a diagnosis of CAD or history of cardiac surgery who have a current or prior LVEF < 40% who were prescribed beta-blocker therap

2) Percentage of patients with a diagnosis of CAD or history of cardiac surgery who have a prior (within the past 3 years) myocardial infarction who were prescribed beta-blocker therapy

The eligible clincian should submit data on one of the reporting criteria, depending on the clinical findings. If the patient has CAD or history of cardiac surgery and a current or prior LVEF < 40%, use Reporting Criteria 1. If the patient has CAD or history of cardiac surgery and have prior (resolved) (within the past 3 years) MI, use Reporting Criteria 2. If the patient has both prior (within the past 3 years) MI and LVEF < 40%, the eligible clinician may report quality-data codes for Reporting Criteria 1 and this will count as appropriate reporting for this patient.

Measure Reporting:

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data.

THERE ARE TWO REPORTING CRITERIA FOR THIS MEASURE:

1) Patients who are 18 years and older with a diagnosis of CAD or history of cardiac surgery who have a current or prior LVEF < 40%

OR

2) Patients who are 18 years and older with a diagnosis of CAD or history of cardiac surgery who have a prior myocardial infarction

 

REPORTING CRITERIA 1: ALL PATIENTS WITH A DIAGNOSIS OF CAD OR HISTORY OF CARDIAC SURGERY WHO HAVE A CURRENT OR PRIOR LVEF < 40%

Denominator (Reporting Criteria 1): All patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have a current or prior LVEF < 40%

DENOMINATOR NOTE: The history of cardiac surgery serves as a proxy for a diagnosis of CAD; a diagnosis is not needed if the patient has documented history of cardiac surgery. Only one of the two criteria – a diagnosis of CAD or history of cardiac surgery proxy – is required. To meet the denominator criteria, a patient must have an active diagnosis of CAD (or proxy documented) at the time of the encounter which is used to qualify for the denominator and evaluate the numerator. 

The encounter used to evaluate the numerator counts as 1 of the 2 encounters required for denominator inclusion. If the patient meets the CAD diagnosis criterion, the diagnosis needs to be active only at the encounter being evaluated for the numerator action. If the patient meets the proxy of a history of cardiac surgery inclusion criterion, there should be documentation of the proxy at the encounter being evaluated for the numerator action.

*Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for registrybased measures.

Denominator Criteria (Eligible Cases) 1:

Patients aged ≥ 18 years on date of encounter 

AND

Diagnosis for coronary artery disease (ICD-10-CM): I20.0, I20.1, I20.8, I20.9, I24.0, I24.1, I24.8, I24.9, I25.10, I25.110, I25.111, I25.118, I25.119, I25.5, I25.6, I25.700, I25.701, I25.708, I25.709, I25.710, I25.711, I25.718, I25.719, I25.720, I25.721, I25.728, I25.729, I25.730, I25.731, I25.738, I25.739, I25.750, I25.751, I25.758, I25.759, I25.760, I25.761, I25.768, I25.769, I25.790, I25.791, I25.798, I25.799, I25.810, I25.811, I25.812, I25.82, I25.83, I25.89, I25.9, Z95.1, Z95.5, Z98.61

OR

History of cardiac surgery (CPT): 33140, 33510, 33511, 33512, 33513, 33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536, 92920, 92924, 92928, 92933, 92937, 92941, 92943, 92980, 92981, 92982, 92984, 92995, 92996

AND

Patient encounter during performance period – to be used for numerator evaluation (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241*, 99242*, 99243*, 99244*, 99245*, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350

WITHOUT

Telehealth Modifier: GQ, GT

AND

At least one additional patient encounter during performance period (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241*, 99242*, 99243*, 99244*, 99245*, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350

WITHOUT

Telehealth Modifier: GQ, GT

AND

Left ventricular ejection fraction (LVEF) < 40%: G8694

 

Numerator (Reporting Criteria 1):

Patients who were prescribed beta-blocker therapy 

Definitions: Prescribed – May include prescription given to the patient for beta-blocker therapy at one or more visits in the measurement period OR patient already taking beta-blocker therapy as documented in current medication list.

Beta-blocker Therapy – For patients with prior LVEF < 40%, beta-blocker therapy includes the following: bisoprolol, carvedilol, or sustained release metoprolol succinate.

NUMERATOR NOTE: To meet the intent of the measure, the numerator quality action must be performed at the encounter at which the active diagnosis of CAD or history of cardiac surgical proxy is documented.

Numerator Options:

Performance Met: Beta-blocker therapy prescribed or currently being taken (G9189)

OR

Denominator Exception: Documentation of medical reason(s) for not prescribing beta-blocker therapy (e.g., allergy, intolerance, other medical reasons) (G9190)

OR

Denominator Exception: Documentation of patient reason(s) for not prescribing beta-blocker therapy (e.g., patient declined, other patient reasons) (G9191)

OR

Denominator Exception: Documentation of system reason(s) for not prescribing beta-blocker therapy (e.g., other reasons attributable to the health care system) (G9192)

OR

Performance Not Met: Beta-blocker therapy not prescribed, reason not given (G9188)

 

REPORTING CRITERIA 2: ALL PATIENTS WITH A DIAGNOSIS OF CAD OR HISTORY OF CARDIAC SURGERY WHO HAVE A PRIOR (RESOLVED) (WITHIN THE PAST 3 YEARS) MYOCARDIAL INFARCTION

Denominator (Reporting Criteria 2):

All patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have prior (within the past 3 years) MI

Definition: Prior Myocardial Infarction (MI) – for Reporting Criteria 2, prior MI is limited to those occurring within the past 3 years

DENOMINATOR NOTE: The history of cardiac surgery serves as a proxy for a diagnosis of CAD; a diagnosis is not needed if the patient has documented history of cardiac surgery. Only one of the two criteria – a diagnosis of CAD or history of cardiac surgery proxy – is required. To meet the denominator criteria, a patient must have an active diagnosis of CAD (or proxy documented) at the time of the encounter which is used to qualify for the denominator and evaluate the numerator. 

The encounter used to evaluate the numerator counts as 1 of the 2 encounters required for denominator inclusion. If the patient meets the CAD diagnosis criterion, the diagnosis needs to be active only at the encounter being evaluated for the numerator action. If the patient meets the proxy of a history of cardiac surgery inclusion criterion, there should be documentation of the proxy at the encounter being evaluated for the numerator action.

*Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for registrybased measures.

Denominator Critiera (Eligible Cases) 2:

Patients aged ≥ 18 years on date of encounter  

AND

Diagnosis for coronary artery disease (ICD-10-CM): I20.0, I20.1, I20.8, I20.9, I24.0, I24.1, I24.8, I24.9, I25.10, I25.110, I25.111, I25.118, I25.119, I25.5, I25.6, I25.700, I25.701, I25.708, I25.709, I25.710, I25.711, I25.718, I25.719, I25.720, I25.721, I25.728, I25.729, I25.730, I25.731, I25.738, I25.739, I25.750, I25.751, I25.758, I25.759, I25.760, I25.761, I25.768, I25.769, I25.790, I25.791, I25.798, I25.799, I25.810, I25.811, I25.812, I25.82, I25.83, I25.89, I25.9, Z95.1, Z95.5, Z98.61

OR

History of cardiac surgery (CPT): 33140, 33510, 33511, 33512, 33513, 33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536, 92920, 92924, 92928, 92933, 92937, 92941, 92943, 92980, 92981, 92982, 92984, 92995, 92996

AND

Diagnosis for myocardial infarction– includes patient that had a prior (within the past 3 years) myocardial infarction (ICD-10-CM): I21.01, I21.02, I21.09, I21.11, I21.19, I21.21, I21.29, I21.3, I21.4, I22.0, I22.1, I22.2, I22.8, I22.9, I24.1, I25.2

AND

Patient encounter during performance period – to be used for numerator evaluation (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241*, 99242*, 99243*, 99244*, 99245*, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350

WITHOUT

Telehealth Modifier: GQ, GT

AND

At least one additional patient encounter during performance period (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241*, 99242*, 99243*, 99244*, 99245*, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350

WITHOUT

Telehealth Modifier: GQ, GT

 

Numerator (Reporting Criteria 2):

Patients who were prescribed beta-blocker therapy

Definitions: Prescribed – May include prescription given to the patient for beta-blocker therapy at one or more visits in the measurement period OR patient already taking beta-blocker therapy as documented in current medication list.

Beta-blocker Therapy – For patients with prior MI, beta-blocker therapy includes any agent within the betablocker drug class. As of 2015, no recommendations or evidence are cited in current stable ischemic heart disease guidelines for preferential use of specific agents.

NUMERATOR NOTE: To meet the intent of the measure, the numerator quality action must be performed at the encounter at which the active diagnosis of CAD or history of cardiac surgical proxy is documented.

Numerator Options:

Performance Met: Beta-blocker therapy prescribed or currently being taken (4008F)

OR

Denominator Exception: Documentation of medical reason(s) for not prescribing beta-blocker therapy (eg, allergy, intolerance, other medical reasons) (4008F with 1P) 

OR

Denominator Exception:  Documentation of patient reason(s) for not prescribing beta-blocker therapy (eg, patient declined, other patient reasons) (4008F with 2P)

OR

Denominator Exception: Documentation of system reason(s) for not prescribing beta-blocker therapy (eg, other reasons attributable to the health care system) (4008F with 3P)

OR

Performance Not Met: Beta-blocker therapy not prescribed, reason not otherwise specified (4008F with 8P) 


Quality Measure #008: Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) - National Quality Strategy Domain: Effective Clinical Care

Description:

Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge 

Instructions:

This measure is to be reported for all heart failure patients a minimum of once per performance period when seen in the outpatient setting AND reported at each hospital discharge (99238* and 99239*) during the performance period. Only patients who had at least two denominator eligible visits during the performance period will be counted for Reporting Criteria 1. 

*Note: When reporting CPT code 99238 and 99239, it is recommended the measure be reported each time the code is submitted for hospital discharge. 

This measure is intended to reflect the quality of services provided for patients with heart failure and decreased left ventricular systolic function. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. Only patients who had at least two denominator eligible visits during the performance period will be counted for Reporting Criteria 1. 

Measure Reporting:

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data. 

THERE ARE TWO REPORTING CRITERIA FOR THIS MEASURE:

1) Patients who are 18 years and older with a diagnosis of HF with a current or prior LVEF < 40% seen in the outpatient setting with two denominator eligible visits 

OR

2) Patients who are 18 years and older with a diagnosis of HF with a current or prior LVEF < 40% and discharged from hospital 

 

REPORTING CRITERIA 1: ALL PATIENTS WITH A DIAGNOSIS OF HF SEEN IN THE OUTPATIENT SETTING

Denominator (Reporting Criteria 1):

All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF < 40% 

DENOMINATOR NOTE: LVEF < 40% corresponds to qualitative documentation of moderate dysfunction or severe dysfunction. The left ventricular systolic dysfunction may be determined by quantitative or qualitative assessment, which may be current or historical. Examples of a quantitative or qualitative assessment may include an echocardiogram: 1) that provides a numerical value of left ventricular systolic dysfunction or 2) that uses descriptive terms such as moderately or severely depressed left ventricular systolic function. Any current or prior ejection fraction study documenting LVSD can be used to identify patients. 

To meet the denominator criteria, a patient must have an active diagnosis of heart failure at the time of the encounter which is used to qualify for the denominator and evaluate the numerator. 

The encounter used to evaluate the numerator counts as 1 of the 2 encounters required for denominator inclusion. If the patient meets the heart failure diagnosis criterion, the diagnosis needs to be active only at the encounter being evaluated for the numerator action. 

*Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for registrybased measures. 

Denominator Criteria (Eligible Cases) 1:

Patients aged ≥ 18 years on date of encounter

AND

Diagnosis for heart failure (ICD-10-CM): I11.0, I13.0, I13.2, I50.1, I50.20, I50.21, I50.22, I50.23, I50.30, I50.31, I50.32, I50.33, I50.40, I50.41, I50.42, I50.43, I50.9 

AND

Patient encounter during performance period – to be used for numerator evaluation (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241*, 99242*, 99243*, 99244*, 99245*, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350 

WITHOUT

Telehealth Modifier: GQ, GT

AND

At least one additional patient encounter during performance period (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241*, 99242*, 99243*, 99244*, 99245*, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350 

WITHOUT

Telehealth Modifier: GQ, GT

AND

Left ventricular ejection fraction (LVEF) < 40% or documentation of moderately or severely depressed left ventricular systolic function: G8923 

 

Numerator (Reporting Criteria 1):

Patients who were prescribed beta-blocker therapy within a 12 month period when seen in the outpatient setting 

Definitions: Prescribed - Outpatient Setting — prescription given to the patient for beta-blocker therapy at one or more visits in the measurement period OR patient already taking beta-blocker therapy as documented in current medication list. 

Beta-blocker Therapy — For patients with prior LVEF < 40%, beta-blocker therapy should include bisoprolol, carvedilol, or sustained release metoprolol succinate. 

NUMERATOR NOTE: To meet the intent of the measure, the numerator quality action must be performed at the encounter at which the active diagnosis of heart failure is documented.

Numerator Options:

Performance Met: Beta-blocker therapy prescribed (G8450) 

OR

Denominator Exception: Beta-Blocker Therapy for LVEF < 40% not prescribed for reasons documented by the clinician (e.g., low blood pressure, fluid overload, asthma, patients recently treated with an intravenous positive inotropic agent, allergy, intolerance, other medical reasons, patient declined, other patient reasons, or other reasons attributable to the healthcare system) (G8451)

OR

Performance Not Met: Beta-blocker therapy not prescribed (G8452) 

 

REPORTING CRITERIA 2: ALL PATIENTS WITH A DIAGNOSIS OF HF AND DISCHARGED FROM HOSPITAL

Denominator (Reporting Criteria 2):

All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF <40%  

DENOMINATOR NOTE: LVEF < 40% corresponds to qualitative documentation of moderate dysfunction or severe dysfunction. The left ventricular systolic dysfunction may be determined by quantitative or qualitative assessment, which may be current or historical. Examples of a quantitative or qualitative assessment may include an echocardiogram: 1) that provides a numerical value of left ventricular systolic dysfunction or 2) that uses descriptive terms such as moderately or severely depressed left ventricular systolic function. Any current or prior ejection fraction study documenting LVSD can be used to identify patients. 

Denominator Critera (Eligible Cases) 2:

Patients aged ≥ 18 years on date of encounter 

AND

Diagnosis for heart failure (ICD-10-CM): I11.0, I13.0, I13.2, I50.1, I50.20, I50.21, I50.22, I50.23, I50.30, I50.31, I50.32, I50.33, I50.40, I50.41, I50.42, I50.43, I50.9

AND

Patient encounter during performance period (CPT): 99238, 99239 

AND

Left ventricular ejection fraction (LVEF) < 40% or documentation of moderately or severely depressed left ventricular systolic function: G8923 

 

Numerator (Reporting Criteria 2):

Patients who were prescribed beta-blocker therapy at each hospital discharge  

Definitions: Prescribed - Inpatient Setting — prescription given to the patient for beta-blocker therapy at discharge OR beta-blocker therapy to be continued after discharge as documented in the discharge medication list. 

Beta-blocker Therapy — For patients with prior LVEF < 40%, beta-blocker therapy should include bisoprolol, carvedilol, or sustained release metoprolol succinate. 

NUMERATOR NOTE: To meet the intent of the measure, the numerator quality action must be performed at the each denominator eligible discharge.

Numerator Options:

Performance Met: Beta-blocker therapy prescribed (G8450)

OR

Denominator Exception: Beta-Blocker Therapy for LVEF < 40% not prescribed for reasons documented by the clinician (e.g., low blood pressure, fluid overload, asthma, patients recently treated with an intravenous positive inotropic agent, allergy, intolerance, other medical reasons, patient declined, other patient reasons, other reasons attributable to the healthcare system) (G8451) 

OR

Performance Not Met: Beta-blocker therapy not prescribed (G8452) 


Quality Measure #012: Primary Open-Angle Glaucoma (POAG) Optic Nerve Evaluation - National Qualtiy Strategy Domain: Effective Clinical Care

Description:

Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) who have an optic nerve head evaluation during one or more office visits within 12 months

Instructions:

This measure is to be reported a minimum of once per performance period for patients seen during the performance period. It is anticipated that eligible clinicians who provide the primary management of patients with primary open-angle glaucoma (in either one or both eyes) will submit this measure. 

Measure Reporting: 

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data. 

 

Denominator:

All patients aged 18 years and older with a diagnosis of primary open-angle glaucoma 

DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for registry-based measures.

Denominator Criteria (Eligible Cases):

Patients aged ≥ 18 years on date of encounter 

AND

Diagnosis for primary open-angle glaucoma (ICD-10-CM): H40.10X0, H40.10X1, H40.10X2, H40.10X3, H40.10X4, H40.1110, H40.1111, H40.1112, H40.1113, H40.1114, H40.1120, H40.1121, H40.1122, H40.1123, H40.1124, H40.1130, H40.1131, H40.1132, H40.1133, H40.1134, H40.1190, H40.1191, H40.1192, H40.1193, H40.1194, H40.1210, H40.1211, H40.1212, H40.1213, H40.1214, H40.1220, H40.1221, H40.1222, H40.1223, H40.1224, H40.1230, H40.1231, H40.1232, H40.1233, H40.1234, H40.1290, H40.1291, H40.1292, H40.1293, H40.1294, H40.151, H40.152, H40.153, H40.159 

AND

Patient encounter during the performance period (CPT): 92002, 92004, 92012, 92014, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241*, 99242*, 99243*, 99244*, 99245*, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337 

WITHOUT

Telehealth Modifier: GQ, GT 

 

Numerator:

Patients who have an optic nerve head evaluation during one or more office visits within 12months 

Numerator Options:

Performance Met: Optic nerve head evaluation performed (2027F)

OR

Denominator Exception: Documentation of medical reason(s) for not performing an optic nerve head evaluation (2027F with 1P)

OR

Performance Not Met: Optic nerve head evaluation was not performed, reason not otherwise specified (2027F with 8P)


Quality Measure #065: Appropriate Treatment for Children with Upper Respiratory Infection (URI) - National Quality Strategy Domain: Efficiency and Cost Reduction

Description:

Percentage of children 3 months - 18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode 

Instructions:

This measure is to be reported once for each occurrence of upper respiratory infection during the performance period. Claims data will be analyzed to determine unique occurrences. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

Measure Reporting:

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data. 

 

Denominator:

Children age 3 months to 18 years of age who had an outpatient or emergency department (ED) visit with a diagnosis of upper respiratory infection (URI) during the measurement period.

Denominator Instructions: To determine eligibility, look for any of the listed antibiotic drugs below in the 30 days prior to the visit with the URI diagnosis. As long as there are no prescriptions for the listed antibiotics during this time period, the patient is eligible for denominator inclusion. 

Denominator Criteria (Eligible Cases):

Patients aged 3 months to 18 years on date of encounter 

AND

Diagnosis for URI (ICD-10-CM): J00, J06.0, J06.9 

AND

Patient encounter during the performance period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99281, 99282, 99283, 99284, 99285, G0402

AND NOT

Denominator Exclusions:

Patient prescribed or dispensed antibiotic for documented medical reason(s) (e.g., intestinal infection, pertussis, bacterial infection, Lyme disease, otitis media, acute sinusitis, acute pharyngitis, acute tonsillitis, chronic sinusitis, infection of the pharynx/larynx/tonsils/adenoids, prostatitis, cellulitis, mastoiditis, or bone infections, acute lymphadenitis, impetigo, skin staph infections, pneumonia/gonococcal infections, venereal disease (syphilis, chlamydia, inflammatory diseases [female reproductive organs]), infections of the kidney, cystitis or UTI, and acne (G8709)

OR

Children who are taking antibiotics in the 30 days prior to the date of the encounter during which the diagnosis was established (G9701)

OR

Patients who use hospice services any time during the measurement period (G9700)

 

Numerator:

Children without a prescription for antibiotic medication on or 3 days after the outpatient or ED visit for an upper respiratory infection 

Numerator Instructions: For performance, the measure will be calculated as the number of patient’s encounter(s) where antibiotics were neither prescribed nor dispensed on or within three days of the episode for URI over the total number of encounters in the denominator (patients aged 3 months to 18 years with an outpatient or ED visit for URI. A higher score indicates appropriate treatment of patients with URI (e.g., the proportion for whom antibiotics were not prescribed or dispensed following the episode).

Numerator Options:

Performance Met: Patient not prescribed or dispensed antibiotic (G8708)​ 

OR

Performance Not Met: Patient prescribed or dispensed antibiotic (G8710)


Quality Measure #066: Appropriate Testing for Children with Pharyngitis - National Quality Strategy Domain: Efficiency and Cost Reduction

Description:

Percentage of children 3-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode 

Instructions:

This measure is to be reported once for each occurrence of pharyngitis during the performance period. Claims data will be analyzed to determine unique occurrences. This measure is intended to reflect the quality of services provided for the primary management of patients with pharyngitis who were dispensed an antibiotic. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.  

Measure Reporting: 

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data. 

 

Denominator:

Children 3 - 18 years of age who had an outpatient or emergency department (ED) visit with a diagnosis of pharyngitis during the measurement period and an antibiotic ordered on or three days after the visit

Denominator Instructions: To determine eligibility, look for any of the listed antibiotic drugs below in the 30 days prior to the visit with the pharyngitis diagnosis. As long as there are no prescriptions for the listed antibiotics during this time period, the patient is eligible for denominator inclusion. 

DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for registry-based measures.

Denominator Criteria (Eligible Cases):

Patients aged 3 to 18 years on date of encounter 

AND

Diagnosis for pharyngitis (ICD-10-CM): J02.0, J02.8, J02.9, J03.00, J03.01, J03.80, J03.81, J03.90, J03.91

AND

Patient encounter during the performance period (CPT or HCPCS): 96160, 96161, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99241*, 99242*, 99243*, 99244*, 99245*, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99429*, 99455, 99456, 99281, 99282, 99283, 99284, 99285, G0402

AND

Prescribed or dispensed antibiotic: G8711

AND NOT

Denominator Exclusions:

Patients who use hospice services any time during the measurement period (G9702) 

OR

Children who are taking antibiotics in the 30 days prior to the diagnosis of pharyngitis (G9703) 

 

Numerator:

Children with a group A streptococcus test in the 7-day period from 3 days prior through 3 days after the diagnosis of pharyngitis 

Numerator Instructions: For performance, the measure will be calculated as the number of patient encounters where diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test for the episode over the total number of encounters in the denominator (patients aged 3 to 18 years with an outpatient or ED visit and an antibiotic ordered on or three days after the visit). A higher score indicates appropriate treatment of children with pharyngitis (e.g., the proportion for whom antibiotics were prescribed with an accompanying step test). 

Numerator Options:

Performance Met: Group A Strep Test Performed (3210F)

OR

Performance Not Met: Group A Strep Test not Performed, reason not otherwise specified (3210F with 8P) 


Quality Measure #110: Preventive Care and Screening: Influenza Immunization - National Quality Strategy Domain: Community/Population Health

Description:

Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization

Instructions:

This measure is to be reported a minimum of once for visits for patients seen between January and March for the 2016-2017 influenza season AND a minimum of once for visits for patients seen between October and December for the 2017-2018 influenza season. This measure is intended to determine whether or not all patients aged 6 months and older received (either from the reporting eligible clinician or from an alternate care provider) the influenza immunization during the flu season. There is no diagnosis associated with this measure. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measurespecific denominator coding.

  • If reporting this measure between January 1, 2017 and March 31, 2017, quality-data code G8482 should be reported when the influenza immunization is administered to the patient during the months of August, September, October, November, and December of 2016 or January, February, and March of 2017 for the flu season ending March 31, 2017.
  • If reporting this measure between October 1, 2017 and December 31, 2017, quality-data code G8482 should be reported when the influenza immunization is administered to the patient during the months of August, September, October, November, and December of 2017 for the flu season ending March 31, 2018.
  • • Influenza immunizations administered during the month of August or September of a given flu season (either 2016-2017 flu season OR 2017-2018 flu season) can be reported when a visit occurs during the flu season (October 1 - March 31). In these cases, G8482 should be reported.

Measure Reporting:

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data.

 

Denominator: 

All patients aged 6 months and older seen for at least two visits or at least one preventive visit during the measurement period

DENOMINATOR NOTE: For the purposes of the program, in order to report on the flu season 2016-2017, the patient must have a qualifying encounter between January 1 and March 31, 2017. In order to report on the flu season 2017-2018, the patient must have a qualifying encounter between October 1 and December 31, 2017. At least one of the qualifying encounters needs to occur within the flu season that is being reported; any additional encounter(s) may occur at any time within the measurement period. 

*Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for registrybased measures.

Denominator Criteria (Eligible Cases):

Patients aged ≥ 6 months seen for a visit between October 1 and March 31 

AND

At least two patient encounters with at least one encounter during January thru March and/or October thru December (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241*, 99242*, 99243*, 99244*, 99245*, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350

WITHOUT

Telehealth Modifier: GQ, GT

OR

At least one encounter - January thru March and/or October thru December (CPT or HCPCS): 90945, 90947, 90951, 90952, 90953, 90954, 90955, 90956, 90957, 90958, 90959, 90960, 90961, 90962, 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 96160, 96161, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99381*, 99382*, 99383*, 99384*, 99385*, 99386*, 99387*, 99391*, 99392*, 99393*, 99394*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99429*, 99512*, G0438, G0439

WITHOUT

Telehealth Modifier: GQ, GT

 

Numerator:

Patients who received an influenza immunization OR who reported previous receipt of an influenza immunization 

Numerator Instructions: The numerator for this measure can be met by reporting either administration of an influenza vaccination or that the patient reported previous receipt of the current season’s influenza immunization. If the performance of the numerator is not met, an eligible clinician can report a valid denominator exception for having not administered an influenza vaccination. For eligible clinicians reporting a denominator exception for this measure, there should be a clear rationale and documented reason for not administering an influenza immunization if the patient did not indicate previous receipt, which could include a medical reason (e.g., patient allergy), patient reason (e.g., patient declined), or system reason (e.g., vaccination not available). The system reason should be indicated only for cases of disruption or shortage of influenza vaccination supply.

Definition: Previous Receipt – Receipt of the current season’s influenza immunization from another provider OR from same provider prior to the visit to which the measure is applied (typically, prior vaccination would include influenza vaccine given since August 1st).

Numerator Options:

Performance Met: Influenza immunization administered or previously received (G8482)

OR

Denominator Exception: Influenza immunization was not administered for reasons documented by clinician (e.g., patient allergy or other medical reasons, patient declined or other patient reasons, vaccine not available or other system reasons) (G8483) 

OR

Performance Not Met: Influenza immunization was not administered, reason not given (G8484) 


Quality Measure #111: Pneumococcal Vaccination Status for Older Adults - National Quality Strategy Domain: Community/Population Health

Description:

Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine 

Instructions:

This measure is to be reported a minimum of once per performance period for patients seen during the performance period. There is no diagnosis associated with this measure. Performance for this measure is not limited to the performance period. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on services provided and the measure-specific denominator coding. 

Measure Reporting:

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data. 

 

Denominator:

Patients 65 years of age and older with a visit during the measurement period 

DENOMINATOR NOTE: This measure assesses whether patients 65 years of age or older have received one or more pneumococcal vaccinations. 

Denominator Criteria (Eligible Cases):

Patients aged ≥ 65 years on date of encounter  

AND

Patient encounter during the performance period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0402, G0438, G0439

AND NOT

Denominator Exclusion:

Patient received hospice services any time during the measurement period (G9707)

 

Numerator:

Patients who have ever received a pneumococcal vaccination  

NUMERATOR NOTE: While the measure provides credit for adults 65 years of age and older who have ever received either the PCV13 or PPSV23 vaccine (or both), according to ACIP recommendations, patients should receive both vaccines. The order and timing of the vaccinations depends on certain patient characteristics, and are described in more detail in the ACIP recommendations.

Numerator Options:

Performance Met:  Pneumococcal vaccine administered or previously received (4040F) 

OR

Performance Not Met: Pneumococcal vaccine was not administered or previously received, reason not otherwise specified (4040F with 8P) 


Quality Measure #112: Breast Cancer Screening - National Quality Strategy Domain: Effective Clinical Care

Description:

Percentage of women 50 - 74 years of age who had a mammogram to screen for breast cancer

Instructions:

This measure is to be reported a minimum of once per performance period for female patients seen during the performance period. There is no diagnosis associated with this measure. The patient should either be screened for breast cancer on the date of service OR there should be documentation that the patient was screened for breast cancer at least once within 27 months prior to the date of service. Performance for this measure is not limited to the performance period. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on services provided and the measure-specific denominator coding. 

Measure Reporting:

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data.

 

Denominator:

Women 51 - 74 years of age with a visit during the measurement period 

DENOMINATOR NOTE: The intent of the measure is that starting at age 50 women should have one or more mammograms every 24 months with a 3 month grace period. 

Denominator Critera (Eligible Cases):

Patients 51 to 74 years of age on date of encounter  

AND

Patient encounter during the performance period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0402, G0438, G0439 

AND NOT

Denominator Exclusions:

Women who had a bilateral mastectomy or who have a history of a bilateral mastectomy or for whom there is evidence of a right and a left unilateral mastectomy (G9708)

OR

Hospice services used by patient any time during the measurement period (G9709)

 

Numerator:

Women with one or more mammograms during the measurement period or the 15 months prior to the measurement period

Numerator Options:

Performance Met: Screening mammography results documented and reviewed (3014F)

OR

Performance Not Met: Screening mammography results were not documented and reviewed, reason not otherwise specified (3014F with 8P) 


Quality Measure #113: Colorectal Cancer Screening - National Quality Strategy Domain: Effective Clinical Care

Description:

Percentage of patients 50-75 years of age who had appropriate screening for colorectal cancer  

Instructions:

This measure is to be reported a minimum of once per performance period for patients seen during the performance period. There is no diagnosis associated with this measure. Performance for this measure is not limited to the performance period. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on services provided and the measure-specific denominator coding.

Measure Reporting: 

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data. 

 

Denominator:

Patients 50-75 years of age with a visit during the measurement period 

Denominator Criteria (Eligible Cases):

Patients 50 to 75 years of age on date of encounter 

AND

Patient encounter during the performance period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0402, G0438, G0439

AND NOT

Denominator Exclusions:

Patients with a diagnosis or past history of total colectomy or colorectal cancer (G9711)

OR

Patient was provided hospice services any time during the measurement period (G9710)

 

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
  • Flexible sigmoidoscopy 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 
  • Computed tomography (CT) colonography during the measurement period or the four years prior to the measurement period.
  • Fecal immunochemical DNA test (FIT-DNA) during the measurement period or the two years prior to the measurement period.

Numerator Options:

Performance Met:Colorectal cancer screening results documented and reviewed (3017F)

OR

Performance Not Met: Colorectal cancer screening results were not documented and reviewed, reason not otherwise specified (3017F with 8P) 


Quality Measure #117: Diabetes: Eye Exam - National Quality Strategy Domain: Effective Clinical Care

Description:

Percentage of patients 18 - 75 years of age with diabetes who had a retinal or dilated eye exam by an eyecare professional during the measurement period or a negative retinal or dilated eye exam (no evidence of retinopathy)in the 12 months prior to the measurement period

Instructions:

This measure is to be reported a minimum of once per performance period for patients with diabetes mellitus seen during the performance period. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on services provided and the measure-specific denominator coding.

Measure Reporting:

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data.

 

Denominator:

Patients 18 - 75 years of age with diabetes with a visit during the measurement period

Denominator Criteria (Eligible Cases):

Patients 18 to 75 years of age on date of encounter 

AND

Diagnosis for diabetes (ICD-10-CM): E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, E10.319, E10.3211, E10.3212, E10.3213, E10.3219, E10.3291, E10.3292, E10.3293, E10.3299, E10.3311, E10.3312, E10.3313, E10.3319, E10.3391, E10.3392, E10.3393, E10.3399, E10.3411, E10.3412, E10.3413, E10.3419, E10.3491, E10.3492, E10.3493, E10.3499, E10.3511, E10.3512, E10.3513, E10.3519, E10.3521, E10.3522, E10.3523, E10.3529, E10.3531, E10.3532, E10.3533, E10.3539, E10.3541, E10.3542, E10.3543, E10.3549, E10.3551, E10.3552, E10.3553, E10.3559, E10.3591, E10.3592, E10.3593, E10.3599, E10.36, E10.37X1, E10.37X2, E10.37X3, E10.37X9, E10.39, E10.40, E10.41, E10.42, E10.43, E10.44, E10.49, E10.51, E10.52, E10.59, E10.610, E10.618, E10.620, E10.621, E10.622, E10.628, E10.630, E10.638, E10.641, E10.649, E10.65, E10.69, E10.8, E10.9, E11.00, E11.01, E11.21, E11.22, E11.29, E11.311, E11.319, E11.3211, E11.3212, E11.3213, E11.3219, E11.3291, E11.3292, E11.3293, E11.3299, E11.3311, E11.3312, E11.3313, E11.3319, E11.3391, E11.3392, E11.3393, E11.3399, E11.3411, E11.3412, E11.3413, E11.3419, E11.3491, E11.3492, E11.3493, E11.3499, E11.3511, E11.3512, E11.3513, E11.3519, E11.3521, E11.3522, E11.3523, E11.3529, E11.3531, E11.3532, E11.3533, E11.3539, E11.3541, E11.3542, E11.3543, E11.3549, E11.3551, E11.3552, E11.3553, E11.3559, E11.3591, E11.3592, E11.3593, E11.3599, E11.36, E11.37X1, E11.37X2, E11.37X3, E11.37X9, E11.39, E11.40, E11.41, E11.42, E11.43, E11.44, E11.49, E11.51, E11.52, E11.59, E11.610, E11.618, E11.620, E11.621, E11.622, E11.628, E11.630, E11.638, E11.641, E11.649, E11.65, E11.69, E11.8, E11.9, E13.00, E13.01, E13.10, E13.11, E13.21, E13.22, E13.29, E13.311, E13.319, E13.3211, E13.3212, E13.3213, E13.3219, E13.3291, E13.3292, E13.3293, E13.3299, E13.3311, E13.3312, E13.3313, E13.3319 E13.3391, E13.3392, E13.3393, E13.3399, E13.3411, E13.3412, E13.3413, E13.3419, E13.3491, E13.3492, E13.3493, E13.3499, E13.3511, E13.3512, E13.3513, E13.3519, E13.3521, E13.3522, E13.3523, E13.3529, E13.3531, E13.3532, E13.3533, E13.3539, E13.3541, E13.3542, E13.3543, E13.3549, E13.3551, E13.3552, E13.3553, E13.3559, E13.3591, E13.3592, E13.3593, E13.3599, E13.36, E13.37X1, E13.37X2, E13.37X3, E13.37X9, E13.39, E13.40, E13.41, E13.42, E13.43, E13.44, E13.49, E13.51, E13.52, E13.59, E13.610, E13.618, E13.620, E13.621, E13.622, E13.628, E13.630, E13.638, E13.641, E13.649, E13.65, E13.69, E13.8, E13.9, O24.011, O24.012, O24.013, O24.019, O24.02, O24.03, O24.111, O24.112, O24.113, O24.119, O24.12, O24.13, O24.311, O24.312, O24.313, O24.319, O24.32, O24.33, O24.811, O24.812, O24.813, O24.819, O24.82, O24.83

AND

Patient encounter during the performance period (CPT or HCPCS): 92002, 92004, 92012, 92014, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0402, G0438, G0439

AND NOT

Denominator Exclusion:

Patient is using hospice services any time during the measurement period (G9714) 

 

Numerator:

Patients with an eye screening for diabetic retinal disease. This includes diabetics who had one of the following: A retinal or dilated eye exam by an eye care professional in the measurement period or a negative retinal or dilated eye exam (no evidence of retinopathy) by an eye care professional in the year prior to the measurement period

NUMERATOR NOTE: The eye exam must be performed or reviewed by an ophthalmologist or optometrist. Alternatively, results may be read by a qualified reading center that operates under the direction of a medical director who is a retinal specialist.

Numerator Options:

Performance Met: Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed (2022F)

OR

Performance Met: Seven standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist documented and reviewed (2024F) 

OR

Performance Met: Eye imaging validated to match diagnosis fromseven standard field stereoscopic photos results documented and reviewed (2026F)

OR

Performance Met:  Low risk for retinopathy (no evidence of retinopathy in the prior year)* (3072F) 

*Note: This code can only be used if the claim/encounter was during the measurement period because it indicates that the patient had “no evidence of retinopathy in the prior year”. This code definition indicates results were negative; therefore a result is not required.

OR

Performance Not Met: Dilated eye exam was not performed, reason not otherwise specified (2022F or 2024F or 2026F with 8P)


Quality Measure #119: Diabetes: Medical Attention for Nephropathy – National Quality Strategy Domain: Effective Clinical Care

Description:

The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period

Instructions:

This measure is to be reported a minimum of once per performance period for all patients with diabetes mellitus seen during the performance period. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

Measure Reporting:

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data.

 

Denominator:

Patients 18 - 75 years of age with diabetes with a visit during the measurement period 

Denominator Criteria (Eligible Cases):

Patients aged 18 years to 75 years on date of encounter 

AND

Diagnosis for diabetes (ICD-10-CM): E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, E10.319, E10.3211, E10.3212, E10.3213, E10.3219, E10.3291, E10.3292, E10.3293, E10.3299, E10.3311, E10.3312, E10.3313, E10.3319, E10.3391, E10.3392, E10.3393, E10.3399, E10.3411, E10.3412, E10.3413, E10.3419, E10.3491, E10.3492, E10.3493, E10.3499, E10.3511, E10.3512, E10.3513, E10.3519, E10.3521, E10.3522, E10.3523, E10.3529, E10.3531, E10.3532, E10.3533, E10.3539, E10.3541, E10.3542, E10.3543, E10.3549, E10.3551, E10.3552, E10.3553, E10.3559, E10.3591, E10.3592, E10.3593, E10.3599, E10.36, E10.37X1, E10.37X2, E10.37X3, E10.37X9, E10.39, E10.40, E10.41, E10.42, E10.43, E10.44, E10.49, E10.51, E10.52, E10.59, E10.610, E10.618, E10.620, E10.621, E10.622, E10.628, E10.630, E10.638, E10.641, E10.649, E10.65, E10.69, E10.8, E10.9, E11.00, E11.01, E11.21, E11.22, E11.29, E11.311, E11.319, E11.3211, E11.3212, E11.3213, E11.3219, E11.3291, E11.3292, E11.3293, E11.3299, E11.3311, E11.3312, E11.3313, E11.3319, E11.3391, E11.3392, E11.3393, E11.3399, E11.3411, E11.3412, E11.3413, E11.3419, E11.3491, E11.3492, E11.3493, E11.3499, E11.3511, E11.3512, E11.3513, E11.3519, E11.3521, E11.3522, E11.3523, E11.3529, E11.3531, E11.3532, E11.3533, E11.3539, E11.3541, E11.3542, E11.3543, E11.3549, E11.3551, E11.3552, E11.3553, E11.3559, E11.3591, E11.3592, E11.3593, E11.3599, E11.36, E11.37X1, E11.37X2, E11.37X3, E11.37X9, E11.39, E11.40, E11.41, E11.42, E11.43, E11.44, E11.49, E11.51, E11.52, E11.59, E11.610, E11.618, E11.620, E11.621, E11.622, E11.628, E11.630, E11.638, E11.641, E11.649, E11.65, E11.69, E11.8, E11.9, E13.00, E13.01, E13.10, E13.11, E13.21, E13.22, E13.29, E13.311, E13.319, E13.3211, E13.3212, E13.3213, E13.3219, E13.3291, E13.3292, E13.3293, E13.3299, E13.3311, E13.3312, E13.3313, E13.3319 E13.3391, E13.3392, E13.3393, E13.3399, E13.3411, E13.3412, E13.3413, E13.3419, E13.3491, E13.3492, E13.3493, E13.3499, E13.3511, E13.3512, E13.3513, E13.3519, E13.3521, E13.3522, E13.3523, E13.3529, E13.3531, E13.3532, E13.3533, E13.3539, E13.3541, E13.3542, E13.3543, E13.3549, E13.3551, E13.3552, E13.3553, E13.3559, E13.3591, E13.3592, E13.3593, E13.3599, E13.36, E13.37X1, E13.37X2, E13.37X3, E13.37X9, E13.39, E13.40, E13.41, E13.42, E13.43, E13.44, E13.49, E13.51, E13.52, E13.59, E13.610, E13.618, E13.620, E13.621, E13.622, E13.628, E13.630, E13.638, E13.641, E13.649, E13.65, E13.69, E13.8, E13.9, O24.011, O24.012, O24.013, O24.019, O24.02, O24.03, O24.111, O24.112, O24.113, O24.119, O24.12, O24.13, O24.311, O24.312, O24.313, O24.319, O24.32, O24.33, O24.811, O24.812, O24.813, O24.819, O24.82, O24.83

AND

Patient encounter during the performance period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0402, G0438, G0439

AND NOT

Denominator Exclusion: 

Patients who use hospice services any time during the measurement period (G9715)

 

Numerator:

Patients with a screening for nephropathy or evidence of nephropathy during the measurement period 

Numerator Instructions: This measure is looking for a nephropathy screening test or evidence of nephropathy.

Numerator Options:

Performance Met: Positive microalbuminuria test result documented and reviewed (3060F) 

OR

Performance Met: Negative microalbuminuria test result documented and reviewed (3061F)

OR

Performance Met: Positive macroalbuminuria test result documented and reviewed (3062F)

OR

Performance Met: Documentation of treatment for nephropathy (eg, patient receiving dialysis, patient being treated for ESRD, CRF, ARF, or renal insufficiency, any visit to a nephrologist) (3066F)

OR

Performance Met: Patient receiving angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy (G8506)

OR

Performance Not Met: Nephropathy screening was not performed, reason not otherwise specified (3060F or 3061F or 3062F with 8P)


Quality Measure #128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan - National Quality Strategy Domain

Description:

Percentage of patients aged 18 years and older with a BMI documented during the current encounter or duringthe previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented duringthe encounter or during the previous six months of the current encounter

Normal Parameters: Age 18 years and older BMI ≥ 18.5 and < 25 kg/m2

Instructions: 

There is no diagnosis associated with this measure. This measure is to be reported a minimum of once per performance period for patients seen during the performance period. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on the services provided at the time of the qualifying visit and the measure-specific denominator coding. The BMI may be documented in the medicalrecord of the provider or in outside medical records obtained by the provider. If the most recent documented BMI is outside of normal parameters, then a follow-up plan must be documented during the encounter or during the previoussix months of the current encounter. The documented follow-up plan must be based on the most recent documentBMI outside of normal parameters, example: “Patient referred to nutrition counseling for BMI above or below normal parameters” (See Definitions for examples of follow-up plan treatments). If more than one BMI is reported during the measure period, the most recent BMI will be used to determine if the performance has been met. 

Measure Reporting:

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data.

 

Denominator:

All patients aged 18 years and older on the date of the encounter with at least one eligible encounter during the measurement period

Denominator Criteria (Eligible Cases):

Patients aged ≥18 years on date of encounter  

AND

Patient encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 96150, 96151, 96152, 97161, 97162, 97163, 97165, 97166, 97167, 97802, 97803, 98960, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, D7140, D7210, G0101, G0108, G0270, G0271, G0402, G0438, G0439, G0447

WITHOUT

Telehealth Modifier: GQ, GT 

AND NOT

Denominator Exclusions:

BMI not documented, documentation the patient is not eligible for BMI calculation (G8422)

OR

BMI is documented as being outside of normal limits, follow-up plan is not documented, documentation the patient is not eligible (G8938)

 

Numerator:

Patients with a documented BMI during the encounter or during the previous six months, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous sixmonths of the current encounter

Numerator Instructions:

  • Height and Weight - An eligible professional or their staff is required to measure both height andweight. Both height and weight must be measured within six months of the current encounter and may be obtained from separate encounters. Self-reported values cannot be used.
  • Follow-Up Plan – If the most recent documented BMI is outside of normal parameters, then a follow-up plan is documented during the encounter or during the previous six months of the current encounter.The documented follow-up plan must be based on the most recent documented BMI, outside of normal parameters, example: “Patient referred to nutrition counseling for BMI above or below normal parameters”. (See Definitions for examples of follow-up plan treatments).
  • Performance Met for G8417 & G8418 
    • If the provider documents a BMI and a follow-up plan at the current visit OR
    • If the patient has a documented BMI within the previous six months of the current encounter, the provider documents a follow-up plan at the current visit OR
    • If the patient has a documented BMI within the previous six months of the current encounter ANDthe patient has a documented follow-up plan for a BMI outside normal parameters within the previoussix months of the current visit

Definitions:

BMI – Body mass index (BMI), is a number calculated using the Quetelet index: weight divided byheight squared (W/H2) and is commonly used to classify weight categories. BMI can be calculated using:

  • Metric Units: BMI = Weight (kg) / (Height (m) x Height(m)) OR
  • English Units: BMI = Weight (lbs) / (Height (in) x Height (in)) x 703

Follow-Up Plan – Proposed outline of treatment to be conducted as a result of a BMI out of normal parameters. A follow-up plan may include, but is not limited to:

  • Documentation of education 
  • Referral (for example a registered dietitian, nutritionist, occupational therapist, physical therapist, primary care provider, exercise physiologist, mental health professional, or surgeon)
  • Pharmacological interventions
  • Dietary supplements
  • Exercise counseling
  • Nutrition counseling

Not Eligible for BMI Calculation or Follow-Up Plan (Denominator Exclusion) – A patient is not eligible if one or more of the following reasons are documented:

  • Patients receiving palliative care
  • Patients who are pregnant
  • Patients who refuse measurement of height and/or weight or refuse follow-up

Patients with a documented BMI outside normal limits and a documented reason for not completing BMI follow-up plan (Denominator Exception) – 

  • The Medical Reason exception could include, but is not limited to, the following patients as deemed appropriate by the health care provider
    • Elderly Patients (65 or older) for whom weight reduction/weight gain would complicate other underlying health conditions such as the following examples:
      • Illness or physical disability
      • Mental illness, dementia, confusion
      • Nutritional deficiency, such as Vitamin/mineral deficiency
    • Patient is in an urgent or emergent medical situation where time is of the essence, and to delay treatment would jeopardize the patient’s health status

Numerator Options:

Performance Met: BMI is documented within normal parameters and no follow-up plan is required (G8420)

OR

Performance Met: BMI is documented above normal parameters and a follow-up plan is documented (G8417)

OR

Performance Met: BMI is documented below normal parameters and a follow-up plan is documented (G8418) 

OR

Denominator Exception: BMI is documented as being outside of normal limits, follow-up plan is not completed for documented reason (G9716) 

OR

Performance Not Met: BMI not documented and no reason is given (G8421)

OR

Performance Not Met: BMI documented outside normal parameters, no follow-up plan documented, no reason given (G8419) 


Quality Measure #130: Documentation of Current Medications in the Medical Record - National Quality Strategy Domain: Patient Safety

Description:

Percentage of visits for patients aged 18 years and older for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration 

Instructions:

This measure is to be reported at each denominator eligible visit during the 12 month performance period. Eligible clinicians meet the intent of this measure by making their best effort to document a current, complete and accurate medication list during each encounter. There is no diagnosis associated with this measure. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. 

Measure Reporting:

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data.

 

Denominator:

All visits for patients aged 18 years and older 

Denominator Criteria (Eligible Cases):

Patients aged ≥ 18 years on date of encounter 

AND

Patient encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90839, 92002, 92004, 92012, 92014, 92507, 92508, 92526, 92537, 92538, 92540, 92541, 92542, 92544, 92545, 92547, 92548, 92550, 92557, 92567, 92568, 92570, 92585, 92588, 92626, 96116, 96150, 96151, 96152, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97532, 97802, 97803, 97804, 98960, 98961, 98962, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99495, 99496, G0101, G0108, G0270, G0402, G0438, G0439 

 

Numerator:

Eligible clinician attests to documenting, updating or reviewing a patient’s current medications using all resources available on the date of encounter. This list must include ALL known prescriptions, over-the counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosages, frequency and route of administration

Definitions: 

Current Medications – Medications the patient is presently taking including all prescriptions, over-thecounters, herbals and vitamin/mineral/dietary (nutritional) supplements with each medication’s name, dosage, frequency and administered route.

Route – Documentation of the way the medication enters the body (some examples include but are not limited to: oral, sublingual, subcutaneous injections, and/or topical)

Not Eligible (Denominator Exception) – A patient is not eligible if the following reason is documented:

  • Patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient’s health status

NUMERATOR NOTE: The eligible clinician must document in the medical record they obtained, updated, or reviewed a medication list on the date of the encounter. Eligible clinicians reporting this measure may document medication information received from the patient, authorized representative(s), caregiver(s) or other available healthcare resources. G8427 should be reported if the eligible clinician documented that the patient is not currently taking any medications

Numerator Options:

Performance Met: Eligible clinician attests to documenting in the medical record they obtained, updated, or reviewed the patient’s current medications (G8427)

OR

Denominator Exception: Eligible clinician attests to documenting in the medical record the patient is not eligible for a current list of medications being obtained, updated, or reviewed by the eligible clinician (G8430) 

OR

Performance Not Met: Current list of medications not documented as obtained, updated, or reviewed by the eligible clinician, reason not given (G8428)


Quality Measure #134: Preventive Care and Screening: Screening for Depression and Follow-Up – National Quality Strategy Domain: Community/Population Health

Description:

Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen

Instructions:

This measure is to be reported a minimum of once per performance period for patients seen during the performance period. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. The follow-up plan must be related to a positive depression screening, example: “Patient referred for psychiatric evaluation due to positive depression screening”.

Measure Reporting:

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data.

 

Denominator:

All patients aged 12 years and older 

Denominator Criteria (Eligible Cases):

Patients aged ≥ 12 years on date of encounter 

AND

Patient encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 92625, 96116, 96118, 96150, 96151, 97165, 97166, 97167, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, G0101, G0402, G0438, G0439, G0444

AND NOT

Denominator Exclusion:

Documentation stating the patient has an active diagnosis of depression or has a diagnosed bipolar disorder, therefore screening or follow-up not required (G9717)

 

Numerator:

Patients screened for depression on the date of the encounter using an age appropriate standardized tool AND, if positive, a follow-up plan is documented on the date of the positive screen

Numerator Instructions: : The name of the age appropriate standardized depression screening tool utilized must be documented in the medical record. The depression screening must be reviewed and addressed in the office of the provider filing the code on the date of the encounter.

Definitions:

Screening – Completion of a clinical or diagnostic tool used to identify people at risk of developing or having a certain disease or condition, even in the absence of symptoms.

Standardized Depression Screening Tool – A normalized and validated depression screening tool developed for the patient population in which it is being utilized. The name of the age appropriate standardized depression screening tool utilized must be documented in the medical record.

Examples of depression screening tools include but are not limited to:

  • Adolescent Screening Tools (12-17 years)
    • Patient Health Questionnaire for Adolescents (PHQ-A), Beck Depression Inventory-Primary Care Version (BDI-PC), Mood Feeling Questionnaire (MFQ), Center for Epidemiologic Studies Depression Scale (CES-D), Patient Health Questionnaire (PHQ-9), Pediatric Symptom Checklist (PSC-17), and PRIME MD-PHQ2
  • Adult Screening Tools (18 years and older)
    • Patient Health Questionnaire (PHQ-9), Beck Depression Inventory (BDI or BDI-II), Center for Epidemiologic Studies Depression Scale (CES-D), Depression Scale (DEPS), Duke AnxietyDepression Scale (DADS), Geriatric Depression Scale (GDS), Cornell Scale Screening, and PRIME MD-PHQ2

Follow-Up Plan – Documented follow-up for a positive depression screening must include one or more of the following:

  • Additional evaluation for depression
  • Suicide Risk Assessment
  • Referral to a practitioner who is qualified to diagnose and treat depression
  • Pharmacological interventions
  • Other interventions or follow-up for the diagnosis or treatment of depression

Not Eligible for Depression Screening or Follow-Up Plan (Denominator Exclusion) –

  • Patient has an active diagnosis of Depression
  • Patient has a diagnosed Bipolar Disorder

Patients with a Documented Reason for not Screening for Depression (Denominator Exception) – One or more of the following conditions are documented:

  • Patient refuses to participate
  • Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status
  • Situations where the patient’s functional capacity or motivation to improve may impact the accuracy of results of standardized depression assessment tools. For example: certain court appointed cases or cases of delirium

Numerator Options:

Performance Met: Screening for depression is documented as being positive AND a follow-up plan is documented (G8431) 

OR

Performance Met: Screening for depression is documented as negative, a follow-up plan is not required (G8510)

OR

Denominator Exception: Screening for depression not completed, documented reason (G8433) 

OR

Performance Not Met: Depression screening not documented, reason not given (G8432)

OR

Performance Not Met:  Screening for depression documented as positive, followup plan not documented, reason not given (G8511)


Quality Measure #204: Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet – National Quality Strategy Domain: Effective Clinical Care

Description:

Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antiplatelet during the measurement period

Instructions:

This measure is to be reported a minimum of once per performance period for patients seen during the measurement period who had an active diagnosis of IVD or had an AMI, CABG, or PCI in the 12 months prior to the measurement period. This measuremay be reported by eligible clinicians who perform the quality actions described in the measure based on the servicesprovided and the measure-specific denominator coding.

Measure Reporting:

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data.

 

Denominator:

Patients aged 18 years of age and older with a visit during the measurement period who had an AMI, CABG, or PCI during the 12 months prior to the measurement year or who had a diagnosis of IVD overlapping the measurement year

DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for registry-based measures. 

Denominator Criteria (Eligible Cases):

Patients aged ≥ 18 years on date of encounter 

AND

Diagnosis for Ischemic Vascular Disease (ICD-10-CM): I20.0, I20.8, I20.9, I24.0, I24.1, I24.8, I24.9, I25.10, I25.110, I25.111, I25.118, I25.119, I25.5, I25.6, I25.700, I25.701, I25.708, I25.709, I25.710, I25.711, I25.718, I25.719, I25.720, I25.721, I25.728, I25.729, I25.730, I25.731, I25.738, I25.739, I25.750, I25.751, I25.758, I25.759, I25.760, I25.761, I25.768, I25.769, I25.790, I25.791, I25.798, I25.799, I25.810, I25.811, I25.812, I25.82, I25.83, I25.84, I25.89, I25.9, I63.00, I63.011, I63.012, I63.013, I63.019, I63.02, I63.031, I63.032, I63.033, I63.039, I63.09, I63.10, I63.111, I63.112, I63.113, I63.119, I63.12, I63.131, I63.132, I63.133, I63.139, I63.19, I63.20,I63.211, I63.212, I63.213, I63.219, I63.22, I63.231, I63.232, I63.233, I63.239, I63.29, I63.30, I63.311, I63.312, I63.313, I63.319, I63.321, I63.322, I63.323, I63.329, I63.331, I63.332, I63.333, I63.339, I63.341, I63.342, I63.349, I63.39, I63.40, I63.411, I63.412, I63.413, I63.419, I63.421, I63.422, I63.423 I63.429, I63.431, I63.432, I63.433, I63.439, I63.441, I63.442, I63.449, I63.49, I63.50, I63.511, I63.512, I63.513, I63.519, I63.521, I63.522, I63.523, I63.529, I63.531, I63.532, I63.533, I63.539, I63.541, I63.542, I63.543, I63.549, I63.59, I63.6, I63.8, I63.9, I65.01, I65.02, I65.03, I65.09, I65.1, I65.21, I65.22, I65.23, I65.29, I65.8, I65.9, I66.01, I66.02, I66.03, I66.09, I66.11, I66.12, I66.13, I66.19, I66.21, I66.22, I66.23, I66.29, I66.3, I66.8, I66.9, I67.2, I70.0, I70.1, I70.201, I70.202, I70.203, I70.208, I70.209, I70.211, I70.212, I70.213, I70.218, I70.219, I70.221, I70.222, I70.223, I70.228, I70.229, I70.231, I70.232, I70.233, I70.234, I70.235, I70.238, I70.239, I70.241, I70.242, I70.243, I70.244, I70.245, I70.248, I70.249, I70.25, I70.261, I70.262, I70.263, I70.268, I70.269, I70.291, I70.292, I70.293, I70.298, I70.299, I70.301, I70.302, I70.303, I70.308, I70.309, I70.311, I70.312, I70.313, I70.318, I70.319, I70.321, I70.322, I70.323, I70.328, I70.329, I70.331, I70.332, I70.333, I70.334, I70.335, I70.338, I70.339, I70.341, I70.342, I70.343, I70.344, I70.345, I70.348, I70.349, I70.35, I70.361, I70.362, I70.363, I70.368, I70.369, I70.391, I70.392, I70.393, I70.398, I70.399, I70.401, I70.402, I70.403, I70.408, I70.409, I70.411, I70.412, I70.413, I70.418, I70.419, I70.421, I70.422, I70.423, I70.428, I70.429, I70.431, I70.432, I70.433, I70.434, I70.435, I70.438, I70.439, I70.441, I70.442, I70.443, I70.444, I70.445, I70.448, I70.449, I70.45, I70.461, I70.462, I70.463, I70.468, I70.469, I70.491, I70.492, I70.493, I70.498, I70.499, I70.501, I70.502, I70.503, I70.508, I70.509, I70.511, I70.512, I70.513, I70.518, I70.519, I70.521, I70.522, I70.523, I70.528, I70.529, I70.531, I70.532, I70.533, I70.534, I70.535, I70.538, I70.539, I70.541, I70.542, I70.543, I70.544, I70.545, I70.548, I70.549, I70.55, I70.561, I70.562, I70.563, I70.568, I70.569, I70.591, I70.592, I70.593, I70.598, I70.599, I70.601, I70.602, I70.603, I70.608, I70.609, I70.611, I70.612, I70.613, I70.618, I70.619, I70.621, I70.622, I70.623, I70.628, I70.629, I70.631, I70.632, I70.633, I70.634, I70.635, I70.638, I70.639, I70.641, I70.642, I70.643, I70.644, I70.645, I70.648, I70.649, I70.65, I70.661, I70.662, I70.663, I70.668, I70.669, I70.691, I70.692, I70.693, I70.698, I70.699, I70.701, I70.702, I70.703, I70.708, I70.709, I70.711, I70.712, I70.713, I70.718, I70.719, I70.721, I70.722, I70.723, I70.728, I70.729, I70.731, I70.732, I70.733, I70.734, I70.735, I70.738, I70.739, I70.741, I70.742, I70.743, I70.744, I70.745, I70.748, I70.749, I70.75, I70.761, I70.762, I70.763, I70.768, I70.769, I70.791, I70.792, I70.793, I70.798, I70.799, I70.8, I70.90, I70.91, I70.92, I74.01, I74.09, I74.10, I74.11, I74.19, I74.2, I74.3, I74.4, I74.5, I74.8, I74.9, I75.011, I75.012, I75.013, I75.019, I75.021, I75.022, I75.023, I75.029, I75.81, I75.89

OR

Diagnosis for acute myocardial infarction (ICD-10-CM): I21.01, I21.02, I21.09, I21.11, I21.19, I21.21, I21.29, I21.3, I21.4 

OR

Patient procedure during the performance period (CPT) – Procedure: 33510, 33511, 33512, 33513, 33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536, 92920, 92924, 92928,92933, 92937, 92941, 92943, S2205*, S2206*, S2207*, S2208*, S2209*

AND

Patient encounter during performance period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0402, G0438, G0439

AND NOT

Denominator Exclusions:

Hospice services for patient received any time during the measurement period (G9723)

OR

Patients who had documentation of use of anticoagulant medications overlapping the measurement year (G9724)

 

Numerator:

Patients who had an active medication of aspirin or another antiplatelet during the measurementyear 

Numerator Instructions: Oral antiplatelet therapy consists of: aspirin, clopidogrel, combination of aspirin and extended release dipyridamole, prasugrel, ticagrelor orticlopidine. Anticoagulant medications consist of: Apixaban, Argatroban, Bivalirudin, Dabigatran, Dalteparin, Desirudin, Edoxaban, Enoxaparin, Fondaparinux, Heparin, Lepirudin, Rivaroxaban, Tinzaparin, or Warfarin. 

Numerator Options:

Performance Met: Aspirin or another antiplatelet therapy used (G8598)

OR

Performance Not Met: Aspirin or another antiplatelet therapy not used, reason not given (G8599) 


Quality Measure #226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention – National Quality Strategy Domain: Community/Population Health

Description:

Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user

Instructions:

This measure is to be reported once per performance period for patients seen during the performance period. This measure is intended to reflect the quality of services provided for preventive screening for tobacco use.

Measure Reporting:

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data.

 

Denominator:

All patients aged 18 years and older 

DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for registry-based measures.

Denominator Criteria (Eligible Cases):

Patients aged ≥ 18 years 

AND

At least two patient encounters during the performance period (CPT): 90791, 90792, 90832, 90834, 90837, 90845, 92002, 92004, 92012, 92014, 96150, 96151, 96152, , 97165, 97166, 97167, 97168, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350 

WITHOUT

Telehealth Modifier: GQ, GT 

OR

At least one preventive encounter during the performance period (CPT or HCPCS): 92521, 92522, 92523, 92524, 92540, 92557, 96160, 96161, 92625, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99406, 99407, 99411*, 99412*, 99429*, G0438, G0439 

WITHOUT

Telehealth Modifier: GQ, GT 

 

Numerator:

Patients who were screened for tobacco use at least once within 24 months AND who received tobacco cessation intervention if identified as a tobacco user

Definitions:

Tobacco Use – Includes any type of tobacco

Tobacco Cessation Intervention – Includes brief counseling (3 minutes or less), and/or pharmacotherapy

NUMERATOR NOTE:  In the event that a patient is screened for tobacco use and identified as a user but did not receive tobacco cessation intervention or tobacco status is unknown report 4004F with 8P.

This measure defines tobacco cessation counseling as lasting 3 minutes or less. Services typically provided under CPT codes 99406 and 99407 satisfy the requirement of tobacco cessation intervention, as these services provide tobacco cessation counseling for 3-10 minutes. If a patient received these types of services, report CPT II 4004F.

Numerator Options:

Performance Met: Patient screened for tobacco use AND received tobacco cessation intervention (counseling, pharmacotherapy, or both), if identified as a tobacco user (4004F) 

OR

Performance Met: Current tobacco non-user (1036F)

OR

Denominator Exception: Documentation of medical reason(s) for not screening for tobacco use (eg, limited life expectancy, other medical reason) (4004F with 1P) 

OR

Performance Not Met: Tobacco screening OR tobacco cessation intervention not performed, reason not otherwise specified (4004F with 8P)


Quality Measure #236: Controlling High Blood Pressure – National Quality Strategy Domain: Effective Clinical Care

Description:

Percentage of patients 18 - 85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (< 140/90 mmHg) during the measurement period

Instructions:

This measure is to be reported a minimum of once per performance period for patients with hypertension seen during the performance period. The performance period for this measure is 12 months. The most recent quality code submitted will be used for performance calculation. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

NOTE: In reference to the numerator element, only blood pressure readings performed by a clinician in the provider office are acceptable for numerator compliance with this measure. Do not include blood pressure readings that meet the following criteria:

  • Blood pressure readings from the patient's home (including readings directly from monitoring devices).
  • Taken during an outpatient visit which was for the sole purpose of having a diagnostic test or surgical procedure performed (e.g., sigmoidoscopy, removal of a mole).
  • Obtained the same day as a major diagnostic or surgical procedure (e.g., stress test, administration of IV contrast for a radiology procedure, endoscopy).

If no blood pressure is recorded during the measurement period, the patient’s blood pressure is assumed “not controlled”.

Measure Reporting:

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data

 

Denominator:

Patients 18-85 years of age who had a diagnosis of essential hypertension within the first six months of the measurement period or any time prior to the measurement period

Denominator Criteria (Eligible Cases):

Patients18 to 85 years of age on date of encounter 

AND

Diagnosis for hypertension (ICD-10-CM): I10 

AND

Patient encounter during performance period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0402, G0438, G0439

AND NOT

Denominator Exclusions:

Hospice services given to patient any time during the measurement period: G9740

OR

Documentation of end stage renal disease (ESRD), dialysis, renal transplant before or during the measurement period or pregnancy during the measurement period: G9231

 

Numerator:

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

Numerator Instructions: To describe both systolic and diastolic blood pressure values, each must be reported separately. If there are multiple blood pressures on the same date of service, use the lowest systolic and lowest diastolic blood pressure on that date as the representative blood pressure.

NUMERATOR NOTE: In reference to the numerator element, only blood pressure readings performed by an eligible clinician in the provider office are acceptable for numerator compliance with this measure. Blood pressure readings from the patient's home (including readings directly from monitoring devices) are not acceptable. 

If no blood pressure is recorded during the measurement period, the patient's blood pressure is assumed "not controlled." 

If there are multiple blood pressure readings on the same day, use the lowest systolic and the lowest diastolic reading as the most recent blood pressure reading. 

Numerator Options:

Performance Met: Most recent systolic blood pressure < 140 mmHg (G8752) 

OR

Performance Not Met: Most recent systolic blood pressure ≥ 140 mmHg (G8753)

AND

Performance Met: Most recent diastolic blood pressure < 90 mmHg (G8754)

OR

Performance Not Met: Most recent diastolic blood pressure ≥ 90 mmHg (G8755)

OR

Performance Not Met: No documentation of blood pressure measurement, reason not given (G8756)


Quality Measure #238: Use of High-Risk Medications in the Elderly – National Quality Strategy Domain: Patient Safety

Description:

Percentage of patients 66 years of age and older who were ordered high-risk medications. Two rates are reported.

  1. Percentage of patients who were ordered at least one high-risk medication.
  2. Percentage of patients who were ordered at least two different high-risk medications

Instructions:

This measure is to be reported a minimum of once per performance period for patients seen during the performance period. There is no diagnosis associated with this measure. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

This measure will be caluculated with 2 performance rates:

  1. Percentage of patients who were ordered at least one high-risk medication
  2. Percentage of patients who were ordered at least two different high-risk medications

Eligible clinicians should continue to report the measure as specified, with no additional steps needed to account for multiple performance rates.

Measure Reporting:

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data.

THERE ARE TWO REPORTING CRITERIA FOR THIS MEASURE: 

  1. Percentage of patients who were ordered at least one high-risk medication
  2. Percentage of patients who were ordered at least two different high-risk medications

 

REPORTING CRITERIA 1: PERCENTAGE OF PATIENTS WHO WERE ORDERED AT LEAST ONE HIGH-RISK MEDICATION

Denominator (Reporting Criteria 1):

Patients 66 years and older who had a visit during the measurement period 

Denominator Criteria (Eligible Cases) 1:

Patients aged ≥ 66 years on date of encounter  

AND

Patient encounter during performance period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0438, G0439

AND NOT

Denominator Exclusion:

Patients who use hospice services any time during the measurement period: G9741

 

Numerator (Reporting Criteria 1):

Percentage of patients who were ordered at least one high-risk medication during the measurement period 

Numerator Instructions: INVERSE MEASURE - A lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Reporting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.

A high-risk medication is identified by either of the following: 

  • A prescription for medications classified as high risk at any dose and for any duration listed in Table 1
  • Prescriptions for medications classified as high risk at any dose with greater than a 90 daycumulative medication duration listed in Table 2

Definitions:

Cumulative Medication Duration - an individual’s total number of medication days over a specific period; the period counts multiple prescriptions with gaps in between, but does not count the gaps during which a medication was not dispensed. 

To determine the cumulative medication duration, determine first the number of the Medication Days for each prescription in the period: the number of doses divided by the dose frequency per day. Then add the Medication Days for each prescription without counting any days between the prescriptions.

NUMERATOR NOTE: : Some high-risk medications are not included in this specific measure but should be avoided above a specified average daily dose. These medications are listed in table DAE-C. To calculate an averagedaily dose multiply the quantity of pills ordered by the dose of each pill and divide by the days supply. For example,a prescription for a 30-days supply of digoxin containing 15 pills, 0.250 mg each pill, has an average daily dose of 1.125 mg.

Numerator Options:

Performance Met: One high-risk medication ordered (G9365)

OR

Performance Not Met: One high-risk medication not ordered (G9366)

 

REPORTING CRITERIA 2: PERCENTAGE OF PATIENTS WHO WERE ORDERED AT LEAST TWODIFFERENT HIGH-RISK MEDICATIONS

Denominator (Reporting Criteria 2)

Patients 66 years and older who had a visit during the measurement period 

Denominator Criteria (Eligible Cases) 2:

Patients aged ≥ 66 years on date of encounter  

AND

Patient encounter during performance period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0438, G0439

AND NOT

Denominator Exclusion:

Patients who use hospice services any time during the measurement period: G9741

 

Numerator (Reporting Criteria 2):

Percentage of patients who were ordered at least two different high-risk medications during the measurement period 

Numerator Instructions: INVERSE MEASURE - A lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Reporting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.

A high-risk medication is identified by either of the following:

  • A prescription for medications classified as high risk at any dose and for any duration listed in Table 1 
  • Prescriptions for medications classified as high risk at any dose with greater than a 90 daycumulative medication duration listed in Table 2 

NUMERATOR NOTE: Some high-risk medications are not included in this specific measure but shouldbe avoided above a specified average daily dose. These medications are listed in table DAE-C. To calculate an average daily dose multiply the quantity of pills ordered by the dose of each pill and divide by the days supply. For example, a prescription for a 30-days supply of digoxin containing 15 pills, 0.250 mg eachpill, has an average daily dose of 0.125mg.

Numerator Options:

Performance Met: At least two different high-risk medications ordered (G9367)

OR

Performance Not Met: At least two different high-risk medications not ordered (G9368)

 

Table 1

Description Prescription

Anticholinergics (excludes TCAs), first-generation antihistamines

Brompheniramine • Carbinoxamine • Chlorpheniramine • Clemastine • Cyproheptadine • Dexbrompheniramine • Dexchlorpheniramine • Diphenhydramine (oral) • Doxylamine • Hydroxyzine • Promethazine • Triprolidine

Anticholinergics (excludes TCAs), anti-Parkinson agents

Benztropine (oral) • Trihexyphenidyl

Antithrombotics

Dipyridamole, oral • Ticlopidine extended-release short-acting (does not apply to the combination with aspirin) 

Cardiovascular, alpha agonists, central

Guanabenz • Methyldopa • Guanfacine

Cardiovascular, other

Disopyramide • Nifedipine, immediate release

Central nervous system, tertiary TCAs

Amitriptyline • Clomipramine • Imipramine • Trimipramine

Central nervous system, barbiturates

Amobarbital • Butabarbital • Butalbital • Mephobarbital • Pentobarbital • Phenobarbital • Secobarbital

Central nervous system, vasodilators

Ergot mesylates • Isoxsuprine

Central nervous system, other

Thioridazine • Chloral Hydrate • Meprobamate

Endocrine system, estrogens with or without progestins; include only oral and topical patch products

Conjugated estrogen • Estropipate • Estradiol • Esterified estrogen

Endocrine system, sulfonylureas, long- duration

Chlorpropamide • Glyburide

Endocrine system, other

Desiccated thyroid • Megestrol

Gastrointestinal system, other

Trimethobenzamide

Pain medications, skeletal muscle relaxants

Carisoprodol • Chlorzoxazone • Cyclobenzaprine • Metaxalone • Methocarbamol • Orphenadrine

Pain medications, other

Indomethacin • Meperidine • Ketorolac, includes parenteral Pentazocine

Table 2

Description Prescription Days Supply Criteria
Anti-Infectives, other  Nitrofurantoin • Nitrofurantoin • Nitrofurantoin macrocrystalsmacrocrystals monohydrate >90 days 
Nonbenzodiazepine hypnotics Eszopiclone • Zolpidem • Zaleplon >90 days

Quality Measure #317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented – National Quality Strategy Domain: Community/Population Health

Description:

Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated 

Instructions:

This measure is to be reported a minimum of once per performance period for patients seen during the performance period. Eligible clinicians who report the measure must perform the blood pressure screening at the time of a qualifying visit and may not obtain measurements from external sources

This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. The intent of this measure is to screen patients for high blood pressure and provide recommended follow-up as indicated. Both the systolic and diastolic blood pressure measurements are required for inclusion. If there are multiple blood pressures on the same date of service, use the most recent as the representative blood pressure. The documented follow-up plan must be related to the current BP reading as indicated, example: “Patient referred to primary care provider for BP management”. 

Measure Reporting:

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data. 

 

Denominator:

All patients aged 18 years and older  

Denominator Criteria (Eligible Cases):

Patients aged ≥ 18 years 

AND

Patient encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90839, 90845, 90880, 92002, 92004, 92012, 92014, 96118, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99281, 99282, 99283, 99284, 99285, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, D7140, D7210, G0101, G0402, G0438, G0439

WITHOUT

Telehealth Modifier: GQ, GT 

AND NOT

Denominator Exclusion:

Patient not eligible due to active diagnosis of hypertension: G9744

 

Numerator:

Patients who were screened for high blood pressure AND have a recommended follow-up plan documented, as indicated, if the blood pressure is pre-hypertensive or hypertensive

NUMERATOR NOTE: Although the recommended screening interval for a normal BP reading is every 2 years, to meet the intent of this measure, BP screening and follow-up must be performed once per measurement period. For patients with Normal blood pressure a follow-up plan is not required. If the blood pressure is prehypertensive (SBP > 120 and <139 OR DBP >80 and <89) at a PCP encounter no additional follow-up would be needed, this would meet the intent of the measure (G8783).

Definitions: 

Blood Pressure (BP) Classification - BP is defined by four (4) BP reading classifications: Normal, PreHypertensive, First Hypertensive, and Second Hypertensive Readings

Recommended BP Follow-Up - The Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) recommends BP screening intervals, lifestyle modifications and interventions based on the current BP reading as listed in the “Recommended Blood Pressure Follow- Up Interventions” listed below

Recommended Lifestyle Modifications - The JNC 7 report outlines lifestyle modifications which must include one or more of the following as indicated:

  • Weight Reduction
  • Dietary Approaches to Stop Hypertension (DASH) Eating Plan
  • Dietary Sodium Restriction
  • Increased Physical Activity
  • Moderation in alcohol (ETOH) Consumption

Second Hypertensive Reading - Requires a BP reading of Systolic BP ≥ 140 mmHg OR Diastolic BP ≥ 90 mmHg during the current encounter AND a most recent BP reading within the last 12 months Systolic BP ≥ 140 mmHg OR Diastolic BP ≥ 90 mmHg

Second Hypertensive BP Reading Interventions - The JNC 7 report outlines BP follow-up interventions for a second hypertensive BP reading and must include one or more of the following as indicated:

  • Anti-Hypertensive Pharmacologic Therapy
  • Laboratory Tests
  • Electrocardiogram (ECG)

Recommended Blood Pressure Follow-up Interventions - 

  • Normal BP: No follow-up required for Systolic BP <120 mmHg AND Diastolic BP < 80 mmHg
  • • Pre-Hypertensive BP: Follow-up with rescreen every year with systolic BP of 120 – 139 mmHg OR diastolic BP of 80 – 89 mmHg AND recommended lifestyle modifications OR referral to Alternate/Primary Care Provider
  • First Hypertensive BP Reading: Patients with one elevated reading of systolic BP >= 140 mmHg OR diastolic BP >= 90 mmHg:
    • Follow-up with rescreen > 1 day and < 4 weeks AND recommend lifestyle modifications OR referral to Alternative/Primary Care Provider
  • Second Hypertensive BP Reading: Patients with second elevated reading of systolic BP >= 140 mmHg OR diastolic BP >= 90 mmHg:
    • Follow-up with Recommended lifestyle modifications AND one or more of the Second Hypertensive Reading Interventions OR referral to Alternative/Primary Care Provider

Not Eligible for High Blood Pressure Screening (Denominator Exclusion)-  

  • Patient has an active diagnosis of hypertension

Patients with a Documented Reason for not Screening or Follow-Up Plan for High Blood Pressure (Denominator Exception)-

  • Patient refuses to participate (either BP measurement or follow-up)
  • Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status. This may include but is not limited to severely elevated BP when immediate medical treatment is indicated

Numerator Options:

Performance Met: Normal blood pressure reading documented, follow-up not required (G8783) 

OR

Performance Met: Pre-Hypertensive or Hypertensive blood pressure reading documented, AND the indicated follow-up is documented (G8950)

OR

Denominator Exception: Documented reason for not screening or recommending a follow-up for high blood pressure (G9745) 

OR

Performance Not Met: Blood pressure reading not documented, reason not given (G8785)

OR

Performance Not Met: Pre-Hypertensive or Hypertensive blood pressure reading documented, indicated follow-up not documented, reason not given (G8952)