MIPS 2019 eCQM (Quality) Manual for the Aprima® User · The MIPS eligible clinician’s quality...
114
MIPS 2019 eCQM (Quality) Manual for the Aprima® User
Transcript of MIPS 2019 eCQM (Quality) Manual for the Aprima® User · The MIPS eligible clinician’s quality...
MIPS 2019 eCQM (Quality) Manual for the Aprima® User
2
CONTENTS QUALITY MEASURES REQUIREMENTS.......................................................................... 5
CMS 2: SCREENING FOR CLINICAL DEPRESSION AND FOLLOW-UP PLAN ………….…..…….7
CMS 22: SCREENING FOR HIGH BLOOD PRESSURE AND FOLLOW-UP PLAN…..…..……...10
CMS 50: CLOSING THE REFERRAL LOOP…………………………….………………………………………14
CMS 52: PNEUMOCYSTIS JIROVECI PNEUMONIA (PCP) PROPHYLAXIS…………………..….16
CMS 56: FUNCTIONAL STATUS ASSESSMENT FOR HIP REPLACEMENT ………………………18
CMS 62: HIV/AIDS: MEDICAL VISIT ………………………………………..………….……………………..20
CMS 66: FUNCTIONAL STATUS ASSESSMENT FOR KNEE REPLACEMENT ……………….…..21
CMS 68: DOCUMENTATION OF CURRENT MEDICATION IN THE MEDICAL RECORD….…23
CMS 69: BMI SCREENING AND FOLLOW-UP …………………………………………………….……….24
CMS 74: PRIMARY CARIES PREVENTION INTERVENTION AS OFFERED BY PCP ……….….25
CMS 75: CHILDREN WHO HAVE DENTAL DECAY OR CAVITIES ……………………………....….28
CMS 77: HIV/AIDS: RNA CONTROL FOR PATIENTS WITH HIV ……………..…………………….29
CMS 82: MATERNAL DEPRESSION SCREENING ………………………………………………………….31
CMS 90: FUNCTIONAL STATUS ASSESSMENT FOR COMPLEX CHRONIC CONDITIONS ..32
CMS 117: CHILDHOOD IMMUNIZATION STATUS ……………..……………………………………….34
CMS 122: DIABETES: HEMOGLOBIN A1C POOR CONTROL …………………….………………….35
CMS 124: CERVICAL CANCER SCREENING ………………..……………………………………………….37
CMS 125: BREAST CANCER SCREENING ……………………..………………………………………….….38
CMS 126: USE OF APPROPRIATE MEDICATIONS FOR ASTHMA ………………………………….39
CMS 127: PNEUMONIA VACCINATION STATUS FOR OLDER ADULTS …………………………40
CMS 128: ANTI-DEPRESSANT MEDICATION MANAGEMENT ………………………………….….41
CMS 129: PROSTATE CANCER ……………………..……………………………………………….….……….42
CMS 130: COLORECTAL CANCER SCREENING ……………………………………………………..…….46
CMS 131: DIABETES: EYE EXAM ……………………….……..……………………………………………...48
CMS 132: COMPLICATIONS WITHIN 30 DAYS FOLLOWING CATARACT SURGERY ……..50
3
CMS 133: CATARACTS: 20/40 OR BETTER VISUAL ACUITY WITHIN 90 DAYS FOLLOWING
CATARACT SURGERY ………………………………………..……………………………………………………..52
CMS 134: DIABETES: URINE PROTEIN SCREENING ………..………………………………………….54
CMS 135: HF: ACE INHIBITOR OR ARB THERAPY FOR LVSD……………….……..……………….58
CMS 136: FOLLOW-UP CARE FOR CHILDREN PRESCRIBED ADHD MEDICATION …………61
CMS 137: INITIATION AND ENGAGEMENT OF ALCOHOL AND OTHER DRUG
DEPENDENCE TREATMENT ………………………………………..…………………………………………….63
CMS 138: TOBACCO USE: SCREENING AND CESSATION INTERVENTION………….…….…..67
CMS 139: SCREENING FOR FUTURE FALL RISK …..………………………………………….………….68
CMS 140: BREAST CANCER ………………………………………..…………………………………..….…….70
CMS 141: COLON CANCER ………………………………………..………………………………………………71
CMS 142: DIABETIC RETINOPATHY: COMMUNICATION WITH THE PHYSICIAN
MANAGING ONGOING DIABETES CARE …………………………..…………………………….…………72
CMS 143: PRIMARY OPEN ANGLE GLAUCOMA: OPTIC NERVE EVALUATION…….………..74
CMS 144: HEART FAILURE (HF): BETA-BLOCKER THERAPY FOR LVSD………………………….76
CMS 145: CAD: BETA-BLOCKER THERAPY- PRIOR MI OR LVEF <40%……………….………….78
CMS 146: APPROPRIATE TESTING FOR CHILDREN WITH PHARYNGITIS ……………………..81
CMS 147: INFLUENZA IMMUNIZATION ………………………………………………………..………..…83
CMS 148: HEMOGLOBIN A1C TEST FOR PEDIATRIC PATIENTS …………………………………..85
CMS 149: DEMENTIA: COGNITIVE ASSESSMENT ……………………………………………..……….87
CMS 153: CHLAMYDIA SCREENING FOR WOMEN ……..……………………………………………..89
CMS 154: APPROPRIATE TREATMENT FOR CHILDREN WITH URI……..………….…..….….…91
CMS 155: WEIGHT ASSESSMENT & COUNSELING FOR NUTRITION & PHYSICAL....……..92
CMS 156: USE OF HIGH RISK MEDICATIONS IN THE ELDERLY…………………………….…..….94
CMS 157: ONCOLOGY: MEDICAL AND RADIATION – PAIN INTENSITY QUANTIFIED …..95
CMS 159: DEPRESSION AT TWELVE MONTHS …………………………..…………………………...…96
CMS 160: DEPRESSION UTILIZATION OF THE PHQ-9 TOOL ………………..…………..….……..98
CMS 161: MAJOR DEPRESSIVE DISORDER (MDD): SUICIDE RISK ASSESSMENT ...…….100
CMS 163: DIABETES: LOW DENSITY LIPOPROTEIN (LDL) MANAGEMENT ……….…….…101
4
CMS 165: CONTROLLING HIGH BLOOD PRESSURE …………………………………………….…..103
CMS 166: USE OF IMAGING STUDIES FOR LOW BACK PAIN ……………………………………104
CMS 177; NQF 1365; PQRS 382 CHILD AND ADOLESCENT MAJOR DEPRESSIVE
DISORDER: SUICIDE RISK ASSESSMENT…………………...………………………………………..……106
CMS 179; NQF NA; PQRS 380 ADE PREVENTION AND MONITORING: WARFIN AND
TIME IN THERAPEUTIC RANGE………………………………………………………………………....….…108
CMS 249; NQF NA; PQRS APPROPRIATE USE OF DXA SCANS IN WOMEN UNDER 65
YEARS WHO DO NOT MEET THE RISK FACTOR PROFILE FOR OSTEOPOROTIC
FRACTURES ……………………………………………………………………………………………………………109
CMS 349; NQF NA; PQRS HIV SCREENING ………………………………………………………….…. 111
HOW TO RUN THE QUALITY REPORT…………...……..………..……………….….…...…….….……112
5
QUALITY MEASURES REQUIREMENTS This performance category measures health care processes, outcomes, and patient care experiences. Requirements may change each Performance Year (PY) due to shifting rules. Quality is 45% of your MIPS Final Score. Participants must submit data for at least 6 measures for the 12-month performance period (January 1 - December 31, 2019). Participants should:
Submit collected data for at least 6 measures One of these measures should be an outcome measure; if you have no applicable
outcome measure, you can submit a high priority measure instead There are 6 ways participants can submit data:
Electronic Health Record (EHR) – Using eCQM Specifications Qualified Clinical Data Registry (QCDR) Qualified Registry – Using MIPS CQMs Specifications CMS Web Interface (Groups of 25 or more clinicians) CAHPS (Registered Groups and Virtual Groups Only) Claims (Small Practice Status Clinicians Only)
There are 266 Measures to choose from. Not all the measures are reportable through the eCQM (EHR) method. Those that are, have additional information below as they pertain to the Aprima® EHR system.
6
MIPS Eligible Clinicians (ECs) receive 3 to 10 achievement points for each scored quality measure based on the MIPS ECs performance when compared to the benchmark:
The measure must have a benchmark to be considered for a performance score, otherwise it will receive 3 points for the 2018 performance period.
All quality measures have a 20-case minimum, otherwise it will receive 3 points in MIPS payment year 2020.
In order to meet the data completeness requirement, you must report on 60% of the patients that qualify for the measure. (i.e. if your denominator is 100 then your numerator must be above 60), otherwise your score will be capped at 3 points.
Bonus Points:
High priority measures receive 1 bonus point One bonus point awarded for measures submitted with end-to-end electronic reporting MIPS Eligible Clinicians who are eligible for the Small Practice Status will receive a 6-
point bonus
The MIPS eligible clinician’s quality reporting category score equals the sum of all the points assigned for the measures required for the reporting category plus any bonus points. The sum of total points is then divided by the sum of total points possible for the final score.
7
CMS 2; NQF 0418; PQRS 134 PREVENTIVE CARE AND SCREENING: SCREENING FOR CLINICAL DEPRESSION AND FOLLOW-UP PLAN
Measure Type
Benchmark
Decile 3 Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 0.51 -
1.29
1.30 -
5.09
5.10 -
12.51
12.52 -
25.60
25.61 -
42.30
42.31 -
64.36
64.37 -
83.73
>= 83.74
No
DOMAIN Population/Public Health MEASURE Percentage of patients aged 12 years and older screened for clinical 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. EXCLUSIONS OR EXCEPTIONS
Patient Reason(s): Patient refuses to participate. Medical Reason(s): 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.
ENTERING DENOMINATOR DATA The patient must be 12 years and older at the beginning of the measurement period. The patient must have at least one eligible visit during the measurement period.
8
ENTERING NUMERATOR DATA There are two numerators for this measure. The first numerator requires an appropriate depression screening. To chart the screening, you must enter a procedure code that is associated with a qualifying SNOMED code. You may enter the procedure code in either the SP or the SO tab of Full Note Composer or other clinical note type window. SNOMED CODES FOR THE SCREENING 10197000, 10997001, 29657007, 38756009, 45392008, 79094001, 90407005, 165171009, 165190001, 171207006, 225337009, 370803007, 428151000124107, 428161000124109, 428171000124102, 428181000124104 The second numerator applies when the screening result is positive, and you diagnose the patient. Enter the diagnosis with a qualifying ICD-9 or ICD-10 code or a diagnosis code associated with a qualifying SNOMED code for depression in the Dx tab of Full Note Composer or other clinical note type window. ICD-9 290.13, 290.21, 290.43, 296.2, 296.21, 296.22, 296.23, 296.24, 296.25, 296.26, 296.3,296.31, 296.32, 296.33, 296.34, 296.36, 296.82, 298.0, 300.4, 301.12, 309.0, 309.1,309.28, 311 ICD-10 F31.1, F31.11, F31.12, F31.13, F31.2, F31.73, F31.74, F31.9, F01.51, F03, F32.0, F32.1, F32.2, F32.3, F32.4, F32.5, F32.8, F32.9, F33.0, F33.1, F33.2, F33.3, F33.42, F33.9, F34.1, F43.21, F43.23 SNOMED 162004, 832007, 1196001, 1499003, 2506003, 2618002, 3109008, 3530005, 4441000, 5703000, 9340000, 10875004, 10981006, 13313007, 13581000, 13746004, 14183003, 14495005, 15193003, 15639000, 16295005, 16506000, 17782008, 18818009, 19300006, 19527009, 19694002, 20250007, 20960007, 21900002, 22121000, 22407005, 25922000, 26203008, 26530004, 28475009, 28663008, 28884001, 29929003, 30520009, 30687003, 30935000, 31446002, 33078009, 33380008, 34315001, 35481005, 35489007, 35846004, 36170009, 36474008, 36583000, 36923009, 38368003, 38451003, 38694004, 39809009, 40379007, 40568001, 40926005, 41552001, 41832009, 41836007, 42925002, 43568002, 43769008, 45479006, 46229002, 48589009, 48937005, 49468007, 49512000, 51637008, 53049002, 53607008, 54761006, 55516002, 59617007, 61403008, 63249007, 63778009, 64731001, 65042007, 66344007, 66631006, 67711008, 68569003, 69392006, 70546001, 71294008, 71336009, 71984005, 73471000, 73867007, 74686005, 75084000, 75360000, 75752004, 75837004, 76441001, 77486005, 77911002, 78269000, 78640000, 78667006, 79298009, 79584002, 81319007, 81319007, 82998009, 83176005, 83225003, 84760002, 85080004, 85248005, 86058007, 87203005, 87512008, 87950005, 111485001, 191610000, 191611001, 191613003, 191616006, 191618007, 191620005, 191621009, 191623007, 191625000, 191627008, 191629006, 191630001, 191632009, 191634005, 191636007, 191638008, 191639000, 191641004, 191643001, 191659001, 192080009, 192362008, 231444002, 231504006, 231542000, 268621008, 319768000, 320751009, 370143000, 371596008, 371599001, 371600003, 371604007, 430852001, 44205700 You must establish a follow up plan, which may include medication, an additional screening, or a
9
referral to another qualifying medical services provider. To chart the screening, you must enter a procedure code that is associated with a qualifying SNOMED code. You may enter the in either the SP or the SO tab of Full Note Composer or other clinical note type window. SNOMED CODES FOR THE FOLLOW UP PLAN 5694008, 5694008, 88848003, 88848003, 91310009, 91310009, 372067001, 372067001, 385721005, 385721005, 385724002, 385724002, 385725001, 385725001, 385726000, 385726000, 385727009, 385727009, 385887004, 385887004, 385889001, 385889001, 385890005, 385890005, 401277000, 401277000, 410223002, 410223002, 410224008, 410224008, 410225009, 410225009, 410226005, 410226005, 410227001, 410227001, 410228006, 410228006, 410229003, 410229003, 410230008, 410230008, 410231007, 410231007, 410232000, 410232000, 410233005, 410233005, 410234004, 410234004, 425604002, 425604002, 439141002, 4391410 To use a referral as the follow-up plan, you must order the referral by entering a procedure code that is associated with a qualifying SNOMED code. SNOMED CODES FOR DEPRESSION REFERRAL 183524004, 183583007, 183851006, 183866009, 305922005, 306136006, 306137002, 306226009, 306227000, 306252003, 306291008, 306294000, 308459004, 308477009, 309627007, 390866009, 401174001, 429387009, 61801003, 14129001, 183524004, 183528001, 183583007, 183866009, 305922005, 306136006, 306137002, 306138007, 306204008, 306226009, 306227000, 306252003, 306294000, 308459004, 308477009, 390866009, 401174001, 408293001, 429387009, 61801003
To use medication as the follow-up plan, you must prescribe a qualifying medication as the follow up plan. Write the prescription through the SIG Writer window, and then either print it or submit it electronically.
10
CMS 22; PQRS 317 PREVENTIVE CARE AND SCREENING: SCREENING FOR HIGH BLOOD PRESSURE AND FOLLOW-UP DOCUMENTED Measure
Type Benchmark Decile
3 Decile
4 Decile
5 Decile
6 Decile
7 Decile
8 Decile
9 Decile
10 Topped
Out
Process Y 16.53
- 20.40
20.41 -
23.94
23.95 -
26.93
26.94 -
29.99
30.00 -
33.32
33.33 -
37.61
37.62 -
45.98
>= 45.99 No
DOMAIN Population/Public Health MEASURE 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. EXCLUSIONS OR EXCEPTIONS
Patient Reason(s): Patient refuses to participate. OR
Medical Reason(s): 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. This may include but is not limited to severely elevated BP when immediate medical treatment is indicated.
ENTERING DENOMINATOR DATA Patients must be 18 years old or older before the start of the measurement period. Patients do not already have an active diagnosis of hypertension. ENTERING NUMERATOR DATA Patients who were screened for high blood pressure AND a recommended follow-up plan is documented as indicated if the blood pressure is pre-hypertensive or hypertensive. To report on this measure, you must enter the patient’s blood pressure (both systolic and diastolic values) in the Vitals tab of Full Note Composer or other clinical note type window. Use the system-defined blood pressure fields (Blood Pressure 1, 2, 3, or 4). These observation items for these blood pressure fields are associated with the appropriate LOIN codes. The blood pressure measurement from the most recent visit is used to report on this measure. When that visit contains more than one blood pressure measurement, then the measurement with the lowest systolic and diastolic blood pressure is used.
11
If the patient’s blood pressure is between 120/80 and 140/90, then within one day of the visit, you must either:
Order referral to another provider, or Document a plan to retest the blood pressure within a year and document lifestyle
change recommendations that may include diet, exercise, weight loss, and alcohol consumption.
If the patient’s blood pressure is 140/90 or greater, but has not been high in the year prior to this visit, then within one day of the visit, you must either:
Order referral to another provider, or Document a plan to retest the blood pressure within four weeks and document lifestyle
change recommendations that may include diet, exercise, weight loss, and alcohol consumption.
If the patient’s blood pressure is 140/90 or greater, and has been high in the year prior to this visit, then within one day of the visit, you must either:
Order referral to another provider, or Document a plan to retest the blood pressure within four weeks and document lifestyle
change recommendations that may include diet, exercise, weight loss, and alcohol consumption, and either
• Write a prescription for medication, or • Order a screening or test, such as a comprehensive metabolic panel or an
electrocardiogram. To chart a referral to another provider, you must order the referral by entering a procedure code that is associated with a qualifying SNOMED code. The system-defined Referral Order procedure code is associated with SNOMED code 306253008. You may associate other procedure codes with more specific qualifying SNOMED codes as needed. Enter the procedure code in either the SP or the SO tab of Full Note Composer or other clinical note type window.
SNOMED 134403003, 183516009, 183561008, 183856001, 306206005, 306253008, or 308470006 You may also create the referral from Patient/Provider Tracking. When you create the referral in this way, you must create the referral within one day of the visit date and associate it with the visit. To chart that you plan to retest the blood pressure, you must one or more custom procedure codes and associate them with a qualifying SNOMED code that indicates the timeframe for the follow up test. Enter the procedure in the SP tab of Full Note Composer or other clinical note type window. Please note that simply entering the referral in Referral Tracking or Patient Provider Tracking will not count for this measure. SNOMED CODES FOR RETEST WITHIN 4 WEEKS 183617005, 183618000, 183619008,183620002, 183621003, 183622005, 183623000 SNOMED CODES FOR RETEST WITHIN 1 YEAR
12
61342007, 183617005, 183618000, 183619008, 183620002, 183621003, 183622005, 183623000, 183624006, 183625007, 183626008, 183627004, 183628009, 300042001 For diet, exercise, weight loss, or alcohol consumption recommendations, counseling, or education, you must chart an appropriate procedure. Select the desired procedure code in the SP or SO tab of Full Note Composer or other clinical note type window. If the procedure code is associated with an education form, such as for counseling, then selecting the education form from the Education Form slider will add the procedure code to the SP tab. ALCOHOL SNOMED 24165007, 38670004, 390857005, 408947007, 413473000, 417096006, 419822006, 431260004 DIET HCPCS G8417, S9452, S9470 DIET SNOMED 11816003, 14044002, 31002004, 40546006, 54123004, 61310001, 103699006, 169411000, 182922004, 182954008, 182955009, 182956005, 182960008, 183061003, 183065007, 183070000, 183071001, 226164007, 281085002, 284071006, 284352003, 304491008, 305849009, 306163007, 361231003, 370847001, 386464006, 386619000, 386620006, 410114009, 410171007, 410177006, 410270001, 413315001, 418995006, 424753004, 443288003 EXERCISE HCPCS GS9451 EXERCISE SNOMED 281090004, 304507003, 304549008, 386291006, 386292004, 386373004, 386463000, 410289001 LIFESTYLE SNOMED 313204009, 364706004, 39155009, 415510005, 443402002, 60134006 WEIGHT LOSS HCPCS S9449 WEIGHT LOSS SNOMED 170795002, 266724001, 268523001, 275919002, 401003006, 408289007, 410200000 To use medication as part of the follow-up plan, you must prescribe a qualifying medication as the follow up plan. Write the prescription through the SIG Writer window, and then either print it or submit it electronically. To chart a screening or test, you must enter a procedure code that is associated with a qualifying SNOMED code. You may enter the in either the SP or the SO tab of Full Note Composer or other clinical note type window. CPT 80047, 80048, 80050, 80053, or 80069
13
SNOMED 2278000, 5540006, 8879006, 15373003, 18207002, 20501000, 27171005, 27260001, 28317006, 36793009, 59573005, 60218003, 68994006, 70901006, 71878006, 73668004, 82912006, 88480006, 102811001, 105362001,113075003, 127800008, 164846002, 167181009, 167182002, 167183007, 167222005, 167470001, 251838003, 259295006, 271000000, 271075006, 271236005, 271240001, 290127004, 301119002, 301120008, 304048005, 312468003, 312472004, 313502007, 313936008, 365616005, 365618006, 365756002, 365757006, 365760004, 390963002, 390964008, 420155008, 444164000, 444275009, 444336003 TROUBLESHOOTING This measure looks at both the systolic and diastolic measures. Both the patient’s systolic measure and diastolic measure must be equal to or greater than the criteria to move to the next level. If either measure is less than the criteria, then the patient remains in the lower level group.
14
CMS 50; NQF NA; PQRS 374 CLOSING THE REFERRAL LOOP: RECIEPT OF SPECIALIST REPORT
Measure Type
Benchmark Decile 3
Decile 4
Decile 5 Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 14.29
- 24.13
24.14 -
33.57
33.58 -
43.65
43.66 -
54.33
54.34 -
63.78
63.79 -
74.99
75.00 -
88.63
>= 88.64
No
DOMAIN Care Coordination MEASURE Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred. EXCLUSIONS OR EXCEPTIONS None ENTERING DENOMINATOR DATA The patient must have at least one visit during the measurement period. You must order the referral. This can be done in either of the following ways.
In the visit note, enter a procedure code that is associated with a qualifying SNOMED code.
Create the referral from Patient/Provider Tracking. When you create the referral in this way, you must associate the referral with the visit.
The system-defined Referral Order procedure code is associated with SNOMED code 306253008. You may associate other procedure codes with more specific qualifying SNOMED codes as needed. Enter the procedure code in either the SP or the SO tab of Full Note Composer or other clinical note type window. REFERRAL SNOMED 54395008,103697008,103699006,183515008,183517000,183528001, 183529009, 183530004, 183541002, 183555005, 183557002, 183561008,183567007, 183569005, 183591003, 183878008, 183879000, 183880002, 183881003,183882005, 183884006, 183885007, 183886008, 183887004, 183888009, 183889001,183890005, 183891009, 183892002, 183893007, 183894001, 183895000, 183896004,183897008, 183899006, 183900001, 183901002, 183902009, 83903004, 83904005, 183905006, 183906007, 183907003, 183908008, 183909000, 183910005, 183911009,183913007, 183914001, 183915000, 183916004, 266747000, 274410002, 06160005,306161009, 306162002, 306253008, 306254002, 306255001, 306256000, 306257009,306258004, 306259007, 306260002, 306261003, 306262005, 306263000, 306264006,306265007, 306266008, 306267004, 306268009, 306269001, 306270000, 306271001,306272008, 306273003, 306274009, 306275005, 306276006, 306277002, 306278007, 306279004, 306280001, 306281002, 306282009, 306284005, 306285006, 306286007, 3087003, 306288008, 306289000, 306290009, 306291008,
15
306293006, 306294000, 306295004, 306296003, 306297007, 306298002, 306299005, 306300002, 306301003, 306302005, 306303000, 306304006, 306305007, 306306008, 306307004, 306308009, 306309001, 306310006, 306311005, 306312003, 306313008, 306314002, 306315001, 306316000, 306317009, 306318004, 306320001, 306338003, 306351008, 306352001, 306353006, 306354000, 306355004, 306356003, 306357007, 306358002, 306359005, 306360000, 306361001, 306736002, 307063001, 307777008, 308447003, 308449000, 308450000, 308451001, 308452008, 308453003, 308465004, 308469005, 308470006, 308471005, 308472003, 308473008, 308474002, 308475001, 308476000, 308477009, 308478004, 308479007, 308480005, 308481009, 308482002, 308483007, 308484001, 308485000, 309046007, 309627007, 309629005, 310515004, 312487009, 312488004, 390807002, 406158007, 406159004, 408285001, 415277000, 416116000, 425971006, 429365000, 428441000124100, 428451000124103, 428461000124101, 428471000124108, 428481000124106, 428491000124109, 428541000124104 ENTERING NUMERATOR DATA When you receive the consultation report from the referred to physician or medical service provider, you must attach the consultation report to the referral record using Document Linking. You must use the attachment type Consultation Report when attaching the report to the referral. The Consultation Report attachment type has the SNOMED code 371530004 in the ID field. Please note that referral entries with a status of Historical Reference or of Relationship are not included.
16
CMS 52; NQF 0405; PQRS 160 HIV/AIDS: PNEUMOCYSTIS JIROVECI PNEUMONIA (PCP) PROPHYLAXIS
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process N -- -- -- -- -- -- -- -- --
DOMAIN Clinical Process/Effectiveness MEASURE Percentage of patients aged 6 weeks and older with a diagnosis of HIV/AIDS who were prescribed Pneumocystis jiroveci pneumonia (PCP) prophylaxis. EXCLUSIONS OR EXCEPTIONS
Numerator 1: Patient did not receive PCP prophylaxis because there was a CD4 count above 200 cells/mm3 during the 3 months after a CD4 count below 200 cells/mm3
Numerator 2: Patient did not receive PCP prophylaxis because there was a CD4 count above 500 cells/mm3 or CD4 percentage above 15 percent during the three months after a CD4 count below 500 cells/mm3 or CD4 percentage below 15 percent.
Numerator 3: None ENTERING DENOMINATOR DATA
Denominator 1: All patients aged 6 years and older with a diagnosis of HIV/AIDS and a CD4 count below 200 cells/mm3 who had at least two visits during the measurement year, with at least 90 days in between each visit. The test must be performed less than 9 months after the start of the measurement period.
Denominator 2: All patients aged 1-5 years of age with a diagnosis of HIV/AIDS and a CD4 count below 500 cells/mm3 or a CD4 percentage below 15 percent who had at least two visits during the measurement year, with at least 90 days in between each visit. The test must be performed less than 9 months after the start of the measurement period.
Denominator 3: All patients aged 6 weeks to 12 months with a diagnosis of HIV who had at least two visits during the measurement year, with at least 90 days in between each visit.
To include a patient in the denominator, you must enter a qualifying diagnosis code or a diagnosis code associated with a qualifying SNOMED code in the Dx tab of Full Note Composer or other clinical note type window or enter a problem associated with a qualifying SNOMED code in the problem history category in either the Hx tab of Full Note Composer or the History window.
17
ICD-9 042, V08 ICD-10 B20, Z21 SNOMED 5810003, 40780007, 48794007, 52079000, 62246005, 62479008, 77070006, 79019005, 86406008, 87117006, 91947003, 111880001, 186706006, 186707002, 186708007, 186709004, 186717007, 186718002, 186719005, 186721000, 186723002, 186725009, 186726005, 230180003, 230201009, 230598008, 235009000, 235726002, 240103002, 276666007, 315019000, 359791000, 397763006, 398329009, 402915006, 402916007 To report on this measure, you must order or perform a CD4+Count or CD4+Percentage test, and then either enter the test results or receive them through an interface and give them a status of Resulted or Approved. Test results not received through an interface must be entered as discrete, quantifiable data. Enter the results in the Patients Results window using a lab template enabling you to enter the test result value. Results stored in the database as text notes or image file cannot be used for reporting. You must associate a LOINC code to the CD4+Count or CD4+Percentagetest item on each lab template for both manually entered and electronic results. CD4+COUNT LOINC: 24467-3, 32515-9, 32532-4, 40898-9, 63450-1 CD4+PERCENTAGE LOINC: 17822-8, 32516-7, 32533-2, 40623-1, 43970-3, 51300-2, 8123-2 ENTERING NUMERATOR DATA
Numerator 1: Patients who were prescribed pneumocystis jiroveci pneumonia (PCP) prophylaxis within 3 months of CD4 count below 200 cells/mm3.
Numerator 2: Patients who were prescribed pneumocystic jiroveci pneumonia (PCP) prophylaxis within 3 months of CD4 count below 500 cells/ mm3 or a CD4 percentage below 15%.
Numerator 3: Patients who were prescribed Pneumocystic jiroveci pneumonia (PCP) prophylaxis at the time of diagnosis of HIV.
To report on this measure, you must write a prescription for a Pneumocystic jiroveci pneumonia (PCP) prophylaxis medication through the SIG Writer window and either print it or submit it electronically through the Surescripts pharmacy clearinghouse. The prescription counts for the rendering provider on the visit note, even if another provider enters and submits the prescription. For numerators 1 and 2, you must write the prescription within 3 months of performing the CD4 test that had results qualifying for the numerator. For numerator 3, you must enter the diagnosis of HIV and the prescription in the same visit note.
18
CMS 56; NQF NA; PQRS 376 FUNCTIONAL STATUS ASSESSMENT FOR HIP REPLACEMENT
Measure Type
Benchmark Decile 3 Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 10.34
- 26.08
26.09 -
41.66
41.67 -
47.82
47.83 -
56.50
56.51 -
61.15
61.16 -
64.99
65.00 -
72.72
>= 72.73 No
DOMAIN Patient and Family Engagement MEASURE Percentage of patients aged 18 years and older with primary total hip arthroplasty (THA) who completed baseline and follow-up (patient-reported) functional status assessments EXCLUSIONS OR EXCEPTIONS Patients with multiple trauma at the time of the total hip arthroplasty or patients with severe cognitive impairment. ENTERING DENOMINATOR DATA Adults aged 18 and older with a primary total hip arthroplasty (THA) and who had an outpatient encounter not more than 180 days prior to procedure, and at least 60 days and not more than 180 days after THA procedure. You must enter a qualifying procedure code or a procedure code associated with a qualifying SNOMED code for the hip replacement in the surgical history category in the Hx tab of Full Note Composer or the Patient History window. HCPCS S2118 CPT 27130 SNOMED 15163009, 19954002,33788003, 52734007, 53081006, 55423004, 57589001, 76915002, 179294005, 179304004, 179305003, 265157000, 265160007, 314489006, 314491003, 425443008, 426618001, 426904006, 427728006, 429156003, 443435007 Please note that the system- defined hip surgery question in the surgical history does not count for this measure. This is because that entry may be for any hip surgery; it is not specifically total hip arthroplasty.
19
ENTERING NUMERATOR DATA Patients with patient reported functional status assessment results (e.g., VR- 12, VR-36, PROMIS-10- Global Health, PROMIS-29, HOOS) not more than 180 days prior to the primary THA procedure, and at least 60 days and not more than 180 days after the THA procedure. To report on this measure, you must have set up an observation item for the score of each assessment that you use, and put these observation items in an observation template. The observation item for each assessment’s score must include the appropriate LOINC code for the functional status assessment. You must also have a clinical note type defined to include the Observation tab so that you can use the observation template to chart the assessment. None of the system-defined clinical note type windows (such as Full Note Composer) include the Observation tab. So, you must use a custom clinical note type window to chart patient visit notes that will include a functional status assessment. Enter the score of the functional status assessment in the observation template on the Observation tab. Please note that entries in the Cognitive and Functional Assessment history categories do not count for this measure. ACTIVITIES OF DAILY LIVING LOINC CODE 72095-3 HOOS LOINC CODES 72094-6, 72095-3, 72096-1 PROMIS-10 LOINC CODES 71969-0, 71970-8, 71971-6, 71972-4 PROMIS-29 LOINC CODES 71955-9, 71956-7, 71957-5, 71958-3, 71959-1, 71960-9, 71961-7, 71962-5, 71963-3, 71964-1, 71965-8, 71966-6, 71967-4, 71968-2,71970-8 VR12 LOINC CODES 72009-4, 72010-2, 72011-0, 72012-8, 72013-6, 72014-4, 72015-1, 72016-9, 72017-7, 72018-5, 72019-3, 72020-1, 72021-9, 72022-7, 72023-5, 72024-3, 72025-0, 72026-8, 72027-6, 72028-4 VR-36 LOINC CODES 71973-2, 71974-0, 71975-7, 71976-5, 71977-3, 71978-1, 71979-9, 71980-7, 71981-5, 71982-3, 719831, 71984-9, 71985-6, 71986-4, 71987-2, 71988-0, 71989-8, 71990-6, 71991-4, 71992-2, 71993-0, 719948, 71995-5, 71996-3, 71997-1, 71998-9, 71999-7, 72000-3, 72001-1, 72002-9, 72003-7, 72004-5, 720052, 72006-0, 72007-8, 72008-6
20
CMS 62; NQF 0403, PQRS 368 HIV/AIDS: MEDICAL VISIT
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6 Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 28.74
- 39.12
39.13 -
46.96
46.97 -
52.34
52.35 -
58.55
58.56 -
64.70
64.71 -
71.17
71.18 -
78.37
>= 78.38 No
DOMAIN Clinical Process/Effectiveness MEASURE Percentage of patients, regardless of age, with a diagnosis of HIV/AIDS with at least two medical visits during the measurement year with a minimum of 90 days between each visit. EXCLUSIONS OR EXCEPTIONS None ENTERING DENOMINATOR DATA All patients, regardless of age, with a diagnosis of HIV/AIDS seen within a 12-month period. To include a patient in the denominator, you must enter a qualifying diagnosis code or a diagnosis code associated with a qualifying SNOMED code in the Dx tab of Full Note Composer or other clinical note type window or enter a problem associated with a qualifying SNOMED code in the problem history category in either the Hx tab of Full Note Composer or the History window. ICD-9 042, V08 ICD-10 B20, Z21 SNOMED 5810003, 5810003, 40780007, 48794007, 52079000, 62246005, 62479008, 77070006, 79019005, 86406008, 87117006, 91947003, 111880001, 186706006, 186707002, 186708007, 186709004, 397763006, 398329009, 402915006, 402916007 ENTERING NUMERATOR DATA Patients with at least two medical visits during the measurement year with a minimum of 90 days between visits.
21
CMS 66; NQF NA; PQRS 375 FUNCTIONAL STATUS ASSESSMENT FOR KNEE REPLACEMENT
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 5.08
- 14.80
14.81 -
25.76
25.77 -
36.51
36.52 -
44.73
44.74 -
51.27
51.28 -
60.55
60.56 -
79.99
>= 80.00 No
DOMAIN Patient and Family Engagement MEASURE Percentage of patients aged 18 years and older with primary total knee arthroplasty (TKA) who completed baseline and follow-up (patient-reported) functional status assessments. EXCLUSIONS OR EXCEPTIONS Patients with multiple traumas at the time of the total knee arthroplasty or patients with severe cognitive impairment. ENTERING DENOMINATOR DATA Adults, aged 18 and older, with a primary total knee arthroplasty (TKA) and who had an outpatient encounter not more than 180 days prior to procedure, and at least 60 days and not more than 180 days after TKA procedure. You must enter a qualifying procedure code or a procedure code associated with a qualifying SNOMED code for the knee replacement in the surgical history category in the Hx tab of Full Note Composer or the Patient History window. CPT 27447 SNOMED 179344006, 179345007, 179351002, 179352009, 265170009, 265172001, 392237008, 430698003, 443681002, 443682009 ENTERING NUMERATOR DATA Patients with patient reported functional status assessment results (e.g., VR- 12, VR-36, PROMIS-10 Global Health, PROMIS-29, KOOS) not more than 180 days prior to the primary TKA procedure, and at least 60 days and not more than 180 days after the TKA procedure. To report on this measure, you must have set up an observation item for the score of each assessment that you use, and put these observation items in an observation template. The observation item for each assessment’s score must include the appropriate LOINC code for the functional status assessment.
22
You must also have a clinical note type defined to include the Observation tab so that you can use the observation template to chart the assessment. None of the system-defined clinical note type windows (such as Full Note Composer) include the Observation tab. So, you must use a custom clinical note type window to chart patient visit notes that will include a functional status assessment. Enter the score of the functional status assessment in the observation template on the Observation tab. Please note that entries in the Cognitive and Functional Assessment history categories do not count for this measure. ACTIVITIES OF DAILY LIVING LOINC CODE 72100-1 KOOS LOINC CODES 72102-7, 72099-5, 72101-9 PROMIS-10 LOINC CODES 71969-0, 71970-8, 71971-6, 71972-4 PROMIS-29 LOINC CODES 71955-9, 71956-7, 71957-5, 71958-3, 71959-1, 71960-9, 71961-7, 71962-5, 71963-3, 71964-1, 71965-8, 71966-6, 71967-4, 71968-2, 71970-8 VR12 LOINC CODES 72009-4, 72010-2, 72011-0, 72012-8, 72013-6, 72014-4, 72015-1, 72016-9, 72017-7, 72018-5, 72019-3, 72020-1, 72021-9, 72022-7, 72023-5, 72024-3, 72025-0, 72026-8, 72027-6, 72028-4 VR-36 LOINC CODES 71973-2, 71974-0, 71975-7, 71976-5, 71977-3, 71978-1, 71979-9, 71980-7, 71981-5, 71982-3, 719831, 71984-9, 71985-6, 71986-4, 71987-2, 71988-0, 71989-8, 71990-6, 71991-4, 71992-2, 71993-0, 719948, 71995-5, 71996-3, 71997-1, 71998-9, 71999-7, 72000-3, 72001-1, 72002-9, 72003-7, 72004-5, 72005-2, 72006-0, 72007
23
CMS 68; NQF 0419; PQRS 130 DOCUMENTATION OF CURRENT MEDICATION IN THE MEDICAL RECORD
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 86.25
- 91.91
91.92 –
94.85
94.86 –
96.69
96.70 -
97.98
97.99 -
98.87
98.88 -
99.54
99.55 -
99.95
>= 99.96 Yes
DOMAIN Patient Safety MEASURE Percentage of specified visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications to the best of his/her knowledge and ability. This list must include ALL prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency, and route of administration. EXCLUSIONS OR EXCEPTIONS None ENTERING DENOMINATOR DATA The patient must be 18 years old or older at the beginning before the start of the measurement period. ENTERING NUMERATOR DATA To report on this measure, you must either:
Select the checkbox for the Medication History category in the Hx tab of Full Note Composer or other clinical note type to indicate that you have reviewed the medication list, or
Create a custom defined procedure code for documenting a list of the patient’s current medications. This procedure code must be associated to SNOMED code 428191000124101. You must then include this custom procedure code in visit notes for all patient visits during which you document a list of current medications. You may want to include your custom-defined procedure code in your SP charge ticket so that it is easy to select when charting visit notes.
24
CMS 69; NQF 0421; PQRS 128 PREVENTIVE CARE AND SCREENING: BODY MASS INDEX (BMI) SCREENING AND FOLLOW-UP
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 28.22
- 31.92
31.93 -
35.34
35.35 -
38.76
38.77 -
42.88
42.89 -
49.18
49.19 -
64.83
64.84 -
85.93
>= 85.94 No
DOMAIN Population/Public Health MEASURE Percentage of patients aged 18 years and older with an encounter during the reporting period with a documented calculated BMI during the encounter or during the previous six months, AND when the BMI is outside of normal parameters, follow-up is documented during the encounter or during the previous six months of the encounter with the BMI outside of normal parameters. Normal parameters for patients age 65 years and older is a BMI between ≥23 and <30. Normal parameters for patients age 18 years to 64 years is a BMI between ≥18.5 and <25.
Denominator 1: All patients aged 65 years and older Numerator 1: Patients with BMI calculated within the past six months or during the
current visit and a follow-up plan documented if the BMI is outside of parameters. • Numerator Inclusions: Population Stratification 1: (BMI < 30 kg/m2 and 23 kg/m2)
Denominator 2: All patients aged 18 through 64 years. • Denominator Inclusions: Population Stratification 2: (Patients aged 18-64)
Numerator 2: Patients with BMI calculated within the past six months or during the current visit and a follow-up plan documented if the BMI is outside of parameters. • Numerator Inclusions: Population Stratification 2: (BMI < 25 kg/m2 and 18.5 kg/m2)
EXCLUSIONS OR EXCEPTIONS Patients who are pregnant. ENTERING DENOMINATOR DATA For denominator 1, the patient must be 65 years of age or older before the beginning of the measurement period. The patient must have at least one eligible encounter during the measurement period. For denominator 2, the patient must be between 18 and 64 years old before the beginning of the measurement period. For both denominators, the patient must have at least one eligible encounter during the measurement period. Eligible encounters do not include encounters where the patient is receiving palliative care, refuses BMI measurement, the patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the
25
patient’s health status, or there is any other reason documented in the medical record by the provider explaining why BMI measurement was not appropriate. ENTERING NUMERATOR DATA To report on this measure, you must enter the patient’s height and weight in the Vitals tab of the patient visit note window. The BMI is calculated automatically from the height and weight entries, and then displayed on the Vitals tab and charted in the visit note. The application determines the appropriate LOINC code to associate with the BMI based on the patient’s age. If there is a medical reason for not calculating the BMI, then you must enter one of the following HCPCS procedure codes and enter an appropriate negation reason on that procedure. HCPCS FOR BMI G8938, G8421, G8417, G8418, G8419, G8420, G8422, G8938 If the BMI is out of the established normal range, then you must establish a follow up plan, which may include medication, procedures, counseling, or a referral to another qualifying medical services provider. To document the follow-up plan using a procedure, counseling, or referral, use a procedure code that is associated with a qualifying SNOMED code. You may enter the procedure code in either the SP or the SO tab of Full Note Composer or other clinical note type window. If you are using an ICD-9 procedure code, enter it on the Dx tab of Full Note Composer or other clinical note type window. If the procedure code you want has been associated with an education form, such as for counseling, then selecting the education form from the Education Form slider will add the procedure code to the SP tab. The education form assigned to the patient must be associated with a patient communication type of Overweight or Underweight. Please note that since only one patient communication type can be associated with an education form, you must have separate forms for these conditions. If you use an education form on a general topic, such as nutrition, for both underweight and overweight, then you must have two copies of education form in your database. Above Normal Follow Up CPT 43644, 43645, 43770, 43771, 43772, 43773, 43774, 43842, 43843, 43845, 43846, 43847, 43848, 97804, 98960, 99078 HCPCS G8417, S9449, S9451, S9452, S9470 ICD-9 V65.3, V65.41 SNOMED
26
304549008, 307818003, 361231003, 370847001, 386291006, 386292004, 386373004, 386463000, 386464006, 401003006, 410177006, 413315001, 418995006, 424753004, 443288003 Above Normal Referral SNOMED 103698003, 103699006, 183515008, 183524004, 183583007, 185359002, 305922005, 306136006, 306163007, 306164001, 306165000, 306166004, 306167008, 306168003, 306226009, 306227000, 306252003, 306344004, 306353006, 306354000, 308459004, 308470006, 308477009, 390864007, 390866009, 390893007, 408289007, 410160006, 416790000, 424203006, 91251008 Below Normal Follow Up HCPCS G8418, S9449, S9452, S9470 ICD-9 V65.3 SNOMED 386464006, 404923009, 410177006, 413315001, 418995006, 424753004, 429095004, 443288003 Below Normal Referral SNOMED 91251008, 103698003, 103699006, 183515008, 183524004, 183583007, 185359002, 305922005, 306136006, 306163007, 306164001, 306165000, 306166004, 306167008, 306168003, 306226009, 306227000, 306252003, 306344004, 306353006, 306354000, 308459004, 308470006, 308477009, 390866009, 390893007, 408289007, 410160006, 416790000, 424203006 To document the follow-up plan using a medication, write a prescription for an appropriate medication using the SIG Writer window. Then print or electronically submit the prescription.
27
CMS 74; NQF NA; PQRS 379 PRIMARY CARIES PREVENTION INTERVENTION AS OFFERED BY PRIMARY CARE PROVIDERS, INCLUDING DENTISTS
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 0.36
- 0.54
0.55 -
0.78
0.79 -
1.11
1.12 –
2.03
2.04 -
4.40
4.41 -
5.09
5.10 -
7.36
>= 7.37 No
DOMAIN Clinical Process/Effectiveness MEASURE Percentage of children, age 0-20 years, who received a fluoride varnish application during the measurement period. EXCLUSIONS OR EXCEPTIONS None ENTERING DENOMINATOR DATA Children, age 0-20 years, with a visit during the measurement period. ENTERING NUMERATOR DATA Children who receive a fluoride varnish application. To report on this measure, you must enter a qualifying procedure code or a procedure code associated with a qualifying SNOMED code for a fluoride varnish application. HCPCS D1203, D1206 SNOMED 35889000, 70468009, 234723000, 313042009
28
CMS 75; NQF NA; PQRS 378 CHILDREN WHO HAVE DENTAL DECAY OR CAVITIES
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Outcome Y -- -- -- -- -- -- -- 0 Yes
DOMAIN Clinical Process/Effectiveness MEASURE Percentage of children, age 0 through 20 years, who have had tooth decay or cavities during the measurement period. EXCLUSIONS OR EXCEPTIONS None ENTERING DENOMINATOR DATA The patient must be 0 through 20 years old, and must have at least one visit during the measurement period. ENTERING NUMERATOR DATA To report on this measure, you must enter the diagnosis code in the Dx tab of Full Note Composer or other clinical note type window. ICD-9 CODES 521.00, 521.01, 521.02, 521.03, 521.04, 521.05, 521.06, 521.07, 521.08, 521.09 ICD-10 K02.3, K02.51, K02.52, K02.53, K02.61, K02.62, K02.63, K02.7, K02.9
29
CMS 77; NQF NA; PQRS 381 HIV/AIDS: RNA CONTROL OF PATIENTS WITH HIV
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Outcome Y 23.63
- 34.99
35.00 -
44.43
44.44 -
52.62
52.63 -
86.51
86.52 -
91.99
92.00 -
93.32
93.33 -
96.42
>= 96.43 No
DOMAIN Clinical Process/Effectiveness MEASURE Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS, with at least two visits during the measurement year, with at least 90 days between each visit, whose most recent HIV RNA level is <200 copies/mL. EXCLUSIONS OR EXCEPTIONS None ENTERING DENOMINATOR DATA All patients aged 13 years and older with a diagnosis of HIV/AIDS with at least two visits during the measurement year. To include a patient in the denominator, you must enter a qualifying diagnosis code or a diagnosis code associated with a qualifying SNOMED code in the Dx tab of Full Note Composer or other clinical note type window or enter a problem associated with a qualifying SNOMED code in the problem history category in either the Hx tab of Full Note Composer or the History window. ICD-9 042, V08 ICD-10 B20, Z21 SNOMED 5810003, 40780007, 48794007, 52079000, 62246005, 62479008, 77070006, 79019005, 86406008, 87117006, 91947003, 111880001, 186706006, 186707002, 186708007, 186709004, 186717007, 186718002, 186719005, 186721000, 186723002, 186725009, 186726005, 230180003, 230201009, 230598008, 235009000, 235726002, 240103002, 276666007, 315019000, 359791000, 397763006, 398329009, 402915006, 402916007 ENTERING NUMERATOR DATA Patients whose most recent HIV RNA level is <200 copies/mL.
30
To report on this measure, you must order or perform an HIV RNA test, and then either enter the test results or receive them through an interface and give them a status of Resulted or Approved. Test results not received through an interface must be entered as discrete, quantifiable data. Enter the results in the Patients Results window using a lab template enabling you to enter the test result value. Results stored in the database as text notes or image file cannot be used for reporting. You must associate a LOINC code to the HIV RNA test item on each lab template for both manually entered and electronic results. LOINC CODES 20447-9, 21333-0, 23876-6, 41515-8, 48511-0, 59419-2, 70241-5
31
CMS 82; NQF 1401; PQRS 372 MATERNAL DEPRESSION SCREENING
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process N -- -- -- -- -- -- -- -- No
DOMAIN Population/Public Health MEASURE The percentage of children who turned 6 months of age during the measurement year, who had a face-to-face visit between the clinician and the child during child’s first 6 months, and who had a maternal depression screening for the mother at least once between 0 and 6 months of life. EXCLUSIONS OR EXCEPTIONS None ENTERING DENOMINATOR DATA Children with a visit who turned 6 months of age in the measurement period. ENTERING NUMERATOR DATA Children with documentation of maternal screening or treatment for postpartum depression for the mother. Enter the mother’s screening using a procedure code associated with the SNOMED code 428221000124108 in the SP tab of Full Note Composer or other clinical note type. Enter the mother’s treatment using a procedure code associated with the SNOMED code 428231000124106 in the SP tab of Full Note Composer or other clinical note type. If you use the same procedure when screening or treating patients, then you may need to associate the procedure with two different SNOMED codes, one that indicates patient screening or treatment and one that indicates maternal screening or treatment. Or you can create custom procedure codes for the maternal screening and treatment, and associate those custom procedure codes with the appropriate SNOMED codes.
32
CMS 90; NQF NA; PQRS 377 FUNCTIONAL STATUS ASSESSMENT FOR COMPLEX CHRONIC CONDITIONS
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process N -- -- -- -- -- -- -- -- --
DOMAIN Patient and Family Engagement MEASURE Percentage of patients aged 65 years and older with heart failure who completed initial and follow-up patient-reported functional status assessments. EXCLUSIONS OR EXCEPTIONS Patients with severe cognitive impairment or patients with an active diagnosis of cancer. ENTERING DENOMINATOR DATA The patient must be 65 years old or older. The patient must have an active diagnosis of heart failure. ICD-9 402.01, 402.11, 402.91, 404.01, 404.03, 404.11, 404.13, 404.91, 404.93, 428.0, 428.1, 428.20, 428.21,428.22, 428.23, 428.30, 428.31, 428.32, 428.33, 428.40, 428.41, 428.42, 428.43, 428.9 ICD-10 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 SNOMED 364006, 5053004, 5148006, 5375005, 10091002, 10335000, 10633002, 25544003, 42343007, 43736008, 44313006, 46113002, 48447003, 56675007, 60856006, 66989003, 74960003, 77737007, 80479009, 82523003, 83105008, 84114007, 85232009, 88805009, 90727007, 92506005,111283005, 128404006, 194767001, 194779001, 194781004, 195111005, 195112003, 195114002, 206586007, 233924009, 277639002, 314206003, 359617009, 359620001, 367363000, 410431009, 417996009, 418304008, 424404003, 426012001, 426263006, 426611007, 441481004, 441530006 This measure requires at least two patient visits. The first visit must be within the first 185 days of the measurement period (January 1 through July 4). The second visit must be within the assessment period, and must be at least 30 days after and not more than 180 days after the first visit. The assessment must be done during or within two weeks prior to each of these two visits. Because of the timing constraints on the first and second visit, this measure is not optimal if your reporting period is 90 days.
33
ENTERING NUMERATOR DATA To report on this measure, you must have set up an observation item for the score of each assessment that you use, and put these observation items in an observation template. The observation item for each assessment’s score must include the appropriate LOINC code for the functional status assessment. LOINC CODES 71938-5, 71940-1, 71955-9, 71956-7, 71957-5, 71958-3, 71959-1, 71960-9, 71961-7, 71962-5, 71963-3, 71964-1, 71965-8, 71966-6, 71967-4, 71968-2, 71969-0, 71970-8, 71971-6, 71972-4, 71973-2, 71974-0, 71975-7, 71976-5, 71977-3, 71978-1, 71979-9, 71980-7, 71981-5, 71982-3, 71983-1, 71984-9, 71985-6, 71986-4, 71987-2, 71988-0, 71989-8, 71990-6, 71991-4, 71992-2, 71993-0, 71994-8, 71995-5, 71996-3, 71997-1, 71998-9, 71999-7, 72000-3, 72001-1, 72002-9, 72003-7, 72004-5, 72005-2, 72006-0, 72007-8, 72008-6, 72009-4, 72010-2, 72011-0, 72012-8, 72013-6, 72014-4, 72015-1, 72016-9, 72017-7, 72018-5, 72019-3, 72020-1, 72021-9, 72022-7, 72023-5, 72024-3, 72025-0, 72026-8, 72027-6, 72028-4, 72188-6, 72189-4, 72190-2, 72191-0, 72192-8, 72193-6, 72194-4, 72195-1, 72196-9 You must also have a clinical note type defined to include the Observation tab so that you can use the observation template to chart the assessment. None of the system-defined clinical note type windows (such as Full Note Composer) include the Observation tab. So, you must use a custom clinical note type window to chart patient visit notes that will include a functional status assessment for a complex chronic condition. Enter the score of the functional status assessment in the observation template on the Observation tab. Please note that entries in the Cognitive and Functional Assessment history categories do not count for this measure.
34
CMS 117; NQF 0038; PQRS 240 CHILDHOOD IMMUNIZATION STATUS
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 4.35
- 8.84
8.85 -
11.95
11.96 -
16.16
16.17 -
23.80
23.81 -
31.25
31.26 -
38.79
38.80 -
50.87
>= 50.88 No
DOMAIN Population/Public Health MEASURE Percentage of children two years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday.
Denominator: All patients who turn two years of age during the measurement period. Numerator: Patients who received four diphtheria, tetanus and acellular pertussis
(DTaP); three polio (IPV); one measles, mumps, rubella (MMR); three H influenza type B (HIB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); two hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday.
EXCLUSIONS OR EXCEPTIONS None ENTERING DENOMINATOR DATA The patient must turn two years old during the measurement period. The patient must have at least one visit during the measurement period. ENTERING NUMERATOR DATA To report on this measure, document the administration of the each of the required vaccines. To document an immunization, enter the appropriate CPT code for that immunization and enter the vaccination details in the Vaccine Administration Record. This can be done in the patient visit note or in the Patient History, Immunization History category. The vaccine type for the vaccination must be associated with the appropriate CVX code. All vaccinations must be given according to the recommended schedule for the vaccine. The first DTaP, HIB, IPV, PCV vaccinations must be given when the patient is 42 days old or older. Vaccinations administered prior to 42 days are not counted. Patient refusal is not considered valid reporting for this measure and will be in denominator.
35
CMS 122; NQF 0059; PQRS 1 DIABETES: HEMOGLOBIN A1C POOR CONTROL
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Outcome Y 83.10
- 67.96
67.95 -
54.09
54.08 -
43.22
43.21 -
34.12
34.11 -
27.28
27.27 -
21.75
21.74 -
15.74
<= 15.73 No
DOMAIN Clinical Processes and Effectiveness MEASURE Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period. EXCLUSIONS OR EXCEPTIONS Patients with a diagnosis of gestational diabetes during the measurement period. ENTERING DENOMINATOR DATA Patients 18-75 years of age with diabetes with a visit during the measurement period. Enter the diabetes diagnosis with a qualifying diagnosis code or diagnosis code associated with a SNOMED code in the Dx tab of Full Note Composer or other clinical note type window or enter a problem associated with a qualifying SNOMED code in the problem history category in the Hx tab of Full Note Composer or the Patient History window. ICD-9 250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91, 250.92, 250.93, 648.01, 648.02, 648.03, 648.04 ICD-10 E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, E10.319, E10.321, E10.329, E10.331, E10.339, E10.341, E10.349, E10.351, E10.359, E10.36, 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, E11.321, E11.329, E11.331, E11.339, E11.341, E11.349, E11.351, E11.359, E11.36, 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, O24.011, O24.012, O24.013, O24.019, O24.02, O24.03, O24.111, O24.112, O24.113, O24.119, O24.12, O24.13 SNOMED 4783006, 9859006, 23045005, 28032008, 44054006, 46635009, 75682002, 76751001, 81531005, 190330002, 190331003, 190368000, 190369008, 190372001, 190389009, 190390000, 199223000, 199225007, 199226008, 199227004, 199228009, 199229001, 199230006, 237599002, 237618001, 237626009, 237627000, 313435000, 313436004,
36
314771006, 314772004, 314893005, 314894004, 314902007, 314903002, 314904008, 359642000, 359939009 ENTERING NUMERATOR DATA Patients whose most recent HbA1c level (performed during the measurement period) is >9.0%. Patients who do not have an HbA1c level entered during the measurement period are also included in the numerator. Please note that for this measure, a low numerator is the desired outcome. To report on this measure, you must order or perform an A1c test and then either enter the test results or receive them through an interface. You must associate the results with the order, and give them a status of Resulted or Approved. The A1c test results must be entered as discrete, quantifiable data. Enter the results in the Patients Results window using a lab template enabling you to enter the HGB A1c value. Results stored in the database as text notes or an image file cannot be used for reporting. You must associate a LOINC code to the A1C test item on each lab template for both manually entered and electronic results. LOINC codes for this result are 17855-8, 17856-6, 4548-4. 314771006, 314772004, 314893005, 314894004, 314902007, 314903002, 314904008, 359642000, 359939009 ENTERING NUMERATOR DATA Patients who received a foot exam during the measurement period. The foot exam must include a visual inspection and either a sensory exam or a pulse exam. To report on this measure, you must order or perform a visual foot exam, a sensory exam, and a pulse exam. You may chart the exams using procedure codes that are associated with the SNOMED codes for the exams. PULSE EXAM 91161007 SENSORY EXAM 134388005 VISUAL EXAM 401191002 The procedure codes 2028-F and G9226 are associated with the proper SNOMED codes, and configured to report as a complete foot exam (visual, sensory, and pulse).
37
CMS 124; NQF 0032; PQRS 309 CERVICAL CANCER SCREENING
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 8.82
- 14.57
14.58 -
20.88
20.89 -
28.29
28.30 -
37.64
37.65 -
47.75
47.76 -
58.15
58.16 -
71.63
>= 71.64 No
DOMAIN Clinical Processes and Effectiveness MEASURE Percentage of women 21-64 years of age, who received one or more Pap tests to screen for cervical cancer. EXCLUSIONS OR EXCEPTIONS Women who had a hysterectomy with no residual cervix. ENTERING DENOMINATOR DATA Women 24-64 years of age with a visit during the measurement period. ENTERING NUMERATOR DATA Women with one or more Pap tests during the measurement period or the two years prior to the measurement period. To report on this measure, you must order or perform a Pap test, and then either enter the test results or receive them through an interface and give them a status of Resulted or Approved. To chart the Pap test, to chart the screening, you must enter a procedure code that is associated with a qualifying LOINC code. You may enter the procedure in either the SP or the SO tab of Full Note Composer or other clinical note type window. Pap test results not received through an interface must be entered as discrete, quantifiable data. Enter the results in the Patients Results window using a lab template enabling you to enter the test result value. Results stored in the database as text notes or image file cannot be used for reporting. You must associate a LOINC code to the Chlamydia test item on each lab template for both manually entered and electronic results. LOINC CODES 10524-7, 18500-9, 19762-4, 19764-0, 19765-7, 19766-5, 19774-9, 33717-0, 47527-7, 47528-5
38
CMS 125; NQF NA; PQRS 112 BREAST CANCER SCREENING
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 19.19
- 31.97
31.98 -
40.58
40.59 -
48.40
48.41 -
55.73
55.74 -
63.12
63.13 -
70.05
70.06 -
78.94
>= 78.95 No
DOMAIN Clinical Processes and Effectiveness MEASURE Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer. EXCLUSIONS OR EXCEPTIONS Women who had a bilateral mastectomy or for whom there is evidence of two unilateral mastectomies. ENTERING DENOMINATOR DATA Women 50-74 years of age with a visit during the measurement period. ENTERING NUMERATOR DATA Women with one or more mammograms during the measurement period or the year prior to the measurement period. To report on this measure, you must order or perform the mammography and enter the result. The mammography may be ordered or performed within 12 months prior to the start of the measurement period or during the measurement period. To document the test and its results, order the mammography test using one of the HCPCS codes below. Then enter and approve the mammography results in the Patient Results window, and give them a status of Resulted or Approved. HCPCS CODES G0202, G0204, G0206 LOINC CODES 24604-1, 24605-8, 24606-6, 24610-8, 26175-0, 26176-8, 26177-6, 26287-3, 26289-9, 26291-5, 263467, 26347-5, 26348-3, 26349-1, 26350-9, 26351-7, 36319-2, 36625-2, 36626-0, 36627-8, 36642-7,36962-9, 37005-6, 37006-4, 37016-3, 37017-1, 37028-8, 37029-6, 37030-4, 37037-9, 37038-7, 37052-8, 37053-6, 37539-4, 37542-8, 37543-6, 37551-9, 37552-7, 37553-5, 37554-3, 37768-9, 37769-7,37770-5, 37771-3, 37772-1, 37773-9, 37774-7, 37775-4, 38067-5, 38070-9, 38071-7, 38072-5, 380907, 38091-5, 38807-4, 38820-7, 38854-6, 38855-3, 39150-8, 39152-4, 39153-2, 39154-0, 42168-5,42169-3, 42174-3, 42415-0, 42416-8, 46335-6, 46336-4, 46337-2, 46338-0, 46339-8, 46342-2, 46350-5, 46351-3, 46354-7, 46355-4, 46356-2, 46380-2, 48475-8, 48492-3, 69150-1, 69251-7, 69259-0
39
CMS 126; NQF 0036; PQRS 311 USE OF APPROPRIATE MEDICATION FOR ASTHMA
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 26.92
- 40.15
40.16 -
57.13
57.14 -
67.85
67.86 -
77.87
77.88 -
83.86
83.87 -
89.05
89.06 -
92.60
>= 92.61 No
DOMAIN Clinical Processes and Effectiveness MEASURE Percentage of patients five through 64 years of age who were identified as having persistent asthma and were appropriately prescribed medication during the measurement period. EXCLUSIONS OR EXCEPTIONS Patients with emphysema, COPD, cystic fibrosis or acute respiratory failure during or prior to the measurement period. ENTERING DENOMINATOR DATA The patient must be between 5 and 64 years old. The patient must have at least one visit during the measurement period. You must identify patients with asthma with an appropriate ICD-10 code or with a SNOMED code associated with an ICD-9 code. The active diagnosis may be entered in the Problem/Diagnosis category in the Patient History window or in Dx tab of Full Note Composer. ICD-10 CODES J45.30, J45.31, J45.32, J45.40, J45.41, J45.42, J45.50, J45.51, J45.52 SNOMED CODES 426656000, 426979002, 427295004 ENTERING NUMERATOR DATA To report on this measure, you must prescribe an asthma medication. To report the asthma medication, write the prescription through the SIG Writer window or prescription refill message and print the prescription or send it electronically. TROUBLESHOOTING The diagnosis for persistent asthma cannot be made inactive or resolved prior to the start of the measurement period.
40
CMS 127; NQF 0043; PQRS 111 PNEUMONIA VACCINATION STATUS FOR OLDER ADULTS
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 15.40
- 25.61
25.62 -
37.30
37.31 -
47.48
47.49 -
56.46
56.47 -
65.52
65.53 -
75.08
75.09 -
85.70
>= 85.71 No
DOMAIN Clinical Processes and Effectiveness MEASURE Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine. EXCLUSIONS OR EXCEPTIONS None ENTERING DENOMINATOR DATA Patients 65 years of age and older with a visit during the measurement period. Please note that the E&M codes 99211 and 99243 do not count for this measure. ENTERING NUMERATOR DATA Patients who have ever received a pneumococcal vaccination. To report on this measure, you must document the administration of the pneumonia vaccine or document it in the patient’s history. The vaccination may have been given at any time prior to or during the measurement period. To document the pneumonia immunization, enter the administration using a procedure code associated to an appropriate SNOMED code. Enter the procedure in the SP tab of Full Note Composer or other clinical note type window. Then document the vaccination details in the vaccine administration record. Enter the vaccination in the vaccination history category in the Hx tab of Full Note Composer or in the Patient History window. Then, identify the type of vaccine when documenting the vaccine details in the vaccine administration record. CVX: 33 SNOMED FOR ADMINISTERING THE VACCINATION 12866006, 394678003
41
CMS 128; PQRS 0105; PQRS 9 ANTI-DEPRESSANT MEDICATION MANAGEMENT
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 54.90
- 69.89
69.90 -
80.35
80.36 -
85.86
85.87 -
88.56
88.57 -
90.71
90.72 -
92.96
92.97 -
96.53
>= 96.54 No
*This measure requires a reporting period that is greater than six months. You cannot use this measure if your reporting period is six months or less. DOMAIN Clinical Processes and Effectiveness MEASURE Percentage of patients 18 years of age and older who were diagnosed with major depression and treated with antidepressant medication, and who remained on antidepressant medication treatment.
Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks).
Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months).
EXCLUSIONS OR EXCEPTIONS Patients who were actively on an antidepressant medication in the 90 days prior to the Index Prescription Start Date. (for the eCQM Specifications collection type to allow medical reasons for not obtaining the BMI.) ENTERING DENOMINATOR DATA Patients 18 years of age and older with a diagnosis of major depression in the 180 days (6 months) prior to the measurement period or the first 180 days (6 months) of the measurement period, who were treated with antidepressant medication, and with a visit during the measurement period. Enter the diagnosis with a qualifying diagnosis code or diagnosis code associated with a SNOMED code in the Dx tab of Full Note Composer or other clinical note type window or with a problem associated with a qualifying SNOMED code in the problem history category in the Hx tab of Full Note Composer or the Patient History window. ICD-9 296.20, 296.21, 296.22, 296.23, 296.24, 296.25, 296.30, 296.31, 296.32, 296.33, 296.34, 296.35, 298.0, 300.4, 309.1, 311 ICD-10 F32.0, F32.1, F32.2, F32.3, F32.4, F32.9, F33.0, F33.1, F33.2, F33.3, F33.40, F33.41, F33.8, F33.9, F34.1
42
SNOMED 832007, 2506003, 2618002, 3109008, 14183003, 15193003, 15639000, 18818009, 19694002, 20250007, 25922000, 28475009, 30605009, 33078009, 33135002, 33736005, 36170009, 36474008, 36923009, 38451003, 38694004, 39809009, 40379007, 42810003, 42925002, 60099002, 63778009, 66344007, 67711008, 68019004, 69392006, 70747007, 71336009, 73867007, 75084000, 76441001, 77911002, 78667006, 79298009, 83176005, 83458005, 84788008, 85080004, 87414006, 87512008, 191601008, 191602001, 191604000, 191610000, 191611001, 191613003, 191676002, 192049004, 231499006, 231504006, 268620009, 268621008, 274948002, 300706003, 319768000, 320751009, 321717001, 370143000, 430852001, A prescription for a qualifying antidepressant medication must have been written within 30 days prior to and 14 days after the visit in which depression was diagnosed. Write the prescription through the SIG Writer window or prescription refill message and print the prescription or send it electronically. ENTERING NUMERATOR DATA
Numerator 1: Patients who have received antidepressant medication for at least 84 days (12 weeks) of continuous treatment during the 114-day period following the Index Prescription Start Date.
Numerator 2: Patients who have received antidepressant medications for at least 180 days (6 months) of continuous treatment during the 231-day period following the Index Prescription Start Date.
To report on this measure for acute phase treatment, you must prescribe antidepressant medication for 84 days (12 weeks) within the 4 months following the new episode of major depression. To report on this measure for continuation phase treatment, you must prescribe antidepressant medication for 180 days (6 months) within 8 months following the new episode of major depression. To report the antidepressant therapy, write the prescription through the SIG Writer window or prescription refill message and print the prescription or send it electronically.
43
CMS 129; NQF 0389; PQRS 102 PROSTATE CANCER: AVOIDANCE OF OVERUSE OF BONE SCAN FOR STAGING LOW RISK PROSTATE CANCER PATIENTS *Not on benchmark spreadsheet
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process N -- -- -- -- -- -- -- -- --
DOMAIN Efficient Use of Healthcare Resources MEASURE Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer EXCLUSIONS OR EXCEPTIONS Documentation of reason(s) for performing a bone scan (including documented pain, salvage therapy, other medical reasons, bone scan ordered by someone other than reporting physician). ENTERING DENOMINATOR DATA All patients, regardless of age, with a diagnosis of prostate cancer. The patient must be male, and must have an active diagnosis of prostate cancer before or during the measurement period with a low risk for prostate cancer recurrence and a PSA test of less than or equal to 10 ng/mL and a Gleason Score of less than or equal to 6 before or during the prostate cancer treatment. Enter the diagnosis with a qualifying diagnosis code or diagnosis code associated with a SNOMED code in the Dx tab of Full Note Composer or other clinical note type window or enter a problem associated with a qualifying SNOMED code in the problem history category in the Hx tab of Full Note Composer or the Patient History window. ICD-9 185 ICD-10 C61 SNOMED 93974005, 94503003, 254900004, 278060005, 314969001, 369485004, 369486003, 396198006, 399068003, 399490008, 399590005, 427492003
44
You must order the desired lab test using the appropriate procedure code with the procedure code type Lab. Then either enters the test results or receives them through an interface and gives them a status of Resulted or Approved. The test results not received through an interface must be entered as discrete, quantifiable data. Enter the results in the Patients Results window using a lab template enabling you to enter the result values in a positive/negative or numerical format. The lab test in the template must be associated with an appropriate LOINC code. LOINC FOR GLEASON RESULTS 35266-6 LOINC FOR PSA RESULTS 10508-0, 10886-0, 12841-3, 15323-9, 15324-7, 15325-4, 19195-7, 19201-3, 2857-1, 33667-7, 34611-4, 35741-8 You must perform at least one prostate cancer treatment during the measurement period. Enter an appropriate CPT code or a procedure coded associated with an appropriate SNOMED code on the SP or SO tab of the patient visit note window. CPT CODES FOR TREATMENT 55810, 55812, 55815, 55840, 55842, 55845, 55866, 55873, 55875, 55876, 77427, 77776, 77777, 77778, and 77787 SNOMED FOR THERAPY 8782006, 10492003, 14473006, 19149007, 21190008, 21372000, 24242005, 26294005, 27877006, 28579000, 29860002, 30426000, 36253005, 37851009, 38915000, 41371003, 41416003, 57525009, 62867004, 64978007, 65381004, 65551008, 67598001, 68986004, 72388004, 77613002, 81232004, 83154001, 84755001, 85768003, 87795007, 90199006, 90470006, 91531008, 113120007, 116244007, 118161009, 118162002, 118163007, 168922004, 169327006, 169328001, 169329009, 169340001, 169349000, 169359004, 169374002, 176106009, 176258007, 176260009, 176261008, 176262001, 176263006, 176267007, 176286004, 176288003, 176319004, 228677009, 228684001, 228688003, 228690002, 228692005, 228693000, 228694006, 228695007, 228697004, 228698009, 228699001, 228701001, 228702008, 236209003, 236211007, 236252003, 265589001, 271291003, 312235007, 314202001, 359922007, 359926005, 384691004, 384692006, 394902000, 394918006, 399124002, 399180008, 399315003, 420529003, 427357007, 427985002, 433224001, 433225000, 440093006, 440094000 ENTERING NUMERATOR DATA Patients who did not have a bone scan performed at any time since diagnosis of prostate cancer. To report on this measure, you would not have ordered a bone scan for the patient at any time since diagnosis of prostate cancer. Therefore, you will not have received results for the bone scan, and none of the following LOINC codes would be in the patient’s chart. To ensure accurate reporting, one of the following LOINC codes should be associated to all bone scan procedures performed or ordered by the practice.
45
LOINC 25031-6, 25032-4, 39627-5, 39812-3, 39813-1, 39814-9, 39815-6, 39816-4, 39817-2, 39818-0, 398198, 39820-6, 39858-6, 39879-2, 39880-0, 39881-8, 39882-6, 39883-4, 39884-2, 39901-4, 39902-2, 39903-0, 39904-8, 39905-5, 41772-5, 41836-8, 42700-5, 44142-8
46
CMS 130; NQF 0034; PQRS 113 COLORECTAL CANCER SCREENING
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 12.61
- 23.91
23.92 -
34.31
34.32 -
44.54
44.55 -
54.09
54.10 -
63.63
63.64 -
73.09
73.10 -
83.14
>= 83.15 No
DOMAIN Clinical Processes and Effectiveness MEASURE Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer. EXCLUSIONS OR EXCEPTIONS Patients with a diagnosis or past history of total colectomy or colorectal cancer. ENTERING DENOMINATOR DATA Patients 51-75 years of age with a visit during the measurement period ENTERING NUMERATOR DATA Patients with one or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria below:
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.
To report on this measure, you must perform the screening test and enter the results during or prior to measurement period. To document the test and its results, chart the performance of the screening test using one of the procedure codes listed below. Then enter and approve the screening results in the Patient Results window, and give them a status of Resulted or Approved. Test results not received through an interface must be entered as discrete, quantifiable data. Enter the results in the Patients Results window using a lab template enabling you to enter the test result value. Results stored in the database as text notes or image file cannot be used for reporting. You must associate a LOINC code to the FOBT test item on each lab template for both manually entered and electronic results. FOBT LOINC CODES
47
12503-9, 12504-7, 14563-1, 14564-9, 14565-6, 2335-8, 27396-1, 27401-9, 27925-7, 27926-5, 29771-3, 56490-6, 56491-4, 57905-2, 58453-2 Flexible Sigmoidoscopy CPT CODES 45330, 45331, 45332, 45333, 45334, 45335, 45337, 45338, 45339, 45340, 45341, 45342, 45345 HCPCS CODES G0104 SNOMED CODES 44441009, 112870002, 396226005, 425634007 Colonoscopy CPT CODES 44388, 44389, 44390, 44391, 44392, 44393, 44394, 44397, 45355, 45378, 45379, 45380, 45381, 45382, 45383, 45384, 45385, 45386, 45387, 45391, 45392 HCPCS CODES G0105, G0121 SNOMED CODES 8180007, 12350003, 25732003, 34264006, 73761001, 174158000, 174184006, 235150006, 235151005, 303587008, 310634005, 367535003, 418714002, 427459009, 443998000, 444783004, 446521004, 446745002, 447021001
48
CMS 131; NQF 0055; PQRS 117 DIABETIC: EYE EXAM
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 84.83
- 92.85
92.86 -
95.32
95.33 -
96.96
96.97 -
98.19
98.20 -
99.17
99.18 -
99.82
99.83 -
99.99
100.00 No
DOMAIN Clinical Process/Effectiveness MEASURE Percentage of patients 18-75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal exam (no evidence of retinopathy) in the 12 months prior to the measurement period. EXCLUSIONS OR EXCEPTIONS Patients with a diagnosis of gestational diabetes during the measurement period. ENTERING DENOMINATOR DATA Patients 18-75 years of age with diabetes with a visit during the measurement period. Enter the diagnosis with a qualifying diagnosis code or diagnosis code associated with a SNOMED code in the Dx tab of Full Note Composer or other clinical note type window or enter a problem associated with a qualifying SNOMED code in the problem history category in the Hx tab of Full Note Composer or the Patient History window. ICD-9 250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91, 250.92, 250.93, 648.01, 648.02, 648.03, 648.04 ICD-10 E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, E10.319, E10.321, E10.329, E10.331, E10.339, E10.341, E10.349, E10.351, E10.359, E10.36, 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, E11.321, E11.329, E11.331, E11.339, E11.341, E11.349, E11.351, E11.359, E11.36, 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, O24.011, O24.012, O24.013, O24.019, O24.02, O24.03, O24.111, O24.112, O24.113, O24.119, O24.12, O24.13
49
SNOMED 4783006, 9859006, 23045005, 28032008, 44054006, 46635009, 75682002, 76751001, 81531005, 190330002, 190331003, 190368000, 190369008, 190372001, 190389009, 190390000, 199223000, 199225007, 199226008, 199227004, 199228009, 199229001, 199230006, 237599002, 237618001, 237626009, 237627000, 313435000, 313436004, 314771006, 314772004, 314893005, 314894004, 314902007, 314903002, 314904008, 359642000, 359939009 ENTERING NUMERATOR DATA 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 exam (no evidence of retinopathy) by an eye care professional in the
year prior to the measurement period. Please note that the application can only be used to report on the first option for this measure. The exam must be performed, and documented in the visit note. Please also note that the procedure must be performed by an ophthalmologist or optometrist. Other providers cannot use this measure. To report on this measure, you must perform the eye exam and enter it on the SP tab using a procedure code associated with one of the following SNOMED codes. SNOMED CODES 6615001, 252779009, 252780007, 252781006, 252782004, 252783009, 252784003, 252788000, 252789008, 252790004, 274795007, 274798009, 308110009, 314971001, 314972008, 410451008, 410452001, 410453006, 410455004, 420213007, 425816006, 427478009
50
CMS 132; NQF 0564; PQRS 192 CATARACTS: COMPLICATIONS WITHIN 30 DAYS FOLLOWING CATARACT SURGERY REQUIRING ADDITIONAL SURGICAL PROCEDURES
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Outcome Y 0.33
- 0.01
-- -- -- -- -- -- 0 Yes
DOMAIN Patient Safety MEASURE Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and had any of a specified list of surgical procedures in the 30 days following cataract surgery which would indicate the occurrence of any of the following major complications:
Retained nuclear fragments Endophthalmitis Dislocated or wrong power IOL Retinal detachment Wound dehiscence
EXCLUSIONS OR EXCEPTIONS Patients with any one of a specified list of comorbid conditions that impact the surgical complication rate. ENTERING DENOMINATOR DATA All patients aged 18 years and older who had cataract surgery and no significant pre-operative ocular conditions impacting the surgical complication rate. Enter the procedure code or a procedure code associated with a SNOMED code for the cataract surgery in the SP or SO tab of Full Note Composer or other clinical note type or in the surgical history category of the Hx tab of Full Note Composer or the Patient History window. CPT 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984 SNOMED 5130002, 9137006, 10178000, 12163000, 31705006, 35717002, 39243005, 46309001, 46426006, 46562009, 50538003, 51839008, 54885007, 65812008, 67760003, 69360005, 74490003, 75814005, 79611007, 82155009, 84149000, 85622008, 88282000, 89153001, 110473004, 112963003, 112964009, 231744001, 308694002, 308695001, 313999004, 335636001, 336651000, 361191005, 385468004, 397544007, 404628003, 415089008, 417493007, 418430006, 419767009, 420260004, 420526005, 424945000, 446548003
51
ENTERING NUMERATOR DATA Patients who had one or more specified operative procedures for any of the following major complications within 30 days following cataract surgery: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence. Enter the procedure code or a procedure code associated with a SNOMED code in the SP or SO tab of Full Note Composer or other clinical note type or in the surgical history category of the Hx tab of Full Note Composer or the Patient History window. CPT 65235, 65900, 65920, 65930, 66030, 66250, 66820, 66825, 66830, 66852, 66986, 67005, 67010, 67015, 67025, 67028, 67030, 67031, 67036, 67039, 67041, 67042, 67043, 67101, 67105, 67107, 67108, 67110, 67112, 67141, 67145, 67250, 67255 SNOMED 2536007, 3499006, 3938007, 4143006, 4344007, 4503005, 5671007, 8813000, 8920006, 9137006, 9255007, 10006000, 10807008, 12651006, 12868007, 13767004, 14707009, 18752000, 20647004, 21491001, 22768003, 30113009, 30246007, 31530007, 35552007, 37332006, 37958004, 43908008, 45817009, 46562009, 47470009, 48671003, 48933009, 49789002, 50737005, 51281007, 53570002, 54085006, 54211003, 54362002, 57103007, 58689006, 61220009, 64340000, 65812008, 66134002, 67546003, 68999001, 72199008, 74948004, 75734004, 77950003, 78191003, 78290008, 78362007, 78917001, 84016007, 84077007, 84542000, 85145001, 85231002, 89788006, 89942008, 90997007, 120119003, 172426003, 172451002, 172498005, 172548007, 172574001, 223217009, 224227005, 225184003, 231741009, 231751005, 231752003, 231780001, 287233001, 287236009, 287242008, 296867007, 312705004, 312706003, 312707007, 312714009, 360405005, 360411008, 363726008, 416773006, 417297006, 430833007, 444600006, 445023004, 445024005
52
CMS 133; NQF 0565; PQRS 191 CATARACTS: 20/40 OR BETTER VISUAL ACUITY WITHIN 90 DAYS FOLLOWING CATARACT SURGERY
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Outcome Y 83.33
- 88.82
88.83 -
91.81
91.82 -
94.11
94.12 -
95.69
95.70 -
96.88
96.89 -
97.98
97.99 -
99.31
>= 99.32 No
DOMAIN Clinical Process/Effectiveness MEASURE Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following the cataract surgery. EXCLUSIONS OR EXCEPTIONS Patients with specified comorbid conditions that impact the visual outcome of surgery. ENTERING DENOMINATOR DATA All patients aged 18 years and older who had cataract surgery. Enter the procedure code or a procedure code associated with a SNOMED code for the cataract surgery in the SP or SO tab of Full Note Composer or other clinical note type or in the surgical history category of the Hx tab of Full Note Composer or the Patient History window. CPT 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984 SNOMED 5130002, 9137006, 10178000, 12163000, 31705006, 35717002, 39243005, 46309001, 46426006, 46562009, 50538003, 51839008, 54885007, 65812008, 67760003, 69360005, 74490003, 75814005, 79611007, 82155009, 84149000, 85622008, 88282000, 89153001, 110473004, 112963003, 112964009, 231744001, 308694002, 308695001, 313999004, 335636001, 336651000, 361191005, 385468004, 397544007, 404628003, 415089008, 417493007, 418430006, 419767009, 420260004, 420526005, 424945000, 446548003 ENTERING NUMERATOR DATA Patients who had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following cataract surgery. There are two ways you can report on this measure. You can use observation items or you can use a physical exam item.
53
To use observations, you must have set up an observation item or items for the visual acuity test, and put these observation items in an observation template. The observation item for must be associated with a qualifying SNOMED code for the test. SNOMED 422497000, 423059004, 423862000, 424703005 You must also have a clinical note type defined to include the Observation tab so that you can use the observation template to chart the test. None of the system- defined clinical note type windows (such as Full Note Composer) include the Observation tab. So, you must use a custom clinical note type window to chart patient visit notes that will include a functional status assessment. Perform the visual acuity test, and enter the results in the observation template on the Observation tab. To use a physical exam, you must have set up a visual acuity finding in a physical exam. The finding must have SNOMED code 419775003 in the ID field of the PE Finding window. Perform the visual acuity test, and select the finding in the physical exam.
54
CMS 134; NQF 0062; PQRS 119 DIABETES: URINE PROTEIN SCREENING
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Outcome Y 64.29
- 70.20
70.21 -
75.27
75.28 -
79.68
79.69 -
83.49
83.50 -
87.36
87.37 -
91.17
91.18 -
94.99
>= 95.00 No
DOMAIN Clinical Process/Effectiveness MEASURE 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. EXCLUSIONS OR EXCEPTIONS Patients with a diagnosis of gestational diabetes during the measurement period. ENTERING DENOMINATOR DATA Patients 18-75 years of age with diabetes with a visit during the measurement period. Enter the diagnosis with a qualifying diagnosis code or diagnosis code associated with a SNOMED code in the Dx tab of Full Note Composer or other clinical note type window or enter a problem associated with a qualifying SNOMED code in the problem history category in the Hx tab of Full Note Composer or the Patient History window. ICD-9 250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91, 250.92, 250.93, 648.01, 648.02, 648.03, 648.04 ICD-10 E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, E10.319, E10.321, E10.329, E10.331, E10.339, E10.341, E10.349, E10.351, E10.359, E10.36, 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, E11.321, E11.329, E11.331, E11.339, E11.341, E11.349, E11.351, E11.359, E11.36, 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, O24.011, O24.012, O24.013, O24.019, O24.02, O24.03, O24.111, O24.112, O24.113, O24.119, O24.12, O24.13 SNOMED 4783006, 9859006, 23045005, 28032008, 44054006, 46635009, 75682002, 76751001, 81531005, 190330002, 190331003, 190368000, 190369008, 190372001, 190389009,
55
190390000, 199223000, 199225007, 199226008, 199227004, 199228009, 199229001, 199230006, 237599002, 237618001, 237626009, 237627000, 313435000, 313436004, 314771006, 314772004, 314893005, 314894004, 314902007, 314903002, 314904008, 359642000, 359939009 ENTERING NUMERATOR DATA Patients with a screening for nephropathy or evidence of nephropathy during the measurement period. To report on this measure, you must either diagnose the patient with nephropathy, or order or perform urine screening and then enter the results, or order or perform a procedure that indicates nephropathy. For this measure, a prescription for an ACE inhibitor or ARB medication is also an indication of nephropathy. To use the diagnosis, enter the diagnosis code in the Dx tab of Full Note Composer or other clinical note type window or enter a problem associated with a qualifying SNOMED code in the problem history category in the Hx tab of Full Note Composer or the Patient History window. ICD-9 250.40, 250.41, 250.42, 250.43 ICD-10 E08.21, E08.22, E08.29, E09.21, E09.22, E09.29, E10.21, E10.22, E10.29, E11.21, E11.22, E11.29, E13.21, E13.22, E13.29 SNOMED 38046004, 127013003, 236499007, 236500003, 401110002, 420514000, 420715001, 421305000, 421986006, 445170001 To use the urine screening, perform the urine screening, and then either enter the test results or receive them through an interface and give them a status of Resulted or Approved. Test results not received through an interface must be entered as discrete, quantifiable data. Enter the results in the Patients Results window using a lab template enabling you to enter the urine microalbumin value. Results stored in the database as text notes or image file cannot be used for reporting. You must associate a LOINC code to the test item on each lab template for both manually entered and electronic results. MICROALBUMIN LOINC 1755-8, 1753- 3, 1754-1, 1757-4, 2887-8, 2888-6, 2889-4, 2890-2, 9318-7, 11218-5, 12842-1, 13705-9, 13801-6, 14585-4, 14956-7, 14957-5, 14958-3, 14959-1, 18373-1, 20621-9, 21059-1, 21482-5, 26801-1, 27298-9, 30003-8, 30000-4, 30001-2, 32209-9, 32294-1, 32551-4, 34366-5, 35663-4, 40486-3, 40662-9, 40663-7, 43605-5, 43606-3, 43607-1, 44292-1, 47558-2, 49023-5, 50949-7, 53121-0, 53532-8, 53530-2, 53531-0, 56553-1, 57369-1, 58448-2, 58992-9, 59159-4, 60678-0, 63474-1
56
MACROALBUMIN LOINC 1753-3, 24356-8, 24357-6, 39264-7, 50556-0, 50564-4, 50949-7, 57019-2, 57020-0, 58077-9 To use a procedure that indicates nephropathy, you must enter a qualifying procedure code or a procedure code that is associated with a qualifying SNOMED code. You may enter the procedure in either the SP or the SO tab of Full Note Composer or other clinical note type window. DIALYSIS EDUCATION SNOMED 59596005, 66402002, 385972005 DIALYSIS SERVICES CPT 90920, 90921, 90924, 90925, 90935, 90937, 90940, 90945, 90947 DIALYSIS SERVICES HCPCS 108241001 DIALYSIS SERVICES SNOMED 676002, 10848006, 11932001, 14684005, 34897002, 57274006, 67970008, 68341005, 71192002, 108241001, 180273006, 225230008, 225231007, 233575001, 233576000, 233577009, 233578004, 233579007, 233580005, 233581009, 233582002, 233583007, 233584001, 233585000, 233586004, 233587008, 233588003, 233589006, 233590002, 238316008, 238317004, 238318009, 238319001, 238321006, 238322004, 238323009, 265764009, 288182009, 302497006, 427053002, 428648006, 439278006, 439976001 ESRD MONTHLY OUTPATIENT SERVICES CPT 90957, 90958, 90959, 90960, 90961, 90962, 90965, 90966, 90969, 90970, 90989, 90993, 90997, 90999, 99512 KIDNEY TRANSPLANT CPT 50300, 50320, 50340, 50360, 50365, 50370, 50380 KIDNEY TRANSPLANT SNOMED 12976005, 48994000, 52213001, 70536003, 88930008, 175899003, 175901007, 175902000, 175911000, 236138007, 240325001, 313030004 OTHER SERVICES RELATED TO DIALYSIS SNOMED 3257008, 73257006, 233591003, 385970002, 385971003, 385973000, 406168002 VASCULAR ACCESS FOR DIALYSIS CPT 36145, 36147, 36148, 36800, 36810, 36815, 36818, 36819, 36820, 36821, 36831, 36832, 36833 VASCULAR ACCESS FOR DIALYSIS SNOMED 676002, 7459007, 22800003, 34163007, 54817007, 61160002, 61740001, 63421002, 69380006, 79827002, 80634002, 180272001, 180277007, 225892009, 233468004, 233471007, 233472000, 233547003, 238314006, 238315007, 271418008, 426340003, 427992007, 428118009, 431418000, 431440009, 431781000, 432509002, 432654009, 434435000, 438341004, 438342006, 439241008, 439322008, 439349008, 439534001, 443683004, 448591002, 449400003
57
To use medication as an indicator of nephropathy, enter the prescription for an ACE inhibitor or ARB medication in the SIG Writer window, and print or electronically submit the prescription.
58
CMS 135; NQF 0081; PQRS 5 HEART FAILURE (HF): ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITOR OR ANGIOTENSIN RECEPTOR BLOCKER (ARB) THERAPY FOR LEFT VENTRICULAR SYSTOLIC DYSFUNCTION (LVSD)
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 43.53
- 53.26
53.27 -
62.85
62.86 -
68.74
68.75 -
72.40
72.41 -
77.91
77.92 -
85.18
85.19 -
91.33
>= 91.34 No
DOMAIN Clinical Process/Effectiveness MEASURE 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. EXCLUSIONS OR EXCEPTIONS Documentation of medical reason(s) for not prescribing ACE inhibitor or ARB therapy (e.g., hypotensive patients who are at immediate risk of cardiogenic shock, hospitalized patients who have experienced marked azotemia, allergy, intolerance, other medical reasons). Documentation of patient reason(s) for not prescribing ACE inhibitor or ARB therapy (e.g., patient declined, other patient reasons). Documentation of system reason(s) for not prescribing ACE inhibitor or ARB therapy (e.g., other system reasons). ENTERING DENOMINATOR DATA All patients aged 18 years and older with a diagnosis of heart failure. Enter the diagnosis with a qualifying diagnosis code or diagnosis code associated with a SNOMED code in the Dx tab of Full Note Composer or other clinical note type window or enter a problem associated with a qualifying SNOMED code in the problem history category in the Hx tab of Full Note Composer or the Patient History window. ICD-9 402.01, 402.11, 402.91, 404.01, 404.03, 404.11, 404.13, 404.91, 404.93, 428.0, 428.1, 428.20, 428.21, 428.22, 428.23, 428.30, 428.31, 428.32, 428.33, 428.40, 428.41, 428.42, 428.43, 428.9 ICD-10 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
59
SNOMED 364006, 5053004, 5148006, 5375005, 10091002, 10335000, 10633002, 25544003, 42343007, 43736008, 44313006, 46113002, 48447003, 56675007, 60856006, 66989003, 74960003, 77737007, 80479009, 82523003, 83105008, 84114007, 85232009, 88805009, 90727007, 92506005, 111283005, 128404006, 194767001, 194779001, 194781004, 195111005, 195112003, 195114002, 206586007, 233924009, 277639002, 314206003, 359617009, 359620001, 367363000, 410431009, 417996009, 418304008, 424404003, 426012001, 426263006, 426611007, 441481004, 441530006 To report on this measure, you must order or perform an LVEF test and enter the result data. When the LVEF result is equal to or less than 40 percent, then you must prescribe either an ACE inhibitor or ARB therapy. LVEF test results may be entered as results in a lab template using LOINC codes, or as observation items in an observation template using SNOMED codes. To report the LVEF test using a lab template, the results must either be received through an interface or entered as discrete, quantifiable data in the Patient Results window using a lab template enabling you to enter the LVEF percentage. The results must be given a status of Resulted or Approved. Test results not received through an interface must be entered as discrete, quantifiable data. Enter the results in the Patients Results window using a lab template enabling you to enter the test result value. Results stored in the database as text notes or image file cannot be used for reporting. You must associate a LOINC code to the LVEF test item on each lab template for both manually entered and electronic results. LOINC 8808-8, 8809-6, 8806-2, 8810-4, 8807-0, 8811-2, 8812-0, 10230-1, 18044-8, 18048-9, 18045-5, 18049-7, 18043-0, 18046-3, 18047-1 To report the LVEF test using an observation template, you must have set up an observation item for the LVEF test, and put the observation item in an observation template. The observation item must include the appropriate SNOMED code. SNOMED 134401001, 981000124106, 991000124109 You must also have a clinical note type defined to include the Observation tab so that you can use the observation template to chart the LVEF test. None of the system -defined clinical note type windows (such as Full Note Composer) include the Observation tab. You must use a custom clinical note type window to chart patient visit notes that will include the test. ENTERING NUMERATOR DATA Patients who were prescribed ACE inhibitor or ARB therapy either within a 12-month period when seen in the outpatient setting or at hospital discharge.
60
To report the ACE inhibitor or ARB therapy, write the prescription through the SIG Writer window or prescription refill message and print the prescription or send it electronically.
61
CMS 136; NQF 0108; PQRS 366 FOLLOW-UP CARE FOR CHILDREN PRESCRIBED ATTENTION DEFICIT/ HYPERACTIVITY DISORDER (ADHD) MEDICATION
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process N -- -- -- -- -- -- -- -- --
DOMAIN Clinical Processes and Effectiveness MEASURE Percentage of children 6 through 12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported.
Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase.
Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (nine months) after the Initiation Phase ended.
EXCLUSIONS OR EXCEPTIONS
Denominator Exclusion 1: • Exclude patients diagnosed with narcolepsy at any point in their history or
during the measurement period. • Exclude patients who had an acute inpatient stay with a principal diagnosis of
mental health or substance abuse during the 30 days after the IPSD. • Exclude patients who were actively on an ADHD medication in the 120 days
prior to the Index Prescription Start Date.
Denominator Exclusion 2: • Exclude patients diagnosed with narcolepsy at any point in their history or
during the measurement period. • Exclude patients who had an acute inpatient stay with a principal diagnosis of
mental health or substance abuse during the 300 days after the IPSD. • Exclude patients who were actively on an ADHD medication in the 120 days
prior to the Index Prescription Start Date.
ENTERING DENOMINATOR DATA The patient must be between 6 and 12 years of age, and must have at least one visit during the measurement period. For the first denominator, you must prescribe an ADHD medication for the patient for the first time will be included in the denominator. (The patient is excluded if already taking an ADHD
62
medication.) The first prescription must be written between 90 days prior to start of the measurement period and no later than 60 days from the start of the measurement period. For the second denominator, the patient must meet the requirements for the first denominator and must remain on medication for at least 210 of the 300 days following the IPSD. Write the prescription through the SIG Writer window and print the prescription or send it electronically. ENTERING NUMERATOR DATA To include the patient in the numerator for the first part of this measure, you must conduct a follow-up visit with the patient within 30 of the initial ADHD prescription and within the measurement period. A patient must be in the numerator for the first part of this measure in order to be included in the numerator for the second part. To be included in the second numerator, you must conduct a second follow-up visit at least 31 days after and no more than 300 days after the initial ADHD prescription. The patient must also have been on the ADHD medication for at least 210 days. To report the medication, write the prescriptions and/or refills through the SIG Writer window or prescription refill message and print the prescription or send it electronically.
63
CMS 137; NQF 0004; PQRS 305 INITIATIONS AND ENGAGEMENT OF ALCOHOL AND OTHER DRUG DEPENDENCE TREATMENT
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 0.49
- 0.65
0.66 -
0.77
0.78 -
0.89
0.90 -
2.10
2.11 -
2.71
2.72 -
4.06
4.07 -
14.48
>= 14.49 No
DOMAIN Clinical Process/Effectiveness MEASURE Percentage of patients 13 years of age and older with a new episode of alcohol and other drug (AOD) dependence who received the following. Two rates are reported.
Percentage of patients who initiated treatment within 14 days of the diagnosis. Percentage of patients who initiated treatment and who had two or more additional
services with an AOD diagnosis within 30 days of the initiation visit. EXCLUSIONS OR EXCEPTIONS Patients with a previous active diagnosis of alcohol or drug dependence in the 60 days prior to the first episode of alcohol or drug dependence. ENTERING DENOMINATOR DATA Patients age 13 years of age and older who were diagnosed with a new episode of alcohol or drug dependency during a visit in the first 11 months of the measurement period. Patients presenting with a subsequent episode of alcohol and other drug (AOD) dependence are not eligible for this measure. ICD-9 291.0, 291.1, 291.2, 291.3, 291.4, 291.5, 291.81, 291.82, 291.89, 291.9, 292.0, 292.11, 292.12, 292.2, 292.81, 292.82, 292.83, 292.84, 292.85, 292.89, 292.9, 303.00, 303.01, 303.02, 303.90, 303.91, 303.92, 304.00, 304.01, 304.02, 304.10, 304.11, 304.12, 304.20, 304.21, 304.22, 304.30, 304.31, 304.32, 304.40, 304.41, 304.42, 304.50, 304.51, 304.52, 304.60, 304.61, 304.62, 304.70, 304.71, 304.72, 304.80, 304.81, 304.82, 304.90, 304.91, 304.92, 305.00, 305.01, 305.02, 305.20, 305.21, 305.22, 305.30, 305.31, 305.32, 305.40, 305.41, 305.42, 305.50, 305.51, 305.52, 305.60, 305.61, 305.62, 305.70, 305.71, 305.72, 305.80, 305.81, 305.82, 305.90, 305.91, 305.92, 535.30, 535.31, 571.1 ICD-10 F10, F10.10, F10.120, F10.121, F10.129, F10.14, F10.150, F10.151, F10.159, F10.180, F10.181, F10.182, F10.188, F10.19, F10.20, F10.220, F10.221, F10.229, F10.230, F10.231, F10.232, F10.239, F10.24, F10.250, F10.251, F10.259, F10.26, F10.27, F10.280, F10.281, F10.282, F10.288, F10.29, F10.920, F10.921, F10.929, F10.94, F10.950, F10.951, F10.959, F10.96, F10.97, F10.980, F10.981, F10.982, F10.988, F10.99, F11.10, F11.120, F11.121, F11.122, F11.129, F11.14, F11.150, F11.151, F11.159, F11.181, F11.182, F11.188, F11.19, F11.20, F11.220, F11.221, F11.222,
64
F11.229, F11.23, F11.24, F11.250, F11.251, F11.259, F11.281, F11.282, F11.288, F11.29, F11.90, F11.920, F11.921, F11.922, F11.929, F11.93, F11.94, F11.950, F11.951, F11.959, F11.981, F11.982, F11.988, F11.99, F12.10, F12.120, F12.121, F12.122, F12.129, F12.150, F12.151, F12.159, F12.180, F12.188, F12.19, F12.20, F12.220, F12.221, F12.222, F12.229, F12.250, F12.251, F12.259, F12.280, F12.288, F12.29, F12.90, F12.920, F12.921, F12.922, F12.929, F12.950, F12.951, F12.959, F12.980, F12.988, F12.99, F13.10, F13.120, F13.121, F13.129, F13.14, F13.150, F13.151, F13.159, F13.180, F13.181, F13.182, F13.188, F13.19, F13.20, F13.220, F13.221, F13.229, F13.230, F13.231, F13.232, F13.239, F13.24, F13.250, F13.251, F13.259, F13.26, F13.27, F13.280, F13.281, F13.282, F13.288, F13.29, F13.90, F13.920, F13.921, F13.929, F13.930, F13.931, F13.932, F13.939, F13.94, F13.950, F13.951, F13.959, F13.96, F13.97, F13.980, F13.981, F13.982, F13.988, F13.99, F14.10, F14.120, F14.121, F14.122, F14.129, F14.14, F14.150, F14.151, F14.159, F14.180, F14.181, F14.182, F14.188, F14.19, F14.20, F14.220, F14.221, F14.222, F14.229, F14.23, F14.24, F14.250, F14.251, F14.259, F14.280, F14.281, F14.282, F14.288, F14.29, F14.90, F14.920, F14.921, F14.922, F14.929, F14.94, F14.950, F14.951, F14.959, F14.980, F14.981, F14.982, F14.988, F14.99, F15.10, F15.120, F15.121, F15.122, F15.129, F15.14, F15.150, F15.151, F15.159, F15.180, F15.181, F15.182, F15.188, F15.19, F15.20, F15.220, F15.221, F15.222, F15.229, F15.23, F15.24, F15.250, F15.251, F15.259, F15.280, F15.281, F15.282, F15.288, F15.29, F15.90, F15.920, F15.921, F15.922, F15.929, F15.93, F15.94, F15.950, F15.951, F15.959, F15.980, F15.981, F15.982, F15.988, F15.99, F16.10, F16.120, F16.121, F16.122, F16.129, F16.14, F16.150, F16.151, F16.159, F16.180, F16.183, F16.188, F16.19, F16.20, F16.220, F16.221, F16.229, F16.24, F16.250, F16.251, F16.259, F16.280, F16.283, F16.288, F16.29, F16.90, F16.920, F16.921, F16.929, F16.94, F16.950, F16.951, F16.959, F16.980, F16.983, F16.988, F16.99, F18.10, F18.120, F18.121, F18.129, F18.14, F18.150, F18.151, F18.159, F18.17, F18.180, F18.188, F18.19, F18.20, F18.220, F18.221, F18.229, F18.24, F18.250, F18.251, F18.259, F18.27, F18.280, F18.288, F18.29, F18.90, F18.920, F18.921, F18.929, F18.94, F18.950, F18.951, F18.959, F18.97, F18.980, F18.988, F18.99, F19.10, F19.120, F19.121, F19.122, F19.129, F19.14, F19.150, F19.151, F19.159, F19.16, F19.17, F19.180, F19.181, F19.182, F19.188, F19.19, F19.20, F19.220, F19.221, F19.222, F19.229, F19.230, F19.231, F19.232, F19.239, F19.24, F19.250, F19.251, F19.259, F19.26, F19.27, F19.280, F19.281, F19.282, F19.288, F19.29, F19.90, F19.920, F19.921, F19.922, F19.929, F19.930, F19.931, F19.932, F19.939, F19.94, F19.950, F19.951, F19.959, F19.96, F19.97, F19.980, F19.981, F19.982, F19.988, F19.99, F55.2, K29.20, K29.21, K70.10, K70.11 SNOMED 281004, 1383008, 1686006, 1973000, 2403008, 4863002, 5002000, 5444000, 5602001, 6348008, 7052005, 7071007, 7200002, 8635005, 8837000, 10028000,10327003, 11061003, 11387009, 12380008, 14784000, 15167005, 15277004, 18653004, 18689007, 19445006, 20385005, 20876004, 21000000, 21647008, 25508008, 26714005, 27956007, 28368009, 28864000, 29212009, 29733004, 30310000, 30491001, 30871003, 31715000, 31956009, 32009006, 32358001, 32552001, 32875003, 33845003, 33871004, 34938008, 37331004, 37344009, 38247002, 39003006, 39807006, 39951001, 40571009, 41083005, 42344001, 43497001, 46721000, 46975003, 47664006, 50026000, 50320000, 50722006,50933003, 50983008, 51339003, 51443000, 51493001, 52866005, 53050002, 53936005, 55967005, 56194001, 57588009, 58727001, 59651006, 61104008, 61144001, 63649001, 63983005, 64386003, 66590003, 69482004, 70328006, 70340006, 70545002, 70655008, 70932007, 71328000, 73097000, 74851005, 74934004, 75122001, 75544000, 77355000, 78267003, 78358001, 78524005, 79578000, 80868005, 82339009, 83168008, 83367009, 84758004, 85005007, 85561006, 87132004, 89451009, 90755006, 90790003, 95635002, 95661003,
65
105546006, 105549004,111479008, 111480006, 191471000, 191475009, 191476005, 191477001, 191478006, 191480000, 191483003, 191484009, 191485005, 191486006, 191492000, 191493005, 191494004, 191495003, 191496002, 191802004, 191804003, 191805002, 191811004, 191812006, 191813001, 191816009, 191819002, 191820008, 191825003, 191826002, 191829009, 191831000, 191832007, 191837001, 191838006, 191843004, 191844005, 191849000, 191850000, 191853003, 191855005, 191856006, 191865004, 191867007, 191868002, 191871005, 191873008, 191874002, 191877009, 191882002, 191883007, 191891003, 191893000, 191894006, 191899001, 191900006, 191905001, 191906000, 191907009, 191909007, 19912005, 191913000, 191914006, 191916008, 191918009, 191919001, 191920007, 191924003, 191925002, 191928000, 191930003, 191931004, 191939002, 199252002, 199253007, 199254001, 199255000, 226034001, 228371004, 228372006, 228373001, 228375008, 228376009, 228377000, 228378005, 228379002, 228380004, 228381000, 228382007, 228383002, 228384008, 228386005, 228387001, 228388006, 228389003, 230334008, 230443000, 231451006, 231458000, 231459008, 231461004, 231462006, 231467000, 231468005, 231469002, 231470001, 231472009, 231473004, 231474005, 231475006, 231477003, 231478008, 231479000, 231480002, 231481003, 231482005, 236751006, 237228001, 267206008, 268640002, 268641003, 268645007, 268646008, 268647004, 268648009, 268727002, 280982009, 280983004, 280984005, 280986007, 284591009, 301643003, 302507002, 307052004, 309279000, 310202009, 311173003, 312098001, 312936002, 313915006, 361049005, 361150008, 361151007, 363101005, 396344000, 403590001, 414874007, 416073003, 416714005, 417143004, 417360004, 425339005, 425885002, 426001001, 426095000, 426873000, 427205009, 427229002, 427327003, 427975003, 428219007, 428370001, 428406005, 428493006, 428495004, 428623008, 428659002, 428819003, 428823006, 429179002, 429299000, 429512006, 429672007, 429692000, 429782000, 441681009, 442351006, 442406005 ENTERING NUMERATOR DATA
Numerator 1: Patients who initiated treatment within 14 days of the diagnosis. Numerator 2: Patients who initiated treatment and who had two or more additional
services with an AOD diagnosis within 30 days of the initiation visit. To report on this measure, you must document treatment using either a treatment procedure code associated with a SNOMED code or a psychotherapy visit procedure code. You must enter the procedure code in the SP Tab of Full Note Composer or other clinical note type window. SNOMED FOR TREATMENT 24165007, 60112009, 171047005, 313071005, 370881007, 385989002, 386448003, 386449006, 386450006, 386451005, 408933008, 408934002, 408935001, 408936000, 408941008, 408942001, 408943006, 408944000, 408945004, 408947007, 408948002, 410419007, 413473000, 423416000, 424148004, 424407005, 424589009, 426928008 CPT FOR PSYCHOTHERAPY 90832, 90834, 90837
66
For numerator 2, the patient must have initiated treatment within 14 days of the diagnosis, and then had two or more additional visits with treatment or psychotherapy visits within 30 days the initial encounter.
67
CMS 138; NQF 0028; PQRS 226 PREVENTIVE CARE AND SCREENING: TOBACCO USE - SCREENING AND CESSATION INTERVENTION
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 72.72
- 82.40
82.41 -
87.55
87.56 -
90.50
90.51 -
92.74
92.75 -
94.63
94.64 -
96.52
96.53 -
98.51
>= 98.52 No
DOMAIN Public Health MEASURE 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. ENTERING DENOMINATOR DATA The patient must be 18 years old or older. This measure generally requires two office visits during the measurement period. Some types of office visits require only one during the measurement period. EXCLUSIONS OR EXCEPTIONS Documentation of medical reason(s) for not screening for tobacco use (eg, limited life expectancy, other medical reason). ENTERING NUMERATOR DATA To report on this measure, you must enter the patient’s use or non-use of tobacco in the Hx tab, Social History category, in the patient visit note. When the patient is a tobacco user, then you must either:
Enter CPT code 99406 or 99407 or HCPCS code G0436 to document the cessation counseling, OR
Prescribe an approved cessation medication. If you have entered the patient’s tobacco use in a prior measurement period and that use has not changed, then you must select the checkbox for the Social History category indicating that you have reviewed the patient’s history, including tobacco use. If you typically use an education form with or for cessation counseling, then you can associate the appropriate procedure code with the education form so that selecting the education form from the Education Form slider in Full Note Composer or other clinical note type will add the procedure code to the SP tab. The education form must also be associated with the Smoking Cessation patient communication type.
68
Smoking and tobacco use counseling to the patient is reported using CPT code 99406 (smoking and tobacco cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes) or code 99407 (smoking and tobacco cessation counseling visit; intensive, greater than 10 minutes). Remember that these CPT codes are E&M codes, so if you use them along with another E&M code, you must include in the visit note proper documentation supporting the use of the procedure code. Counseling lasting less than 3 minutes is considered part of an evaluation and management (E/M) service and is not paid separately. Proper documentation for codes 99406 and 99407 includes the total time spent and what was discussed, including cessation techniques, resources and follow-up. The counseling services must be provided by a physician or other qualified health professional and must be provided face-to-face. Some Medicaid programs have not yet adopted payment for these codes. If you are using the optionally licensed Alere education forms, the Alere Smoking Cessation form is recommended. This education form is associated with HCPCS code G0436. This procedure code is associated with the SNOMED code 225323000 which qualifies for this measure. If you not using the Alere education forms, then it is recommended that you associate the HCPCS code G0436 to the custom-defined education form that you use for this purpose. Write the prescription through the SIG Writer window, and either print or electronically submit the prescription.
69
CMS 139; NQF 0101; PQRS 318 SCREENING FOR FUTURE FALL RISK
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 9.14
- 20.16
20.17 -
33.70
33.71 -
48.36
48.37 -
65.67
65.68 -
81.76
81.77 -
93.39
93.40 -
98.80
>= 98.81 No
DOMAIN Patient Safety MEASURE Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period. EXCLUSIONS OR EXCEPTIONS Documentation of medical reason(s) for not screening for fall risk (e.g., patient is not ambulatory). ENTERING DENOMINATOR DATA Patients aged 65 years and older with a visit during the measurement period. ENTERING NUMERATOR DATA Patients who were screened for future fall risk at least once within the measurement period. To chart the screening, you must enter a procedure code that is associated with a qualifying SNOMED code. You may enter the in either the SP or the SO tab of Full Note Composer or other clinical note type window. SNOMED 408422004, 408423009, 408589008, 427206005
70
CMS 140; NQF 0387; PQRS 71 BREAST CANCER: HORMONAL THERAPY FOR STAGE IC-III ESTROGEN RECEPTOR/PROGESTERONE RECEPTOR (ER/PR) POSITIVE BREAST CANCER
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
N Y 67.27
- 89.99
90.00 -
93.32
93.33 -
94.34
94.35 -
97.29
97.30 -
97.77
97.78 -
99.99 -- 100.00 N
Please note that Aprima® PRM 2015 is not certified for this measure. Therefore, information about this measure is not included in this document. This measure cannot be submitted through Aprima PRM.
71
CMS 141; NQF 0385; PQRS 72 COLON CANCER: CHEMOTHERAPY FOR AJCC STAGE III COLON CANCER PATEINTS
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
N -- -- -- -- -- -- -- -- -- N
Please note that Aprima® PRM 2015 is not certified for this measure. Therefore, information about this measure is not included in this document. This measure cannot be submitted through Aprima PRM.
72
CMS 142; NQF 0089; PQRS 19 DIABETIC RETINOPATHY: COMMUNICATION WITH THE PHYSICIAN MANAGING ONGOING DIABETES CARE
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 46.15
- 56.85
56.86 -
65.13
65.14 -
72.38
72.39 -
78.21
78.22 -
84.27
84.28 -
89.93
89.94 -
95.41
>= 95.42 No
DOMAIN Clinical Processes and Effectiveness MEASURE Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months. EXCLUSIONS OR EXCEPTIONS Documentation of medical reason(s) for not communicating the findings of the dilated macular or fundus exam to the physician who manages the ongoing care of the patient with diabetes. Documentation of patient reason(s) for not communicating the findings of the dilated macular or fundus exam to the physician who manages the on-going care of the patient with diabetes. ENTERING DENOMINATOR DATA All patients aged 18 years and older with a diagnosis of diabetic retinopathy. The patient must have two or more visits within the measurement period. Equals Initial Patient Population who had a dilated macular or fundus exam performed during the first visit. Enter the diagnosis with a qualifying diagnosis code or diagnosis code associated with a SNOMED code in the Dx tab of Full Note Composer or other clinical note type window or enter a problem associated with a qualifying SNOMED code in the problem history category in the Hx tab of Full Note Composer or the Patient History window. ICD-9 362.01, 362.02, 362.03, 362.04, 362.05, 362.06 ICD-10 E08.311, E08.319, E08.321, E08.329, E08.331, E08.339, E08.341, E08.349, E08.351, E08.359, E09.311, E09.319, E09.321, E09.329, E09.331, E09.339, E09.341, E09.349, E09.351, E09.359, E10.311, E10.319, E10.321, E10.329, E10.331, E10.339, E10.341, E10.349, E10.351, E10.359, E11.311, E11.319, E11.321, E11.329, E11.331, E11.339, E11.341, E11.349, E11.351, E11.359, E13.311, E13.319, E13.321, E13.329, E13.331, E13.339, E13.341, E13.349, E13.351, E13.359
73
SNOMED 4855003, 25412000, 59276001, 193349004, 193350004, 232020009, 232021008, 232022001, 232023006, 311782002, 312903003, 312904009, 312905005, 312906006, 312907002, 312908007, 312909004, 312912001, 314010006, 314011005, 314014002, 314015001, 390834004, 399862001, 399863006, 399864000, 399865004, 399866003, 399868002, 399869005, 399870006, 399871005, 399872003, 399873008, 399874002, 399875001, 399876000, 399877009, 408409007, 408410002, 408411003, 408412005, 408413000, 408414006, 408415007, 408416008, 414892004, 414894003, 414908005, 414910007, 417677008, 420486006, 420789003, 421779007, 422034002 To report on this measure, you must order or perform a dilated macular or fundus exam, and then either enter the test results or receive them through an interface and give them a status of Resulted or Approved. Test results not received through an interface must be entered as discrete, quantifiable data. Enter the results in the Patients Results window using a lab template enabling you to enter the test result value. Results stored in the database as text notes or image file cannot be used for reporting. You must associate the LOINC code 32451-7 to the test item on each lab template for both manually entered and electronic results. ENTERING NUMERATOR DATA Patients with documentation, at least once within 12 months, of the findings of the dilated macular or fundus exam via communication to the physician who manages the patient’s diabetic care. To report on this measure, you must define custom procedure codes for reporting this information to another provider. You will need three custom procedures codes: one for reporting macular edema findings present, one for reporting macular edema finds absent, and one for reporting the level of severity of retinopathy. Each of these procedure codes must be associated with an appropriate SNOMED code. REPORT MACULAR EDEMA FINDINGS PRESENT 37231002, 193350004, 193387007, 232020009, 312911008, 312912001, 312920004, 312921000, 312922007, 314010006, 314011005, 314014002, 314015001, 399864000, 408415007, 408416008, 414892004, 414908005, 420486006, 421779007, 432789001 REPORT MACULAR EDEMA FINDINGS ABSENT 428341000124108 REPORT LEVEL OF SEVERITY OF RETINOPATHY 193349004, 312903003, 312904009, 312905005, 390834004, 408411003, 408412005
74
CMS 143; NQF 0086; PQRS 12 PRIMARY OPEN ANGLE GLAUCOMA (POAG): OPTIC NERVE ELEVATION
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 82.75
- 87.40
87.41 -
90.76
90.77 -
93.62
93.63 -
96.16
96.17 -
97.87
97.88 -
98.96
98.97 -
99.99
100.00 No
DOMAIN Clinical Processes and Effectiveness MEASURE Percentage of patients aged 18 years and older with a diagnosis of POAG who have an optic nerve head evaluation during one or more office visits within 12 months. EXCLUSIONS OR EXCEPTIONS Documentation of medical reason(s) for not performing an optic nerve head evaluation. ENTERING DENOMINATOR DATA All patients aged 18 years and older with a diagnosis of primary open-angle glaucoma. The patient must have two visits within the measurement period. The first visit must include the diagnosis. Enter the diagnosis with a qualifying diagnosis code or diagnosis code associated with a SNOMED code in the Dx tab of Full Note Composer or other clinical note type window. ICD-9 365.10, 365.11, 365.12, 365.15 ICD-10 H40.10, H40.11, H40.121, H40.122, H40.123, H40.129, H40.151, H40.152, H40.153, H40.159 SNOMED 48705003, 66990007, 77075001, 81416004, 84494001, 111513000 ENTERING NUMERATOR DATA Patients who have an optic nerve head evaluation during one or more office visits within 12 months. To report on this measure, you must order or perform an optic nerve head evaluation. This evaluation must include a cup-to-disc ratio and an optic disc exam for structural abnormalities. Then enter the test results and give them a status of Resulted or Approved. Test results must be entered as discrete, quantifiable data. Enter the results in the Patients Results window using a lab template enabling you to enter the test result value. Results stored in the database as text notes or image file cannot be used for reporting.
75
You must associate a LOINC code to the test item on each lab template for both manually entered and electronic results. CUP-TO-DISC RATIO LOINC 71484-0, 71485-7 OPTIC DISC EXAM FOR STRUCTURAL ABNORMALITIES LOINC 71486-5, 71487-3
76
CMS 144; NQF 0083; PQRS 8 HEART FAILURE (HF): BETA – BLOCKER THERAPY FOR LEFT VENTRICULAR SYSTOLIC DYSFUNCTION (LVSD)
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 60.00
- 65.78
65.79 -
70.58
70.59 -
74.99
75.00 -
79.99
80.00 -
85.95
85.96 -
90.47
90.48 -
95.99
>= 96.00 No
DOMAIN Clinical Processes and Effectiveness MEASURE 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 EXCLUSIONS OR EXCEPTIONS Documentation of medical reason(s) for not prescribing beta-blocker therapy (e.g., low blood pressure, fluid overload, asthma, patients recently treated with an intravenous positive inotropic agent, allergy, intolerance, other medical reasons). Documentation of patient reason(s) for not prescribing beta-blocker therapy (e.g., patient declined, other patient reasons). Documentation of system reason(s) for not prescribing beta-blocker therapy (e.g., other reasons attributable to the healthcare system). ENTERING DENOMINATOR DATA All patients aged 18 years and older with a diagnosis of heart failure, with a current or prior LVEF < 40%. The patient must have two or more visits during the measurement period. Enter the diagnosis with a qualifying diagnosis code or diagnosis code associated with a SNOMED code in the Dx tab of Full Note Composer or other clinical note type window or enter a problem associated with a qualifying SNOMED code in the problem history category in the Hx tab of Full Note Composer or the Patient History window. ICD-9 402.01, 402.11, 402.91, 404.01, 404.03, 404.11, 404.13, 404.91, 404.93, 428.0, 428.1, 428.20, 428.21, 428.22, 428.23, 428.30, 428.31, 428.32, 428.33, 428.40, 428.41, 428.42, 428.43, 428.9 ICD-10 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 SNOMED 364006, 5053004, 5148006, 5375005, 10091002, 10335000, 10633002, 25544003, 42343007,
77
43736008, 44313006, 46113002, 48447003, 56675007, 60856006, 66989003, 74960003, 77737007, 80479009, 82523003, 83105008, 84114007, 85232009, 88805009, 90727007, 92506005, 111283005, 128404006, 194767001, 194779001, 194781004, 195111005, 195112003, 195114002, 206586007, 233924009, 277639002, 314206003, 359617009, 359620001, 367363000, 410431009, 417996009, 418304008, 424404003, 426012001, 426263006, 426611007, 441481004, 441530006 To include all patients in denominator, you must order or perform an LVEF test and enter the result data. The LVEF test results must either be received through an interface or entered as discrete, quantifiable data in the Patient Results window using a lab template enabling you to enter the LVEF percentage. The results must be given a status of Resulted or Approved. Enter the results in the Patients Results window using a lab template enabling you to enter the test result value. Results stored in the database as text notes or image file cannot be used for reporting. You must associate a LOINC code to the LVEF test item on each lab template for both manually entered and electronic results. LOINC 8808-8, 8809-6, 8806-2, 8810-4, 8807-0, 8811-2, 8812-0, 10230-1, 18044-8, 18048-9, 18045-5, 18049-7, 18043-0, 18046-3, 18047-1 ENTERING NUMERATOR DATA When the LVEF result is equal to or less than 40 percent, then you must prescribe either an ACE inhibitor or ARB therapy. Patients who were prescribed beta- blocker therapy either within a 12-month period when seen in the outpatient setting or at hospital discharge. To report the beta-blocker therapy, write the prescription through the SIG Writer window or prescription refill message and print the prescription or send it electronically.
78
CMS 145; NQF 0070; PQRS 7 CORONARY ARTERY DISEASE (CAD): BETA – BLOCKER THERAPY – PRIOR MYOCARDIAL INFARCTION (MI) OR LEFT VENTRICULAR SYSTOLIC DYSFUNCTION (LVEF <40%)
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 51.35
- 68.22
68.23 -
78.77
78.78 -
82.64
82.65 -
86.32
86.33 -
90.79
90.80 -
94.25
94.26 -
97.60
>= 97.61 No
DOMAIN Clinical Processes and Effectiveness MEASURE 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. EXCLUSIONS OR EXCEPTIONS
Documentation of medical reason(s) for not prescribing beta-blocker therapy (e.g., allergy, intolerance, other medical reasons).
Documentation of patient reason(s) for not prescribing beta-blocker therapy (e.g., patient declined, other patient reasons).
Documentation of system reason(s) for not prescribing beta-blocker therapy (e.g., other reasons attributable to the health care system).
ENTERING DENOMINATOR DATA All patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12-month period. The patient must have two visits. Equals Initial Patient Population who also have prior MI or a current or prior LVEF <40%. Please note that this measure produces results for two denominator and numerator combinations. The denominator information given here is correct for both. Enter the diagnosis with a qualifying diagnosis code or diagnosis code associated with a SNOMED code in the Dx tab of Full Note Composer or other clinical note type window or in the problem enter a problem associated with a qualifying SNOMED code in the problem history category in the Hx tab of Full Note Composer or the Patient History window. CAD ICD-9 411.0, 411.1, 411.81, 411.89, 413.0, 413.1, 413.9, 414.00, 414.01, 414.02, 414.03, 414.04, 414.05, 414.06, 414.07, 414.8, 414.9, V45.81, V45.82
79
CAD ICD-10 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, I25.89, I25.9, Z95.1, Z95.5, Z98.61 CAD SNOMED 4557003, 10365005, 19057007, 21470009, 28248000, 29899005, 35928006, 41334000, 50570003, 53741008, 59021001, 61490001, 62207008, 63739005, 66189004, 67682002, 74218008, 75398000, 85284003, 87343002, 89323001, 92517006, 123641001, 123642008, 194823009, 194828000, 194842008, 194843003, 233817007, 233819005, 233821000, 233970002, 300995000, 314116003, 315025001, 315348000, 371803003, 371804009, 371805005, 371806006, 371807002, 371808007, 371809004, 371810009, 371811008, 371812001, 398274000, 408546009, 420006002, 421327009, 427919004, 429245005, 429559004 To document a prior MI, enter a problem associated with a SNOMED code in the problem history category in the Hx tab of Full Note Composer or the Patient History window. MI ICD-9 410.00, 410.01, 410.02, 410.10, 410.11, 410.12, 410.20, 410.21, 410.22, 410.30, 410.31, 410.32, 410.40, 410.41, 410.42, 410.50, 410.51, 410.52, 410.60, 410.61, 410.62, 410.70, 410.71, 410.72, 410.80, 410.81, 410.82, 410.90, 410.91, 410.92, 412 MI ICD-10 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 MI SNOMED 1755008, 10273003, 15990001, 22298006, 30277009, 32574007, 42531007, 52035003, 54329005, 57054005, 58612006, 62695002, 65547006, 70211005, 70422006, 73795002, 79009004, 129574000, 161502000, 161503005, 194798004, 194802003, 194809007, 194856005, 233835003, 233838001, 233839009, 233840006, 233841005, 233842003, 233843008, 275905002, 304914007, 307140009, 308065005, 314207007, 371068009, 394710008, 399211009, 401303003, 401314000, 418044006, 428196007, 428752002 To document cardiac surgery, enter the procedure with a qualifying procedure code or procedure code associated with a SNOMED code in the SP or SO tab of Full Note Composer or other clinical note type window. Or enter the surgery in the surgical history category in the Hx tab of Full Note Composer or the Patient History window. The history question used to enter the cardiac surgery must be associated with a SNOMED code. 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
80
CARDIAC SURGERY SNOMED 3546002, 10326007, 15256002, 30670000, 39202005, 39724006, 48431000, 74371005, 81266008, 82247006, 90205004, 119564002, 119565001, 174911007, 175007008, 175008003, 175009006, 175011002, 175021005, 175022003, 175024002, 175025001, 175026000, 175036008, 175037004, 175038009, 175039001, 175040004, 175041000, 175045009, 175047001, 175048006, 175050003, 232717009, 232719007, 232720001, 232721002, 232722009, 232723004, 232724005, 265481001, 275215001, 275216000, 275227003, 275252001, 275253006, 287277008, 309814006 To report on this measure, you must order or perform an LVEF test and enter the result data. When the LVEF result is equal to or less than 40 percent, then you must prescribe either an ACE inhibitor or ARB therapy. The LVEF test results must either be received through an interface or entered as discrete, quantifiable data in the Patient Results window using a lab template enabling you to enter the LVEF percentage. The results must be given a status of Resulted or Approved. Test results not received through an interface must be entered as discrete, quantifiable data. Enter the results in the Patients Results window using a lab template enabling you to enter the test result value. Results stored in the database as text notes or image file cannot be used for reporting. You must associate a LOINC code to the LVEF test item on each lab template for both manually entered and electronic results. LOINC 8808-8, 8809-6, 8806-2, 8810-4, 8807-0, 8811-2, 8812-0, 10230-1, 18044-8, 18048-9, 18045-5, 18049-7, 18043-0, 18046-3, 18047-1 ENTERING NUMERATOR DATA Patients who were prescribed beta-blocker therapy. To report the beta-blocker therapy, write the prescription through the SIG Writer window or prescription refill message and print the prescription or send it electronically.
81
CMS 146; NQF 0002; PQRS 66 APPROPRIATE TESTING FOR CHILDREN WITH PHARYNGITIS
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 43.33
- 56.18
56.19 -
66.66
66.67 -
74.74
74.75 -
80.51
80.52 -
84.43
84.44 -
87.29
87.30 -
91.88
>= 91.89 No
DOMAIN Health Resources MEASURE Percentage of children 2-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode. EXCLUSIONS OR EXCEPTIONS Children who are taking antibiotics in the 30 days prior to the diagnosis of pharyngitis. ENTERING DENOMINATOR DATA Children 2-18 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. You must diagnosis the patient with pharyngitis using one of the diagnosis codes below during a visit within the measurement period. ICD-9 034.0, 462, 463 ICD-10 J02.8, J02.9, J03.80, J03.81, J03.90, J03.91 SNOMED 1532007, 17741008, 40766000, 43878008, 55355000, 58031004, 195655000, 195656004, 195657008, 195658003, 195659006, 195660001, 195662009, 195666007, 195667003, 195668008, 195669000, 195670004, 195671000, 195672007, 195673002, 195676005, 195677001, 232399005, 232400003, 302911003, 363746003 You must prescribe an antibiotic within three days following the visit. To report the antibiotic, write a prescription for an antibiotic using the SIG writer window and print the prescription or send it electronically. The antibiotic must be dispensed within three days after the qualifying visit.
82
ENTERING NUMERATOR DATA Children with a group A streptococcus test in the seven-day period from three days prior through three days after the diagnosis of pharyngitis. To report on this measure, you must prescribe an antibiotic and order a group A streptococcus (strep) test and enter the test results. To report the antibiotic, write a prescription for an antibiotic using the SIG writer window and print the prescription or send it electronically. To report the strep test, order the test and then either enter the test results or receive them through an interface and give them a status of Resulted or Approved. The strep test results not received through an interface must be entered as discrete, quantifiable data. Enter the results in the Patients Results window using a lab template enabling you to enter the strep value. Results stored in the database as text notes or image file cannot be used for reporting. You must associate a LOINC code to the strep test item on each lab template for both manually entered and electronic results. LOINC codes for this result are listed below. LOINC 626-2, 5036-9, 6559-9, 6556-5, 6557-3, 6558-1, 11268-0, 17656-0, 18481-2, 31971-5, 49610-9, 60489-2, 68954-7
83
CMS 147; NQF 0041; PQRS 110 PREVENTATIVE CARE AND SCREENING: INFLUENZA IMMUNIZATION
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 14.55
- 21.83
21.84 -
29.00
29.01 -
35.99
36.00 -
43.53
43.54 -
52.13
52.14 -
63.12
63.13 -
78.42
>= 78.43 No
DOMAIN Public Health MEASURE 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. EXCLUSIONS OR EXCEPTIONS
Documentation of medical reason(s) for not receiving influenza immunization (eg, patient allergy, other medical reasons).
Documentation of patient reason(s) for not receiving influenza immunization (eg, patient declined, other patient reasons).
Documentation of system reason(s) for not receiving influenza immunization (eg, vaccine not available, other system reasons).
ENTERING DENOMINATOR DATA Equals Initial Patient Population and seen for a visit between October 1 and March 31.
The patient must have a visit during flu season, which is defined as October of the prior year through March of the current year.
The patient must also have one, or in some circumstances two, additional visits during the reporting period. ENTERING NUMERATOR DATA Patients who received an influenza immunization OR who reported previous receipt of an influenza immunization. To report on this measure, you must document the administration of the flu immunization, or enter it in the vaccine history category. The vaccine must have been administered between October of the prior year and March of the current year. To document the influenza immunization, enter the vaccination in the vaccine administration record using one of the following CPT codes or a procedure code associated with a SNOMED code. Enter the procedure in the SP tab of Full Note Composer or other clinical note type window. Then document the vaccination details in the vaccine administration record.
84
You may also document the pneumonia immunization by using a type of vaccine associated with the qualifying CVX code. Identify the type of vaccine when documenting the vaccine details in the vaccine administration record. To document a vaccination given in the past, you must use a type of vaccine associated with the qualifying CVX code. Enter the vaccination in the vaccination history category in the Hx tab of Full Note Composer or in the Patient History window. Then, identify the type of vaccine when documenting the vaccine details in the vaccine administration record. Please note that you must make this entry in a visit during the flu season. CPT 90656, 90658, 90660, 90661, 90662, 90664, 90666, 90667, 90668 SNOMED 86198006, 442333005 CVX 111, 135, 140, 141, 144
85
CMS 148; NQF 0060; PQRS 365 HEMOGLOBIN A1C TEST FOR PEDIATRIC PATIENTS
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
N -- -- -- -- -- -- -- -- -- N
DOMAIN Clinical Processes and Effectiveness MEASURE Percentage of patients 5-17 years of age with diabetes with an HbA1c test during the measurement period. EXCLUSIONS OR EXCEPTIONS Patients with a diagnosis of gestational diabetes during the measurement period. ENTERING DENOMINATOR DATA Patients 5 to 17 years of age with a diagnosis of diabetes and a face-to-face visit for diabetes care between the physician and the patient that predates the most recent visit by at least 12 months. Enter the diagnosis with a qualifying diagnosis code or diagnosis code associated with a SNOMED code in the Dx tab of Full Note Composer or other clinical note type window or enter a problem associated with a qualifying SNOMED code in the problem history category in the Hx tab of Full Note Composer or the Patient History window. ICD-9 250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91, 250.92, 250.93, 648.01, 648.02, 648.03, 648.04 ICD-10 E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, E10.319, E10.321, E10.329, E10.331, E10.339, E10.341, E10.349, E10.351, E10.359, E10.36, 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, E11.321, E11.329, E11.331, E11.339, E11.341, E11.349, E11.351, E11.359, E11.36, 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, O24.011, O24.012, O24.013, O24.019, O24.02, O24.03, O24.111, O24.112, O24.113, O24.119, O24.12, O24.13 SNOMED 4783006, 9859006, 23045005, 28032008, 44054006, 46635009, 75682002, 76751001, 81531005, 190330002, 190331003, 190368000, 190369008, 190372001, 190389009, 190390000, 199223000, 199225007, 199226008, 199227004, 199228009, 199229001,
86
199230006, 237599002, 237618001, 237626009, 237627000, 313435000, 313436004, 314771006, 314772004, 314893005, 314894004, 314902007, 314903002, 314904008, 359642000, 359939009 You must have charted a patient visit note for a face -to-face visit with the patient at least 12 months prior to the visit during the reporting period. ENTERING NUMERATOR DATA Patients with documentation of date and result for an HbA1c test during the measurement period. To report on this measure, you must order or perform an A1c test, and then either enter the test results or receive them through an interface and give them a status of Resulted or Approved. The A1c test results not received through an interface must be entered as discrete, quantifiable data. Enter the results in the Patients Results window using a lab template enabling you to enter the HGB A1c value. Results stored in the database as text notes or image file cannot be used reporting. You must associate a LOINC code to the A1C test item on each lab template for both manually entered and electronic results. LOINC 17855-8, 17856-6, 4548-4
87
CMS 149; NQF NA; PQRS 281 DEMENTIA: COGNITIVE ASSESSMENT
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 33.33
- 52.77
52.78 -
59.08
59.09 -
69.41
69.42 -
77.77
77.78 -
86.89
86.90 -
95.23
95.24 -
99.99 100.00 No
DOMAIN Clinical Processes and Effectiveness MEASURE Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period. EXCLUSIONS OR EXCEPTIONS
Documentation of medical reason(s) for not assessing cognition (e.g., patient with very advanced stage dementia, other medical reason).
Documentation of patient reason(s) for not assessing cognition. ENTERING DENOMINATOR DATA All patients, regardless of age, with a diagnosis of dementia. The patient must have two visits. ICD-9 094.1, 290.0, 290.10, 290.11, 290.12, 290.13, 290.20, 290.21, 290.3, 290.40, 290.41, 290.42, 290.43, 290.8, 290.9, 294.10, 294.11, 294.20, 294.21, 294.8, 331.0, 331.11, 331.19, 331.82 ICD-10 A52.17, F01.50, F01.51, F02.80, F02.81, F03.90, F03.91, F05, F06.0, F06.8, G30.0, G30.1, G30.8, G30.9, G31.01, G31.09, G31.83 SNOMED 281004, 4817008, 6475002, 10349009, 10532003, 12348006, 14070001, 15662003, 25772007, 26852004, 32875003, 51928006, 52448006, 54502004, 55009008, 56267009, 59651006, 62239001, 65096006, 66108005, 70936005, 82959004, 90099008, 111480006, 191449005, 191451009, 191452002, 191454001, 191455000, 191457008, 191458003, 191459006, 191461002, 191463004, 191464005, 191465006, 191466007, 191493005, 230270009, 230283005, 230286002, 230287006, 230288001, 230290000, 278857002,279982005, 312991009, 371024007, 371026009, 416780008, 420614009, 421023003, 421529006, 425390006, 429998004, 442344002, 428351000124105 ENTERING NUMERATOR DATA Patients for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period.
88
To report on this measure, enter the assessment using a procedure code or a procedure code associated with a SNOMED code. You may enter the procedure in either the SP or the SO tab of Full Note Composer or other clinical note type window. CPT 97003, 97004 SNOMED 4719001, 113024001 To report on this measure, you must have set up an observation item for the score of each assessment that you use, and put these observation items in an observation template. The observation item for each assessment’s score must include the appropriate LOINC code for the functional status assessment. LOINC 58151-2, 71492-3, 71493-1, 71722-3, 72106-8, 72172-0, 72173-8 You must also have a clinical note type defined to include the Observation tab so that you can use the observation template to chart the assessment. None of the system-defined clinical note type windows (such as Full Note Composer) include the Observation tab. So, you must use a custom clinical note type window to chart patient visit notes that will include a functional status assessment. Enter the score of the functional status assessment in the observation template on the Observation tab. Please note that entries in the Cognitive and Functional Assessment history categories do not count for this measure.
89
CMS 153; NQF 0033; PQRS 310 CHLAMYDIA SCREENING FOR WOMEN
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 13.89
- 19.99
20.00 -
28.12
28.13 -
32.80
32.81 -
38.83
38.84 -
48.14
48.15 -
55.17
55.18 -
63.99
>= 64.00 No
DOMAIN Public Health MEASURE Percentage of women 16 through 24 years of age who were identified as sexually active and who had at least one test for Chlamydia during the measurement period. EXCLUSIONS OR EXCEPTIONS Women who received a pregnancy test solely as a safety precaution before ordering an x-ray or specified medications. ENTERING DENOMINATOR DATA This measure reports for two groups of patients. Those aged 16 to 20, and those age 21 to 24. The patient must have at least one visit during the measurement period. The patient must be identified as sexually active. Patients may identify as sexually active in a number of ways, including a procedure for a pregnancy test, a diagnosis for pregnancy or pregnancy related problem, a procedure for a birth, a lab test for or a diagnosis for a sexually transmitted infection, a prescription for contraceptives, a procedure for a contraceptive device, and a procedure for infertility treatments. Patients who received a pregnancy test solely as a safety precaution before ordering an x-ray or specified medications are excluded. However, this exclusion does not apply to patients who qualify for the initial patient population based on services other than the pregnancy test alone. ENTERING NUMERATOR DATA To report on this measure, you must order or perform a Chlamydia test, and then either enter the test results or receive them through an interface and give them a status of Resulted or Approved. Chlamydia test results not received through an interface must be entered as discrete, quantifiable data. Enter the results in the Patients Results window using a lab template enabling you to enter the test result value. Results stored in the database as text notes or image file cannot be used for reporting. You must associate a LOINC code to the Chlamydia test item on each lab template for both manually entered and electronic results.
90
LOINC CODES 4993-2, 5089-8, 5090-6, 5087-2, 5088-0, 6352-9, 6349-5, 6353-7, 6350-3, 6354-5, 6357-8, 6351-1, 6355-2, 6356-0, 6918-7, 6919- 5, 6920-3, 7824-6, 13220-9, 13217-5, 13221-7, 13218-3, 13219-1, 14201-8, 14199-4, 14202-6, 14203-4, 14200-0, 14204-2, 14461-8, 14462-6, 14465-9, 14463-4, 14470-9, 14464-2, 14467-5, 14471-7, 14468-3, 14472-5, 14469-1, 14474-1, 14507-8, 14508-6, 14509-4, 14513-6, 14510-2, 14511-0, 16596-9, 16594-4, 16597-7, 16600-9, 16598-5, 16595-1, 16601-7, 16599-3, 18492-9, 18490-3, 18491-1, 21188-8, 21189-6, 21190-4, 21187-0, 21191-2, 21192-0, 21613-5, 22187-9, 22188-7, 22192-9, 22189-5, 22193-7, 22190-3, 22194-5, 22197-8, 22191-1, 22198-6, 22195-2, 22201-8, 22199-4, 22196-0, 22202-6, 22200-0, 23838-6, 26626-2, 26663-5, 26666-8, 26664-3, 26667-6, 26668-4, 26665-0, 26715-3, 27167-6, 27185-8, 27370-6, 27371-4, 27368-0, 28556-9, 28557-7, 28558-5, 30204-2, 31295-9, 31293-4, 31296-7, 31294-2, 31297-5, 31298-3, 31771-9, 31768-5, 31772-7, 31769-3, 31776-8, 31770-1, 31774-3, 31777-6, 31775-0, 32006-9, 32007-7, 32005-1, 33574-5, 33575-2, 33605-7, 33604-0, 34709-6, 34710-4, 36902-5, 36903-3, 38469-3, 40710-6, 40855-9, 40856-7, 40854-2, 41157-9, 42931-6, 43058-7, 43062-9, 43059-5, 43060-3, 43061-1, 43175-9, 43173-4, 43174-2, 43304-5, 43355-7, 43356-5, 43357-3, 43406-8, 43404-3, 43405-0, 43848-1, 44005-7, 44079-2, 44806-8, 44807-6, 44983-5, 44986-8, 44984-3, 44987-6, 44991-8, 44988-4, 44985-0, 44992-6, 44995-9, 44989-2, 44993-4, 44996-7, 44990-0, 44994-2, 44997-5, 45000-7, 44998-3, 45004-9, 45001-5, 44999-1, 45002-3, 45005-6, 45009-8, 45003-1, 45006-4, 45007-2, 45008-0, 45067-6, 45068-4, 45072-6, 45075-9, 45069-2, 45073-4, 45076-7, 45070-0, 45080-9, 45074-2, 45078-3, 45085-8, 45086-6, 45090-8, 45084-1, 45091-6, 45092-4, 45095-7, 45089-0, 45093-2, 45096-5, 45094-0, 45130-2, 45135-1, 46176-4, 46177-2, 46178-0, 47211-8, 47212-6, 47234-0, 47362-9, 49096-1, 50387-0, 51734-2, 53925-4, 53926-2, 57287-5, 57288-3, 64017-7
91
CMS 154; NQF 0069; PQRS 65 APPROPRIATE TREATMENT FOR CHILDREN WITH UPPER RESPIRATORY INFECTION (URI)
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 74.00
- 82.42
82.43 -
87.90
87.91 -
91.29
91.30 -
93.99
94.00 -
95.99
96.00 -
98.92
98.93 -
99.99
100.00 No
DOMAIN Health Resources MEASURE Percentage of children 3 months through 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. Please note that for this measure, the desired outcome is to have the numerator be a low number. EXCLUSIONS OR EXCEPTIONS Exclude children who are taking antibiotics in the 30 days prior to the date of the encounter. Exclude children who had an encounter with a competing diagnosis within three days after the initial diagnosis. ENTERING DENOMINATOR DATA The patient must be between 3 months and 18 years of age. The patient must have an outpatient or emergency department visit with a diagnosis of upper respiratory infection (URI) during the measurement period. You must diagnosis the patient with an upper respiratory infection using a qualifying ICD-9 or SNOMED code. Enter the diagnosis code in the Dx tab of Full Note Composer or other clinical note type window. ICD-9 460, 465.0, 465.8, 465.9 ICD-10 J00, J06.0, J06.9 SNOMED 195708003, 281794004, 54150009, 54398005, 55355000, 78337007, 82272006 ENTERING NUMERATOR DATA To report on this measure, you must not write a prescription for an antibiotic on the date of the visit or within three days of the visit. Patients for whom an antibiotic prescription is written are included in the denominator, but not in the numerator.
92
CMS 155; NQF 0024; PQRS 239 WEIGHT ASSESSMENT AND COUNSELING FOR NUTRITION AND PHYSICAL ACTIVITY FOR CHILDREN AND ADOLESCENTS
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process N 21.69
- 26.09
26.10 -
28.86
28.87 -
30.47
30.48 -
31.76
31.77 -
32.65
32.66 -
33.32
33.33 -
40.77
>= 40.78 No
DOMAIN Public Health MEASURE Percentage of patients 3 through 17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported.
Percentage of patients with height, weight, and body mass index (BMI) percentile documentation
Percentage of patients with counseling for nutrition Percentage of patients with counseling for physical activity
EXCLUSIONS OR EXCEPTIONS Patients who have a diagnosis of pregnancy during the measurement period. ENTERING DENOMINATOR DATA The patient must between 3 and 17 years old. The patient must have at least one visit with a primary care physician or an obstetrician/gynecologist (OB/GYN) during the measurement period. ENTERING NUMERATOR DATA This measure has three different numerators. To be included in the first numerator, you must enter the BMI. To record the BMI percentile, you must enter the patient’s height and weight in the Vitals tab of the patient visit note. The application automatically calculates the BMI. For this measure, you must associate one of the qualifying LOINC codes with the system-defined BMI observation item. Please note that the LOINC codes appropriate for children and adolescents are different from the LOINC code for adults. If you are also reporting on CMS 69 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up, you will need to generate your CQM QRDA files twice. You will need to associate the LOINC code for adults to the BMI observation item, and generate the report to obtain your counts for the CMS 69 measure. Then you will need associate the LOINC code for children to the BMI observation item, and generate the report to obtain your counts for this measure.
93
LOINC FOR CHILDREN AND ADOLESCENTS BMI 59574-4, 59575-1, 59576-9 To be included in the second numerator, you must record counseling for nutrition was performed. You can either enter the ICD-9 procedure code V65.3 in the Dx tab or enter one of the following. CPT CODES 97802, 97803, 97804, 98961, 98962, 99078 HCPCS G0270, G0271, G8417, S9451, S9452, S9449, S9470 To be included in the third numerator, you must record that counseling for physical activity was performed. You can either enter the ICD-9 procedure code V65.41 in the Dx tab and one of the following CPT or HCPCS codes in the SP tab of the patient visit note. CPT 98961, 98962, 99078 HCPCS S9449, S9451, G8417 If you typically use an education form with or for nutrition or physical activity counseling and the procedure code is associated with the education form, then select the education form from the Education Form slider in Full Note Composer or other clinical note type will add the procedure code to the SP tab. The education form must also be associated with the patient communication type Nutrition or the patient communication type Physical Activity.
94
CMS 156; NQF 0022; PQRS 238 USE OF HIGH-RISK MEDICATIONS IN THE ELDERLY
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 12.02
- 6.84
6.83 -
3.53
3.52 -
1.50
1.49 -
0.49
0.48 -
0.01 -- -- 0.00 Yes
DOMAIN Patient Safety MEASURE Percentage of patients 66 years of age and older who were ordered high-risk medications. Two rates are reported.
Percentage of patients who were ordered at least one high-risk medication. Percentage of patients who were ordered at least two high-risk medications.
EXCLUSIONS OR EXCEPTIONS None ENTERING DENOMINATOR DATA The patient must be 66 years old or older and must have at least one visit during the measurement period. ENTERING NUMERATOR DATA To report on this measure, you must write all prescriptions through the SIG Writer window or prescription refill message and print the prescriptions or send them electronically. Patients 66 years old or older are counted in the first numerator if there is a prescription for a high-risk medication. These patients are counted in the second numerator if there are prescriptions for two or more high-risk medications.
95
CMS 157; NQF 0384; PQRS 143 ONCOLOGY: MEDICAL AND RADIATION – PAIN INTENSITY QUANTIFIED
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 82.07
- 91.90
91.91 -
96.54
96.55 -
99.07
99.08 -
99.86
99.87 -
99.99 -- -- 100.00 Yes
Please note that Aprima® PRM 2015 is not certified for this measure. Therefore, information about this measure is not included in this document. This measure cannot be submitted through Aprima PRM.
96
CMS 159; NQF 0710; PQRS 370 DEPRESSION REMISSION AT TWELVE MONTHS
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Outcome N -- -- -- -- -- -- -- -- --
DOMAIN Clinical Processes and Effectiveness MEASURE The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event date. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score greater than 9 during the index event. indicates a need for treatment. EXCLUSIONS OR EXCEPTIONS
Patients who died. Patients who received hospice services. Patients who were permanent nursing home residents (> 1 year). Patients with a diagnosis of bipolar disorder. Patients with a diagnosis of personality disorder.
ENTERING DENOMINATOR DATA Adolescent patients 12 to 17 years of age and adults age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine during the index event. Enter the diagnosis with a qualifying diagnosis code or diagnosis code associated with a SNOMED code in the Dx tab of Full Note Composer or other clinical note type window or enter a problem associated with a qualifying SNOMED code in the problem history category in the Hx tab of Full Note Composer or the Patient History window. ICD-9 296.20, 296.21, 296.22, 296.23, 296.24, 296.25, 296.30, 296.31, 296.32, 296.33, 296.34, 296.35, 298.0, 300.4, 309.1, 311 ICD-10 F32.0, F32.1, F32.2, F32.3, F32.4, F32.9, F33.0, F33.1, F33.2, F33.3, F33.40, F33.41, F33.8, F33.9, F34.1, F34.1 SNOMED 832007, 2506003, 2506003, 2618002, 3109008, 3109008, 14183003, 15193003, 15639000, 18818009, 19694002, 19694002, 20250007, 25922000, 28475009, 30605009, 33078009, 33135002, 33736005, 36170009, 36170009, 36474008, 36923009, 38451003, 38451003, 38694004, 39809009, 40379007, 42810003, 42925002, 60099002, 63778009, 66344007,
97
67711008, 67711008, 68019004, 69392006, 70747007, 71336009, 73867007, 75084000, 76441001, 77911002, 78667006, 78667006, 79298009, 83176005, 83176005, 83458005, 84788008, 85080004, 85080004, 87414006, 87512008, 191601008, 191602001, 191604000, 191610000, 191611001, 191613003, 191676002, 192049004,231499006, 231504006, 268620009, 268621008, 274948002, 300706003, 319768000, 320751009, 321717001, 370143000, 430852001 To report on this measure, you must have set up an observation item for the PHQ-9 assessment score, and put the observation item in an observation template. The observation item must include the appropriate LOINC code for the PHQ-9 assessment. LOINC 44249-1, 44257-4, 44261-6, 54635-8 You must also have a clinical note type defined to include the Observation tab so that you can use the observation template to chart the assessment. None of the system-defined clinical note type windows (such as Full Note Composer) include the Observation tab. So, you must use a custom clinical note type window to chart patient visit notes that will include a functional status assessment. Enter the score of the PHQ-9 assessment in the observation template on the Observation tab. ENTERING NUMERATOR DATA Adolescent patients 12 to 17 years of age and adults who achieved remission at twelve months as demonstrated by a twelve month (+/- 60 days) PHQ-9 score of less than five. The visit that includes the follow up PHQ-9 assessment must be at least 11 months after and less than 13 months after the first assessment. To report on this measure, you must have set up an observation item for the PHQ-9 assessment score, and put the observation item in an observation template. The observation item must include the appropriate LOINC code for the PHQ-9 assessment. LOINC 44249-1, 44257-4, 44261-6, 54635-8 You must also have a clinical note type defined to include the Observation tab so that you can use the observation template to chart the assessment. None of the system-defined clinical note type windows (such as Full Note Composer) include the Observation tab. So, you must use a custom clinical note type window to chart patient visit notes that will include a functional status assessment. Enter the score of the PHQ-9 assessment in the observation template on the Observation tab.
98
CMS 160; NQF 0712; PQRS 371 DEPRESSION UTILIZATION OF THE PHQ-9 TOOL
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 1.65
- 2.45
2.46 -
3.32
3.33 -
4.32
4.33 -
5.59
5.60 -
8.32
8.33 -
14.99
15.00 -
48.14
>= 48.15 No
This measure cannot be reported on if the reporting period is less than one year. DOMAIN Clinical Processes and Effectiveness MEASURE The percentage of adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) with a diagnosis of major depression or dysthymia who have a completed PHQ-9 or PHQ-9M tool during the measurement period. EXCLUSIONS OR EXCEPTIONS
Patients who died. Patients who received hospice services. Patients who were permanent nursing home residents (> 1 year). Patients with a diagnosis of bipolar disorder. Patients with a diagnosis of personality disorder.
ENTERING DENOMINATOR DATA Adolescent patients (12 to 17 years of age) and adult patients age 18 and older with an office visit and the diagnosis of major depression or dysthymia who have completed PHQ-9 or PHQ-9M tool during the measurement year. Enter the diagnosis with a qualifying diagnosis code or diagnosis code associated with a SNOMED code in the Dx tab of Full Note Composer or other clinical note type window or enter a problem associated with a qualifying SNOMED code in the problem history category in the Hx tab of Full Note Composer or the Patient History window. ICD-9 296.20, 296.21, 296.22, 296.23, 296.24, 296.25, 296.30, 296.31, 296.32, 296.33, 296.34, 296.35, 298.0, 300.4, 309.1, 311 ICD-10 F32.0, F32.1, F32.2, F32.3, F32.4, F32.9, F33.0, F33.1, F33.2, F33.3, F33.40, F33.41, F33.8, F33.9, F34.1, F34.1 SNOMED 832007, 2506003, 2506003, 2618002, 3109008, 3109008, 14183003, 15193003, 15639000, 18818009, 19694002, 19694002, 20250007, 25922000, 28475009, 30605009, 33078009, 33135002, 33736005, 36170009, 36170009, 36474008, 36923009, 38451003, 38451003,
99
38694004, 39809009, 40379007, 42810003, 42925002, 60099002, 63778009, 66344007, 67711008, 67711008, 68019004, 69392006, 70747007, 71336009, 73867007, 75084000, 76441001, 77911002, 78667006, 78667006, 79298009, 83176005, 83176005,83458005, 84788008, 85080004, 85080004, 87414006, 87512008, 191601008, 191602001, 191604000, 191610000, 191611001, 191613003, 191676002, 192049004, 231499006, 231504006, 268620009, 268621008, 274948002, 300706003, 319768000, 320751009, 321717001, 370143000, 430852001 ENTERING NUMERATOR DATA Adolescent patients (12 to 17 years of age) and adult patients (18 years of age or older) included in the denominator who have at least one PHQ- 9 or PHQ-9M tool administered and completed during a four-month measurement period. To report on this measure, you must have set up an observation item for the PHQ-9 assessment score, and put the observation item in an observation template. The observation item must include the appropriate LOINC code for the PHQ-9 assessment. LOINC 44249-1, 44257-4, 44261-6, 54635-8 You must also have a clinical note type defined to include the Observation tab so that you can use the observation template to chart the assessment. None of the system-defined clinical note type windows (such as Full Note Composer) include the Observation tab. So, you must use a custom clinical note type window to chart patient visit notes that will include a functional status assessment. Enter the score of the PHQ-9 assessment in the observation template on the Observation tab.
100
CMS 161; NQF 0104; PQRS 107 MAJOR DEPRESSIVE DISORDER (MDD): SUICIDE RISK ASSESSMENT
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 22.86
- 51.99
52.00 -
74.42
74.43 -
84.92
84.93 -
88.45
88.46 -
92.80
92.81 -
95.50
95.51 -
96.47
>= 96.48 No
DOMAIN Clinical Processes and Effectiveness MEASURE Percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of MDD who had a suicide risk assessment completed at each visit during the measurement period. EXCLUSIONS OR EXCEPTIONS None. ENTERING DENOMINATOR DATA All patients aged 18 years and older with a new diagnosis or recurrent episode of MDD. Enter the diagnosis with a qualifying diagnosis code or diagnosis code associated with a SNOMED code in the Dx tab of Full Note Composer or other clinical note type window or enter a problem associated with a qualifying SNOMED code in the problem history category in the Hx tab of Full Note Composer or the Patient History window. ICD-9 296.20, 296.21, 296.22, 296.23, 296.24, 296.30, 296.31, 296.32, 296.33, 296.34 ICD-10 F32.0, F32.1, F32.2, F32.3, F32.9, F33.0, F33.1, F33.2, F33.3, F33.9 SNOMED 832007, 2618002, 14183003, 15193003, 15639000, 18818009, 20250007, 25922000, 28475009, 33078009, 33736005, 36474008, 36923009, 38694004, 39809009, 40379007, 42925002, 60099002, 63778009, 66344007, 69392006, 71336009, 73867007, 75084000, 76441001, 77911002, 79298009, 87512008, 191610000, 191611001, 191613003, 268621008, 319768000, 320751009, 370143000, 430852001 ENTERING NUMERATOR DATA Patients who had suicide risk assessment completed at each visit. To chart the assessment, you must enter a procedure code that is associated with the SNOMED code 225337009. Enter the procedure in the SP tab of Full Note Composer or other clinical note type window.
101
CMS 163; NQF 0064; PQRS 2 DIABETES: LOW DENSITY LIPOPROTEIN (LDL) MANAGEMENT
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Outcome Y 23.91
- 30.91
30.92 -
36.79
36.80 -
41.92
41.93 -
46.01
46.02 -
50.19
50.20 -
54.96
54.97 -
61.53
>= 61.54 No
DOMAIN Clinical Processes and Effectiveness MEASURE Percentage of patients 18–75 years of age with diabetes whose LDL-C was adequately controlled (<100 mg/dL) during the measurement period. EXCLUSIONS OR EXCEPTIONS Exclude patients with a diagnosis of gestational diabetes during the measurement period. ENTERING DENOMINATOR DATA Patients 18-75 years of age with diabetes with a visit during the measurement period. Enter the diagnosis with a qualifying diagnosis code or diagnosis code associated with a SNOMED code in the Dx tab of Full Note Composer or other clinical note type window or enter a problem associated with a qualifying SNOMED code in the problem history category in the Hx tab of Full Note Composer or the Patient History window. The diagnosis must be active. ICD-9 250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91, 250.92, 250.93, 648.01, 648.02, 648.03, 648.04 ICD-10 E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, E10.319, E10.321, E10.329, E10.331, E10.339, E10.341, E10.349, E10.351, E10.359, E10.36, 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, E11.321, E11.329, E11.331, E11.339, E11.341, E11.349, E11.351, E11.359, E11.36, 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, O24.011, O24.012, O24.013, O24.019, O24.02, O24.03, O24.111, O24.112, O24.113, O24.119, O24.12, O24.13
102
SNOMED 4783006, 9859006, 23045005, 28032008, 44054006, 46635009, 75682002, 76751001, 81531005,190330002, 190331003, 190368000, 190369008, 190372001, 190389009, 190390000, 199223000, 199225007, 199226008, 199227004, 199228009, 199229001, 199230006, 237599002, 237618001, 237626009, 237627000, 313435000, 313436004, 314771006, 314772004, 314893005, 314894004, 314902007, 314903002, 314904008, 359642000, 359939009 ENTERING NUMERATOR DATA Patients whose most recent LDL-C level performed during the measurement period is <100 mg/dL. To report on this measure, you must order or perform an LDL- C test, and then either enter the test results or receive them through an interface and give them a status of Resulted or Approved. Test results not received through an interface must be entered as discrete, quantifiable data. Enter the results in the Patients Results window using a lab template enabling you to enter the test result value. Results stored in the database as text notes or image file cannot be used for reporting. You must associate a LOINC code to the LDL-C test item on each lab template for both manually entered and electronic results. This uses the most recent test results. LOINC 2089-1, 13457-7, 18262-6
103
CMS 165; NQF 0018; PQRS 236 CONTROLLING HIGH BLOOD PRESSURE
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 51.10
- 56.51
56.52 -
60.77
60.78 -
64.28
64.29 -
67.46
67.47 -
70.93
70.94 -
74.88
74.89 -
80.42
>= 80.43 No
DOMAIN Clinical Processes and Effectiveness MEASURE Percentage of patients 18 through 85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period. EXCLUSIONS OR EXCEPTIONS Patients with evidence of end stage renal disease (ESRD), dialysis or renal transplant before or during the measurement period. Also exclude patients with a diagnosis of pregnancy during the measurement period. ENTERING DENOMINATOR DATA The patient must be between 18 and 85 years old. The patient must have had a diagnosis of essential hypertension at any time prior to the measurement period or be given this diagnosis within the first six months of the measurement period. You may enter the diagnosis in the Dx tab of Full Note Composer or another clinical note type window, or in the Problem/Diagnosis category in the Hx tab of Full Note Composer or in the Patient History window.
ICD-9 401.0, 401.1, 401.9
ICD-10 I10
SNOMED: 1201005, 10725009, 46481004, 48146000, 52698002, 56218007, 59621000, 59720008, 62275004, 65518004, 78975002, 276789009, 371125006, 429198000, 429457004 ENTERING NUMERATOR DATA To report on this measure, enter the patient’s blood pressure (both systolic and diastolic values) in the Vitals tab of Full Note Composer. These observation items for these blood pressure fields are associated with the appropriate LOIN codes. Patients are included in the numerator if the blood pressure entered for the most recent visit in the measurement period exceeds the target blood pressure.
104
CMS 166; NQF 0052; PQRS 312 USE OF IMAGING STUDIES FOR LOW BACK PAIN
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y 90.91
- 96.96
96.97 -
99.99 -- -- -- -- -- 100.00 Yes
DOMAIN Health Resources MEASURE Percentage of patients 18 through 50 years of age with a diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis. EXCLUSIONS OR EXCEPTIONS Exclude patients with a diagnosis of cancer any time in their history or patients with a diagnosis of recent trauma, IV drug abuse, or neurologic impairment during the 12-month period prior to the outpatient or emergency department visit. Exclude patients with a diagnosis of low back pain within the 180 days prior to the outpatient or emergency department visit. ENTERING DENOMINATOR DATA The patient must be between 18 and 50 years old. The patient must be given a diagnosis of low back pain during an outpatient or emergency department visit. This visit must occur prior to the last 28 days of the measurement period (that is, within the first 337 days of the measurement period). You must diagnosis the patient with lower back pain using a qualifying ICD-9 or SNOMED code. Enter the diagnosis code in the Dx tab of Full Note Composer or other clinical note type window. ICD-9 721.3, 722.10, 722.32, 722.52, 722.93, 724.02, 724.03, 724.2, 724.3, 724.5, 724.6, 724.70, 738.5, 739.3, 739.4, 846.0, 846.1, 846.2, 846.3, 846.8, 846.9, 847.2 ICD-10 M43.27, M43.28, M46.46, M46.47, M47.26, M47.27, M47.28, M47.816, M47.817, M47.818, M47.896, M47.897, M47.898, M48.06, M48.07, M51.26, M51.27, M51.36, M51.37, M51.46, M51.47, M51.86, M51.87, M53.2X7, M53.2X8, M53.3, M53.86, M53.87, M53.88, M54.30, M54.31, M54.32, M54.40, M54.41, M54.42, M54.5, M54.89, M54.9, M99.03, M99.04, M99.23, M99.33, M99.43, M99.53, M99.63, M99.73, S33.6XXA, S33.8XXA, S33.9XXA SNOMED 161894002, 202794004, 247368002, 267067009, 267982002, 278860009, 278862001, 279039007, 279040009, 279041008, 279042001, 300957005
105
PATIENTS ARE EXCLUDED FROM THE DENOMINATOR OF THIS MEASURE IF THEY HAVE: A diagnosis of cancer any time in their history, or A diagnosis of trauma, IV drug abuse, or neurologic impairment during the 12-month
period prior to the visit in which lower back pain is diagnosed, or A diagnosis of low back pain within the 180 days prior to the visit in which lower back
pain is diagnosed. ENTERING NUMERATOR DATA To report on this measure, the patient would not have a CT scan, MRI, or x-ray of the lower spine performed within 28 days of diagnosis of low back pain. To ensure accurate reporting, you must associate the procedure codes for all CT scans, MRIs, x-rays, and other imaging studies of the lower spine with one of the following LOINC codes. LOINC CODES 24665-2, 24929-2, 24930-0, 24963-1, 24964-9, 24965-6, 24967-2, 24968-0, 24969-8, 24970-6, 24971-4, 24972-2, 24975-5, 24977-1, 24984-7, 30620-9, 30678-7, 30679-5, 30713-2, 30714-0, 30715-7, 30716-5, 30717-3, 30773-6, 30774-4, 30775-1, 30776-9, 30777-7, 30778-5, 30797-5, 30854-4, 30855-1, 30883-3, 30884-1, 36058-6, 36059-4, 36060-2, 36069-3, 36100-6, 36110-5, 36111-3, 36245-9, 36246-7, 36247-5, 36332-5, 36390-3, 36391-1, 36392-9, 36402-6, 36520-5, 36521-3, 36522-1, 36647-6, 36670-8, 36674-0, 36681-5, 36688-0, 36735-9, 36946-2, 36949-6, 36990-0, 36992-6, 37003-1, 37009-8, 37011-4, 37073-4, 37078-3, 37101-3, 37105-4, 37132-8, 37172-4, 37208-6, 37232-6, 37256-5, 37257-3, 37259-9, 37260-7, 37261-5, 37288-8, 37300-1, 37340-7, 37341-5, 37342-3, 37351-4, 37353-0, 37355-5, 37356-3, 37357-1, 37509-7, 37515-4, 37516-2, 37651-7, 37652-5, 37653-3, 37658-2, 37659-0, 37660-8, 37974-3, 37975-0, 38008-9, 42410-1, 42411-9, 42413-5, 42424-2, 42425-9, 42426-7, 42427-5, 42428-3, 42429-1, 42472-1, 42690-8, 42692-4, 42698-1, 43569-3, 43784-8, 43791-3, 44114-7, 44178-2, 44179-0, 44194-9, 44196-4, 44203-8, 44206-1, 46340-6, 47382-7, 47984-0, 48436-0, 48452-7, 48469-1, 48473-3, 69116-2, 69264-0, 69273-1, 70928-7
106
CMS 177; NQF 1365; PQRS 382 CHILD AND ADOLESCENT MAJOR DEPRESSIVE DISORDER: SUICIDE RISK ASSESSMENT
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process Y -- -- -- -- -- -- -- -- --
DOMAIN Patient Safety MEASURE Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk. Please note that the numerator and denominator counts on this measure are a count of distinct visits, not of distinct patients. Therefore, on the CQM 2014 report, the denominator and numerator counts on the summary page will not equal the count of patients in the patient list accessed through the hyperlink for the denominator or numerator. EXCLUSIONS OR EXCEPTIONS None ENTERING DENOMINATOR DATA All patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder. Enter the diagnosis with a qualifying diagnosis code or diagnosis code associated with a SNOMED code in the Dx tab of Full Note Composer or other clinical note type window or enter a problem associated with a qualifying SNOMED code in the problem history category in the Hx tab of Full Note Composer or the Patient History window. ICD-9 296.20, 296.21, 296.22, 296.23, 296.24, 296.30, 296.31, 296.32, 296.33, 296.34 ICD-10 F32.0, F32.1, F32.2, F32.3, F32.9, F33.0, F33.1, F33.2, F33.3, F33.9 SNOMED 832007, 2618002, 14183003, 15193003, 15639000, 18818009, 20250007, 25922000, 28475009, 33078009, 33736005, 36474008, 36923009, 38694004, 39809009, 40379007, 42925002, 60099002, 63778009, 66344007, 69392006, 71336009, 73867007, 75084000, 76441001, 77911002, 79298009, 87512008, 191610000, 191611001, 191613003, 268621008, 319768000, 320751009, 370143000, 430852001
107
ENTERING NUMERATOR DATA Patient visits with an assessment for suicide risk. To chart the assessment, you must enter a procedure code that is associated with the SNOMED code 225337009. Enter the procedure in the SP tab of Full Note Composer or other clinical note type window.
108
CMS 179; NQF NA; PQRS 380 ADE PREVENTION AND MONITORING: WARFIN AND TIME IN THERAPEUTIC RANGE
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Outcome N -- -- -- -- -- -- -- -- --
Please note that Aprima® PRM 2015 is not certified for this measure. Therefore, information about this measure is not included in this document. This measure cannot be submitted through Aprima PRM.
109
CMS 249; NQF NA; PQRS 472 APPROPRIATE USE OF DXA SCANS IN WOMEN UNDER 65 YEARS WHO DO NOT MEET THE RISK FACTOR PROFILE FOR OSTEOPOROTIC FRACTURE
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process - - -- -- -- -- --
DOMAIN Efficiency and Cost Reduction MEASURE Percentage of female patients aged 50 to 64 without select risk factors for osteoporotic fracture who received an order for a dual-energy x-ray absorptiometry (DXA) scan during the measurement period. EXCLUSIONS OR EXCEPTIONS Exclude from the denominator patients with a combination of risk factors (as determined by age) or one of the independent risk factors:
Ages: 50-54 (>=4 combo risk factors) or 1 independent risk factor Ages: 55-59 (>=3 combo risk factors) or 1 independent risk factor Ages: 60-64 (>=2 combo risk factors) or 1 independent risk factor
Combination risk factors (The following risk factors are all combination risk factors; they are grouped by when they occur in relation to the measurement period): The following risk factors may occur any time in the patient's history but must be active during the measurement period:
White (race) BMI <= 20 kg/m2 (must be the first BMI of the measurement period) Smoker (current during the measurement period) Alcohol consumption (> two units per day (one unit is 12 oz. of beer, 4 oz. of wine, or 1
oz. of liquor)) The following risk factor may occur any time in the patient's history and must not start during the measurement period:
Osteopenia The following risk factors may occur at any time in the patient's history or during the measurement period:
Rheumatoid arthritis Hyperthyroidism Malabsorption syndromes: celiac disease, inflammatory bowel disease, ulcerative colitis,
Crohn's disease, cystic fibrosis, malabsorption Chronic liver disease
110
Chronic malnutrition The following risk factors may occur any time in the patient's history and do not need to be active at the start of the measurement period:
Documentation of history of hip fracture in parent Osteoporotic fracture Glucocorticoids (>= 5 mg/per day) [cumulative medication duration >= 90 days]
Independent risk factors (The following risk factors are all independent risk factors; they are grouped by when they occur in relation to the measurement period): The following risk factors may occur at any time in the patient's history and must not start during the measurement period:
Osteoporosis The following risk factors may occur at any time in the patient's history prior to the start of the measurement period, but do not need to be active during the measurement period:
Gastric bypass FRAX[R] 10-year probability of all major osteoporosis related fracture >= 9.3 percent Aromatase inhibitors
The following risk factors may occur at any time in the patient's history or during the measurement period:
Type I diabetes End stage renal disease Osteogenesis imperfecta Ankylosing spondylitis Psoriatic arthritis Ehlers-Danlos syndrome Cushing’s syndrome Hyperparathyroidism Marfan syndrome Lupus
ENTERING DENOMINATOR DATA Female patients ages 50 to 64 years with an encounter during the measurement period ENTERING NUMERATOR DATA Female patients who received an order for at least one DXA scan in the measurement period.
111
CMS 349; NQF NA; PQRS 475 HIV SCREENING
Measure Type
Benchmark Decile 3
Decile 4
Decile 5
Decile 6
Decile 7
Decile 8
Decile 9
Decile 10
Topped Out
Process - - -- -- -- -- --
DOMAIN Community/Population Health MEASURE Percentage of patients 15-65 years of age who have ever been tested for human immunodeficiency virus (HIV). EXCLUSIONS OR EXCEPTIONS Patients diagnosed with HIV prior to the start of the measurement period. ENTERING DENOMINATOR DATA Patients 15 to 65 years of age who had an outpatient visit during the measurement period ENTERING NUMERATOR DATA Patients with documentation of the occurrence of an HIV test between their 15th and 66th birthdays and before the end of the measurement period. LOINC 56888-1, 20447-9, 29541-0, 62469-2, 87706-8, 25835-0, 31201-7, 75666-8, 80387-4, 89374-3, 53379-4, 85037-0, 29893-5, 18396-2, 30361-0, 5220-9, 53601-1, 5224-1, 89365-1, 80803-3, 68961-2, 81641-3, 86233-4, 69668-2, 49580-4, 25835-0, 20447-9, 29541-0, 5221-7, 32571-2, 49905-3, 35439-9, 85686-4, 31201-7
112
HOW TO RUN THE QUALITY REPORT OBJECTIVE Allow the user to understand how to run the CQM 2015 report for Quality from the Reports icon and export the patient reports for final submission. STEP BY STEP INSTRUCTIONS
From your Aprima® desktop, select the Reports icon.
In the View Report window, select the CQM 2015 report from the Clinical Quality menu. All providers regardless of stage will run this report as it shows you the list of measures based on the final rule released by the CMS in October 2015.
For the Filter Attributes: • Select search next to your Filter Name to pull in a filter if you have created one. If
you do not have a filter please proceed with the following items. • Select CQM2018 in the CQM Version field • The Description field is left blank. • The CMS Program radio button should be on ‘PQRS Meaningful Use Individual’. • The Payer field should be left blank to pull all payer data for the EHR submission
method. • Search for and select the provider name the report is for in the Provider field. (If you
are reporting as a GPRO do not select a provider. This will run the report for all providers.)
• Leave the Provider Option on Billing Provider unless the provider the report is for is never the billing provider then select Rendering Provider.
• The Measure Date is for the entire calendar year or the reporting period you have selected.
• Select the six (or more) measures that you have predetermined. • Leave the Financial Center and Service Site fields blank to include all visits and select
VIEW.
113
Should you have difficulty displaying the report, please contact your Account Manager.
To export the Summary Report, select the Export Icon. From the dropdown menu select Export Summary Report. Save the document to your computer. Once the document is saved you will receive a pop up window saying the document has been saved. Wait for this window to pop up before you close out of any windows.
114
•
