Medicare Shared Savings Program Accountable Care Organization (ACO) Measures Deep Dive Series

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1 Medicare Shared Savings Program Accountable Care Organization (ACO) Measures Deep Dive Series Preventive Care and Screening (PREV-5): Measure 20 Breast Cancer Screening ACO_QRM20PPTv9_0518_IA Approved 1

2 Measure 20: Breast Cancer Screening Objectives: Understand acceptable documentation required to successfully satisfy the Breast Cancer Screening measure Understand the following: Appropriate age parameter Acceptable breast cancer screening tools Two acceptable exclusions 2

3 Measure 20: Breast Cancer Screening Measure Description: Percentage of women years of age who had a mammogram to screen for breast cancer during the measurement period or the 15 months prior to the measurement period. Age Parameters: The 27 month look-back period (October 1, 2016-December 31, 2018) applies to women years. Women ages are included in the initial population sample if they had an office visit during the measurement year. 3

4 Measure 20: Measure Qualification Determine if the patient is qualified for the measure. The measure qualification answer is Yes unless prior approval is received to select: No Other CMS Approved Reason This answer is only acceptable with approval from the Centers for Medicare & Medicaid Services (CMS) 4

5 Measure 20: Measure Qualification If the measure qualification answer is Yes, does the patient meet one of the following three accepted exclusions? Bilateral mastectomy Evidence of a right and left unilateral mastectomies Patients age 65 and older in Institutional Special Needs Plans (SNP) or residing in long-term care with a POS (Place of Service) code 32, 33, 34, 54 or 56 any time during the measurement period Note: All SNF patients are NOT excluded from these measures they must be nursing home / custodial care residents or in a residential treatment facility. Acceptable long-term care facilities are: nursing facilities, custodial care facilities, hospice, intermediate care facilities for individuals with intellectual disabilities or psychiatric residential treatment centers. 5

6 Measure 20: Breast Cancer Screening 1. Is patient breast cancer screening current? (Within age parameters required) Yes Documentation that a breast cancer screening was performed during the measurement year or within 15 months prior to the measurement year. No No documentation that a breast cancer screening was performed per the above age requirements and within the age parameters required 6

7 Measure 20: Breast Cancer Screening 2. Are the required results documented in the medical record? Yes Documentation of a breast cancer screening results/findings and date performed are present in the medical record for the appropriate time parameters No Documentation of the breast cancer screening results/findings or date performed are not present in the medical record for the appropriate time parameters Note: Documentation of normal or abnormal is acceptable. 7

8 Measure 20: Quick Tips 8 Acceptable exclusions are a history of a bilateral mastectomy or history of right AND left unilateral mastectomies: The bilateral mastectomy must have occurred by the end of the measurement period. Documentation of both the date and results of a mammogram are required to successfully complete this measure. Acceptable breast cancer screenings include: screening or diagnostic mammography (film or digital) or digital 3-D mammography. This measure evaluates primary screening. MRI, Ultrasound and Biopsies are not considered breast cancer screening for this measure as they not appropriate methods for primary breast cancer screening. Patient Reported Requirement: Date and type of test Result/finding It is not acceptable to chase screening reports and add them to the medical record after the close of the measurement year even if the exam performed in 2018

9 Measure 20: Skip Vs Performance Met Beneficiary Skip Not Qualified = Hospice, Death, Moved Out of Country, Medicare Not Primary Measure Skip Bilateral mastectomy Evidence of a right and left unilateral mastectomies Patients age 65 and older residing in long-term care facilities at any time during Acceptable long-term care facilities are: nursing facilities, custodial care facilities, hospice, intermediate care facilities for individuals with intellectual disabilities or psychiatric residential treatment centers. 9

10 Measure 20: Skip Vs Performance Met Performance Met Breast cancer screening completed documentation in the medical record of both date and result/finding Performance Not Met Breast cancer screening not completed Breast cancer screening completed but no documentation of date and/or result/finding 10

11 Measure 20: Numerator & Denominator Inclusion in the Denominator: Beneficiary is qualified for the sample Medical record is available Age/Timeframe qualifications met Beneficiary is qualified for the measure Inclusion in the Numerator: Current screening date and results are in the medical record 11

12 Disclaimer: This presentation was current at the time it was published. The CMS Programs are subject to policy changes. Links to the resource documents have been provided in the following page(s) within this document for your reference. Review the link(s) for specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents. 12

13 Resources: CMS Quality Payment Program website: Payment-Program.html Educational Resources: Quality Payment Resource Library: Library/2018-Resources.html Quality Measure Specification Supporting Documents (with codes): Library/2018-Web-Interface-Measures-and-supporting-documents.zip 13

Medicare Shared Savings Program Accountable Care Organization (ACO) Measures Deep Dive Series

Medicare Shared Savings Program Accountable Care Organization (ACO) Measures Deep Dive Series Preventive Care and Screening (PREV-6): Measure 19 Colorectal Cancer Screening ACO_QRM19PPTv9_0518_IA Approved