Possible Denominator Codes Applicable to OMS * Le Fort Fractures 21346, 21347, 21348, 21422, 21423, 21432, 21433, 21435, 21436

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1 2015 Individual PQRS s Eligible OMS #22: Perioperative Care: Discontinuation of Prophylactic Antibiotics (Non- Cardiac Procedures) Percentage of noncardiac surgical patients aged 18 years and older undergoing procedures with the indications for prophylactic parenteral antibiotics who received a prophylactic parenteral antibiotic, who have an order for discontinuation of prophylactic parenteral antibiotics within 24 hours of surgical end time Having one of the non-cardiac surgical procedures for which prophylactic parenteral antibiotics are indicated. Le Fort Fractures 21346, 21347, 21348, 21422, 21423, 21432, 21433, 21435, Mandibular Fractures 21454, 21461, 21462, 21465, Glossectomy 41130, 41135, 41140, 41145, 41150, 41153, Non-cardiac surgical patients who have an order for discontinuation of prophylactic parenteral antibiotics within 24 hours of surgical end time Documentation of Order for Discontinuation of Prophylactic Parenteral Antibiotics (written order, verbal order, or standing order/protocol) Within 24 Hours of Surgical End Time (Two CPT II codes [4049F & 4046F] are required on the claim form to submit this numerator option) CPT II 4049F: Documentation that order was given to discontinue prophylactic antibiotics within 24 hours of surgical end time, non-cardiac procedure Note: CPT Category II code 4049F is provided for documentation that antibiotic discontinuation was ordered or that antibiotic discontinuation was accomplished. Report CPT Category II code 4049F if antibiotics were discontinued within 24 hours. CPT II 4046F: Documentation that prophylactic antibiotics were given within 4 hours prior to surgical incision or given intraoperatively Prophylactic Parenteral Antibiotics not Discontinued for Medical Reasons (Two CPT II codes [4049F-1P & 4046F] are required on the claim form to submit this numerator option) Append a modifier (1P) to CPT Category II code 4049F to report documented circumstances that appropriately exclude patients from the denominator. 4049F with 1P: Documentation of medical reason(s) for not discontinuing prophylactic antibiotics within 24 hours of surgical end time

2 CPT II 4046F: Documentation that prophylactic antibiotics were given within 4 hours prior to surgical incision or given intraoperatively If patient is not eligible for this measure because patient did not receive prophylactic parenteral antibiotics within specified timeframe, report: (One CPT II code [4042F] is required on the claim form to submit this numerator option) CPT II 4042F: Documentation that prophylactic antibiotics were neither given within 4 hours prior to surgical incision nor given intraoperatively Prophylactic Parenteral Antibiotics not Discontinued, Reason not Specified (Two CPT II codes [4049F-8P & 4046F] are required on the claim form to submit this numerator option) Append a reporting modifier (8P) to CPT Category II code 4049F to report circumstances when the action described in the numerator is not performed and the reason is not otherwise specified. 4049F with 8P: Order was not given to discontinue prophylactic antibiotics within 24 hours of surgical end time, non-cardiac procedure, reason not otherwise specified #23: Perioperative Care: Venous Le Fort Fractures 21346, 21347, 21348, 21422, Surgical patients who had an order for CPT II 4046F: Documentation that prophylactic antibiotics were given within 4 hours prior to surgical incision or given intraoperatively CPT II 4044F: Documentation that an order was given for venous thromboembolism (VTE) prophylaxis to be given within 24 hours prior to incision time or 24 hours after surgery end time

3 #46: Thromboembolism (VTE) Prophylaxis Percentage of surgical patients aged 18 years and older undergoing procedures for which VTE prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low- Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time Medication Reconciliation: Reconciliation After Discharge from an Inpatient Facility Percentage of patients aged 65 years and older discharged from any inpatient facility (eg, hospital, skilled nursing facility, or rehabilitation facility) and seen within 60 days following discharge in the office by the physician providing on-going care who had a reconciliation of the discharge, GPRO the s 65 years on the s 21423, 21432, 21433, 21435, Mandibular Fractures 21454, 21461, 21462, 21465, Glossectomy 41130, 41135, 41140, 41145, 41150, 41153, , 99204, 99205, 99212, 99213, 99214, 99215, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, LMWH, LDUH, adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time had a reconciliation of the discharge medications with the current medication list in the outpatient medical record documented 4044F with 1P: Documentation of medical reason(s) for patient not receiving any form of VTE prophylaxis (LMWH, LDUH, adjusted-dose warfarin, fondaparinux or mechanical prophylaxis) within 24 hours prior to incision time or 24 hours after surgery end time 4044F with 8P: Order was not given for venous thromboembolism (VTE) prophylaxis to be given within 24 hours prior to incision time or 24 hours after surgery end time, reason not otherwise specified Documentation of Reconciliation of Discharge Medication with Current Medication List in the Medical Record (CPT II code [1111F] is required on the claim form to submit this numerator option) CPT II 1111F: Discharge medications reconciled with the current medication list in outpatient medical record If patient is not eligible for this measure because patient was not discharged from an inpatient facility within the last 60 days, there are no reporting requirements in this case. Discharge Medication not Reconciled with Current Medication List in the Medical Record, Reason Not Specified

4 medications with the current medication list in the medical record documented (Two CPT II codes [1111F-8P & 1110F] are required on the claim form to submit this numerator option) Append a reporting modifier (8P) to CPT Category II code 1111F to report circumstances when the action described in the numerator is not performed and the reason is not otherwise specified. 1111F with 8P: Discharge medications not reconciled with the current medication list in outpatient medical record, reason not specified #47 Advanced Care Plan, EHR Patients aged > 65 years on Having one of the s during the reporting period 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99234, 99235, 99236, 99291, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0402 have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan Advance Care Planning Discussed and Documented CPT II 1123F: Advance Care Planning discussed and documented; advance care plan or surrogate decision maker documented in the medical record CPT II 1124F: Advance Care Planning discussed and documented in the medical record; patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan Advance Care Planning not Documented, Reason not Otherwise Specified Append a reporting modifier (8P) to CPT Category II code 1123F to report circumstances when the action described in the numerator is not performed and the reason is not otherwise specified. 1123F with 8P: Advance care planning not documented, reason not otherwise specified

5 #130: #131: Documentation of Current Medications in the Medical Record: 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, overthe-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements must contain the medications name, dosage, frequency and route of administration Pain Assessment and Follow-Up: Percentage of visits for patients aged 18 years and older with documentation of a pain assessment through discussion with the patient including the use of a standardized tool(s) on each visit documentation of a follow-up plan when pain is present the s the s 92610, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, D7140, D , 96116, 96150, 97532, 99203, 99204, 99205, 99212, 99213, 99214, Patient documentation substantiates use of a certified, Physician Quality System qualified or other acceptable EHR system. NUMERAT NOTE: If an eligible professional does not use a qualified system to record the, they should not report any G-code. Current medications including name, dosages, frequency and route documented by the provider Encounter Documented Using a Certified, Physician Quality System Qualified or Other Acceptable EHR System G8447: Patient was documented using an EHR system that has been certified by an Authorized Testing and Certification Body (ATCB) G8448: Patient was documented using a Physician Quality System qualified EHR or other acceptable systems G8730: Pain assessment documented as positive utilizing a standardized tool and a followup plan is documented G8731: Pain assessment documented as negative, no follow-up plan required G8442: Documentation that patient is not eligible for a pain assessment

6 G8939: Pain assessment documented, follow-up plan not documented, patient not eligible/appropriate G8732: No documentation of pain assessment, reason not given #173 #193 Preventive Care and Screening: Unhealthy Alcohol Use- Screening: Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use at least once within 24 months using a systematic screening method Perioperative Temperature Management: Percentage of patients, regardless of age, undergoing surgical or therapeutic procedures under general or neuraxial anesthesia of the s All patients, regardless of age, undergoing surgical or therapeutic procedures under general or neuraxial 96150, 96151, 96152, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, G0438, G , 99203, 99204, 99205, 99211, 99212, 99213, 99214, were screened for unhealthy alcohol use at least once within 24 months using a systematic screening method. Patients for whom either active warming was used intraoperatively for the purpose of maintaining normothermia G8509: Documentation of positive pain assessment; no documentation of a follow-up plan, reason not given 3016F: Patient screened for unhealthy alcohol use using a systematic screening method 3016F with 1P: Documentation of medical reasons for not screening for unhealthy alcohol use 3016F with 9P: Unhealthy alcohol use screening not performed, reason not otherwise specified 4250F: Active warming used intraoperatively for the purpose of maintaining normothermia, at least one body temperature equal to or greater than 36 degrees Centigrade (or 96.8 degrees Fahrenheit) recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time

7 # minutes duration or longer, except patients undergoing cardiopulmonary bypass, for whom either active warming was used intraoperatively for the purpose of maintaining normothermia, at least one body temperature equal to or greater than 36 degrees Centigrade (or 96.8 degrees Fahrenheit) was recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time Oncology: Cancer Stage Documented Percentage of patients, regardless of age, with a diagnosis of cancer who are seen in the ambulatory setting who have a baseline AJCC cancer stage or documentation that the cancer is metastatic in the medical record at least once within 12 months anesthesia of 60 minutes duration or longer, except patients undergoing cardiopulmonar y bypass All patients, regardless of age, with a diagnosis of cancer who are seen in the Ambulatory setting Having one or more of the s (ICD-9-CM, CPT codes) , , 160.0, 160.2, 160.3, , , 170.0, 170.1, 171.0, , , , 77261, 77262, 77263, 99201, 99202, 99203, 99204, 99205, at least one body temperature equal to or greater than 36 degrees Centigrade (or 96.8 degrees Fahrenheit) was recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time have a baseline American Joint Committee on Cancer (AJCC) cancer stage or documentation that the cancer is metastatic in the medical record at least once within the 12 month reporting period 4255F: Duration of general or neuraxial anesthesia 60 minutes or longer, as documented in the anesthesia record 4256F: Duration of general or neuraxial anesthesia less than 60 minutes, as documented in the anesthesia record Cancer Stage Documented and Reviewed CPT II 3300F: American Joint Committee on Cancer (AJCC) stage documented and reviewed CPT II 3301F: Cancer stage documented in medical record as metastatic and reviewed Cancer Stage not Documented, Reason not Otherwise Specified Append a reporting modifier (8P) to CPT Category II code 3301F to report circumstances when the action described in the numerator is not performed and the reason is not otherwise specified. 3301F with 8P: Cancer stage not documented, reason not otherwise specified

8 # 226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months who received cessation counseling intervention if identified as a tobacco user, EHR, GPRO the s 99212, 99213, 99214, , 99204, 99205, 99212, 99213, 99214, were screened for tobacco use at least once within 24 months who received tobacco cessation counseling intervention if identified as a tobacco user Patient Screened for Tobacco Use CPT II 4004F: Patient screened for tobacco use received tobacco cessation counseling, if identified as a tobacco user Patient Screened for Tobacco Use and Identified as a Non-User of Tobacco CPT II 1036F: Current tobacco non-user Tobacco Screening not Performed for Medical Reasons Append a modifier (1P) to CPT Category II code 4004F to report documented circumstances that appropriately exclude patients from the denominator 4004F with 1P: Documentation of medical reason(s) for not screening for tobacco use (e.g., limited life expectancy) #265 Biopsy Follow-Up: Percentage of new patients whose biopsy results have been reviewed and communicated to the All patients undergoing a biopsy 11100, 20200, 20205, 20206, 20220, 20225, 20240, 20245, 30100, 31050, se biopsy results have been reviewed and communicated Tobacco Screening not Performed Reason Not Specified Append a reporting modifier (8P) to CPT Category II code 4004F to report circumstances when the action described in the numerator is not performed and the reason is not otherwise specified. 4004F with 8P: Tobacco Screening not performed, reason not otherwise specified G8883: Biopsy results reviewed, communicated, tracked and documented G88884:Clinician documented reason that patient s biopsy results were not reviewed, [e.g.,

9 #317 primary care/referring physician and patient by the performing physician Preventive Care and Screening: Screening for High Blood Pressure and Follow-up Documented Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure a recommended follow-up plan is documented based on the current the s 31051, 38500, 38505, 40490, 40808, 41100, 41108, 42100, 42400, 42405, 42800, 42802, 42804, 42806, 64795, 99201, 99202, 99203, 99204, , 99204, 99205, 99212, 99213, 99214, 99215, 99218, 99219, 99220, 99224, 99225, 99226, 99234, 99235, 99236, 99281, 99282, 99283, 99285, D7140, D7210, G0101, G0402, G0438, G0429 to the primary care/referring physician and the patient by the physician performing the biopsy. The physician performing the biopsy must also acknowledge and/or document the communication in a biopsy tracking log and document in the patient s medical record. were screened for high blood pressure have a recommended follow-up plan documented, as indicated if the blood pressure is prehypertensive or hypertensive patient asks that biopsy results not be communicated to the primary care/referring physician, patient does not have a primary care/referring physician or is a self-referred patient] G8885: Biopsy results NOT reviewed, communicated, tracked or documented G8783: Normal blood pressure reading documented, follow-up not required G8950: Pre-Hypertensive or Hypertensive blood pressure reading documented, the indicated follow-up is documented G8784: Blood pressure reading not documented, documentation the patient is not eligible G8951: Pre-Hypertensive or Hypertensive blood pressure reading documented, indicated followup not documented, documentation the patient is not eligible

10 #332 blood pressure (BP) reading as indicated Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin Prescribed for Patients with Acute Bacterial Sinusitis Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulanate, as a Diagnosis for acute sinusitis [for 1/1/2014-9/30/2014]: 461.0, 461.1, 99204, 99205, 99212, 99213, 99214, 99215, 99281, 99282, 99283, 99284, NUMERAT NOTE: Although the recommended screening interval for a normal BP reading is every 2 years, to meet the intent of this measure, a BP screening must be performed once per measurement period. The intent of this measure is to screen patients for high blood pressure and provide recommended follow-up as indicated. Normal blood pressure follow-up is not recommended for patients with clinical or symptomatic hypotension. were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosis G8785: Blood pressure reading not documented, reason not given G8952: Pre-Hypertensive or Hypertensive blood pressure reading documented, indicated followup not documented, reason not given G9315: Amoxicillin, with or without clavulanate, prescribed as a first line antibiotic at the time of diagnosis G9313: Amoxicillin, with or without clavulanate, not prescribed as first line antibiotic at the time of diagnosis for documented reason (e.g., cystic fibrosis, immotile cilia disorders, ciliary dyskinesia, immune deficiency, prior history of sinus surgery within the past 12 months, and anatomic abnormalities, such as deviated nasal septum, resistant organisms, allergy to medication, recurrent sinusitis, chronic sinusitis, or other reasons)

11 first line antibiotic at the time of diagnosis 461.2, 461.3, 461.8, Diagnosis for acute sinusitis (ICD-10-CM) [for 10/01/ /31/2014]: J01.00, J01.10, J01.20, J01.30, J01.40, J01.80, J01.90 G9314: Amoxicillin, with or without clavulanate, not prescribed as first line antibiotic at the time of diagnosis, reason not given the s #333 Adult Sinusitis: Computed Tomography (CT) for Acute Sinusitis (Overuse): Percentage of patients aged 18 years and older with a diagnosis of acute sinusitis who had a Diagnosis for acute sinusitis 99204, 99205, 99212, 99213, 99214, 99215, 99281, 99282, 99283, 99284, had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or G9349: CT scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after diagnosis G9348: CT scan of the paranasal sinuses ordered at the time of diagnosis for documented reasons (e.g., persons with sinusitis symptoms lasting at least 7 to 10 days, antibiotic resistance, immunocompromised, recurrent

12 computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis [for 1/1/2014-9/30/2014]: 461.0, 461.1, 461.2, 461.3, 461.8, Diagnosis for acute sinusitis (ICD-10-CM) [for 10/01/ /31/2014]: J01.00, J01.10, J01.20, J01.30, J01.40, J01.80, J01.90 received within 28 days after diagnosis sinusitis, acute frontal sinusitis, acute sphenoid sinusitis, periorbital cellulitis, or other medical) G9350: CT scan of the paranasal sinuses not ordered at the time of diagnosis or received within 28 days after diagnosis the s #334 Adult Sinusitis: More than one Computerized Tomography (CT) Scan Within , 99205, 99212, 99213, 99214, 99215, 99281, 99282, had more than one CT scan of the paranasal sinuses ordered or received G9352: More than one CT scan of the paranasal sinuses ordered or received within 90 days after the diagnosis, reason not given

13 Days for Chronic Sinusitis (Overuse): Percentage of patients aged 18 years and older with a diagnosis of chronic sinusitis who had more than one CT scan of the paranasal sinuses ordered or received within 90 days after diagnosis Diagnosis for acute sinusitis [for 1/1/2014-9/30/2014]: 461.0, 461.1, 461.2, 461.3, 461.8, Diagnosis for acute sinusitis (ICD-10-CM) [for 10/01/ /31/2014]: J01.00, J01.10, J01.20, J01.30, J01.40, J01.80, J , 99284, within 90 days after diagnosis G9353: More than one CT scan of the paranasal sinuses ordered or received within 90 days after the diagnosis for documented reasons (e.g., patients with complications, second CT obtained prior to surgery, other medical reasons) G9354: One CT scan or no CT scan of the paranasal sinuses ordered within 90 days after the diagnosis the s #342 Pain Brought Under Control Within 48 Hours: 18 years 99324, 99325, 99326, 99337, G0182 se pain was brought to a G9250: Documentation of patient pain brought to a comfortable level within 48 hours from initial assessment

14 Patients aged 18 and older who report being uncomfortable because of pain at the initial assessment (after admission to palliative care services) who report pain was brought to a comfortable level within 48 hours the s comfortable level within 48 hours of initial assessment (after admission to palliative care services) G9251: Documentation of patient with pain not brought to a comfortable level within 48 hours from initial assessment Patient able to communicate and understand the language of the person asking #402 Tobacco Use and Help with Quitting Among Adolescents National Quality Strategy Domain: Patient selfreported uncomfortable due to pain at the initial assessment Patients aged 1220 years on the 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99406, 99407, were screened for tobacco use at least once within 18 months (during the G9458: Patient documented as tobacco user received tobacco cessation intervention (must include at least one of the following: advice given to quit smoking or tobacco use, counseling on the benefits of quitting smoking or tobacco use, assistance with or referral to external smoking or tobacco cessation support programs, or current enrollment in smoking or tobacco

15 Community / Population Health Tobacco Use and Help with Quitting Among Adolescents National Quality Strategy Domain: Community / Population Health the s measurement period or the six months prior to the measurement period) who received tobacco cessation counseling intervention if identified as a tobacco user use cessation program) if identified as a tobacco user G9459: Currently a tobacco non-user G9460: Tobacco assessment tobacco cessation intervention not performed, reason not otherwise specified CMS has established the QualityNet Help Desk as a resource for those with questions on PQRS reporting. They can be reached at or qnetsupport@sdps.org from 7:00 a.m. 7:00 p.m. CST.

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