Measure Description Notable Measure Details 2019 Documentation Tips

Transcription

1 Keywords and Documentation Tips This document provides simple keywords and documentation tips to help meet measure requirements in the Axon Registry. This is not an exhaustive list, for more information about each measure and other ways to meet it please visit our website here. The measures are listed in alphabetical order by disease state. Key phrases can also be found on the dashboard. Measure Identification ALS Axon 35 QPP 386 Measure Description Notable Measure Details 2019 Documentation Tips Percentage of patients diagnosed with ALS who were offered at least once annually assistance in planning for end of life issues Allowable Exclusion: Patients are not counted in the measure if there is a medical reason to not offer end of life planning (eg patient in hospice) AND the physician decides not to document end of life planning. Advanced directive reviewed Health power of attorney reported Palliative discussed Back Pain Axon 48 Percentage of patients 18 to 65 years of age with back pain who were counseled to remain active and exercise or were referred to physical therapy Allowable Exclusion Examples: - Patient has history of cancer - Patient at risk for fractures - Existing order for physical therapy Documenting just PT will not meet the measure. Referral to physical therapy Referral to PT Activity counseling Resume normal activity Exercise education Child Neurology Axon 32 Percentage of patients receiving appropriate first line treatment for infantile spasms (IS) The drug must be present on the encounter or within one week after the encounter. Please note this measure will be a QI measure only in 2019 Guideline recommended therapy within 1 week of IS diagnosis Currently prescribed ACTH for IS^ Currently prescribed high dose prednisolone for IS^ Currently prescribed VGB for IS^ ^ presence of drug meets the measure Axon 33 Percentage of patients who were queried for psychological and/or behavioral comorbid conditions of tic disorder (TD) or Tourette syndrome (TS), and if present, treated or referred for treatment of comorbid conditions This measure has an AND condition. If your patient has co-morbid condition you must provide a follow up action. If your patient does not have a co-morbid condition you must document that is the case and no further action is required. Evaluation: Querying for co-morbid conditions Querying for psychological conditions Follow- Up if co-morbid conditions present: Treatment plan reviewed Prescription adjusted Axon 34 Percentage of patients with spasticity or dystonia who were evaluated or referred or treated with BoNT-A Allowable Exclusion Examples: - Patient/giver refusal - BoNT-A is contraindicated Evaluation for BoNT-A Treated with BoNT-A Referred for BoNT-A Axon 46 Percentage of pediatric patients who had a medication review at every encounter and a medication list present in the medical record. Applicable to patients aged 0-18 yrs. Be sure to document medication name, dosage, frequency, and route of administration. Current medications obtained Current medications reviewed Current medications updated Check box is sufficient to meet the measure

2 Cross-Cutting Axon 17 QPP 130 Axon 18 QPP 047 Axon 19 QPP 374 Axon 40 Not Eligible for Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter Percentage of patients aged 65 years and older who have an advance plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance plan 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 Percentage of patients age 18 years and older with a neurologic condition who had a PROMIS-29 administered and the results reviewed Be sure to document medication name, dosage, frequency, and route of administration. This is an annual measure. Attaching the advance plan to the patient account and not a specific visit is fine. FIGMD will look for referral order and then look for consultation report received. FIGMD can t read scanned report but can read report file name. Exceptions are made for patients where they are unable to complete the screening instrument. Current medications obtained Current medications reviewed Current medications updated Check box is sufficient to meet the measure An advanced plan was discussed Advance directive DNR Discuss the name of referral documents with your FIGmd representative. Having a standard identifier on the document is helpful for mapping. This measure is for QI only in 2019 PROMIS 29 completed PROMIS 29 reviewed Axon 52 QPP 431 Axon 54 Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user Percentage of patients whose quality of life assessment results are maintained or improved during the measurement period. (Global Health 10) Denominator includes patients who were seen for at least two visits or one preventative visit during the year. Performance is calculated by comparing PROMIS Global Health 10 Physical and Mental T.Score at index visit to the last visit in the 12-month follow-up period Alcohol Abuse Assessment: Alcohol non-user No unhealthy alcohol use Identified unhealthy alcohol use Follow up if positive for abuse: ALC counseling session ALC counseling High risk situations for coping strategies High risk situations for drinking strategies Document the quality of life assessment name followed by a score. Cross-Cutting/Falls Axon 16A QPP 318 Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period This measure is an ecqm for No key words can be used to meet the measure, only codes. Exclusively use codes Axon 16B QPP 154 Percentage of visits for patients aged 65 years and older with a history of falls who had a risk assessment for falls completed within 12 months. History of falls for denominator is defined as 2 or more falls in the past year or any fall with injury in the past year. Home fall hazards assessment Counseling on home fall hazards Axon 16C QPP 155 Percentage of patients aged 65 years and older with a history of falls that had a plan of for falls documented within 12 months History of falls for denominator is defined as 2 or more falls in the past year or any fall with injury in the past year. Fall plan of Balance assessment

3 Axon 07.1 Axon 45 Not Eligible for Axon 53 Cross-Cutting/Opioid Axon 49 QPP 412 Axon 50 QPP 414 Percentage of patients with Parkinson s disease, multiple sclerosis, distal symmetric polyneuropathy, ALS, epilepsy, dementia who were screened for falls at least annually and counseling provided on falls prevention for those with 2 or more falls or 1 fall with injury. Percentage of patients who reported a fall. Percentage of patients that had a plan of for falls documented All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical record Multiple medical reasons for not screening patients for allowable exclusions. The Axon 53 denominator is identified as the numerator of Axon 45. Plan of must include consideration of balance, strength, and gait training OR a referral to physical therapy. Just including PT in the record will not meet the measure. Exclusions Include: Patient admitted to palliative Patient admitted to hospice Exclusions Include: Patient admitted to palliative Patient admitted to hospice Screening for falls, no falls Screening for falls, fall with injury counseling provided Screening for falls, 2 or more falls counseling provided Note: If 2 or more falls or one fall with injury found, counseling must be done. Denies any falls [number] fall Referral to PT Balance, strength, gait training Falls plan of that includes education on balance, and strength, and gait training Falls plan of developed There is only one phrase to meet the measure: Signed opioid treatment agreement Risk of opioid misuse Opioid assessment Opioid interview Opioid risk tool Axon 51 QPP 408 All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record Exclusions Include: Patient admitted to palliative Patient admitted to hospice COT eval done at 3 months COT re eval done Opioid eval done at 3 months Dementia Axon 09 QPP 282 Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of functional status is performed at least once within a 12- month period Exception (Allowable Exclusions) Example: - Medical reasons such as patient severely impaired and giver knowledge is limited Must assess both ADLs and IADLs. IADL component: Bristol ADL Katz ADL FAQ (Followed by numerical ADL component: Barthel ADL Barthel Index Bristol ADL Axon 10.1 QPP 283 Percentage of patients with dementia for whom there was a documented symptoms screening* for behavioral and psychiatric symptoms, including depression, AND for whom, if symptoms Must assess for all behavioral and psychiatric symptoms and if symptoms are positive you must document a follow up plan. Must assess depression, activity disturbances, mood, and thought AND perceptual disturbances. After screening results and symptom management must be documented.

4 Axon 30 QPP 288 Axon 31 QPP 286 Depression screening was positive, there was also documentation of recommendations for symptoms management in the last 12 months Percentage of patients with dementia whose giver(s) were provided with education on dementia disease management and health behavior changes AND were referred to additional resources for support in the last 12 months Percentage of patients with dementia or their giver(s) for whom there was a documented safety screening in two domains of risk: dangerousness to self or others and environmental risks; and if screening was positive in the last 12 months, there was documentation of mitigation recommendations, including but not limited to referral to other resources This measure has an AND condition meaning you must meet both elements to satisfy the numerator. Must document two domains and mitigation strategies if screening is positive. Depression component: PROMIS Depression Cornell Scale for depression Activity disturbances component: Physical aggressiveness Verbal aggressiveness Mood component: Duke Anxiety Depression Scale Self-rating Anxiety Scale Thought and perceptual disturbances component: Thought and perceptual disturbances Having fixed false beliefs Screening Results: Pos beh & psych sxs Neg beh & psych sxs Symptom management: Discussed follow-up plan Treatment plan reviewed Must document education and referral. Education component: Caregiver/spouse/family provided with education Caregiver/spouse/family training Referral component: Referred to additional resources Referred to community resources Meet both components: Caregiver/spouse/family education and referral to Alzheimer s Association Caregiver/Spouse/family education and referral for anxiety Must have safety screening in both domains of risk AND mitigation Dangerousness to self and others: Discuss fences Discuss use of locks Environmental: Access to firearms or other weapons Trip hazards Mitigation: Remove firearms Clear walking paths inside home Install fence Axon 42 QPP 370 The percentage of adolescent patients 12 to 17 years of age and adult patients18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event date. Performance is calculated by comparing PHQ-9 score at index visit to the last PHQ-9 score in the 12- month follow-up period Performance is calculated by comparing PHQ-9 score at index visit to the last visit in the 12-month follow-up period Remission at 12 months Patient admitted to terminal

5 Distal Symmetric Polyneuropathy Axon 11 Epilepsy Axon 01 Percentage of patients age 18 years and older with a diagnosis of distal symmetric polyneuropathy who had screening tests for diabetes reviewed, requested or ordered when seen for an initial evaluation for distal symmetric polyneuropathy Percent of all visits for patients with a diagnosis of epilepsy where the seizure frequency of each seizure type was documented. Glucose tolerance tests over 2 hours are not accepted to meet the numerator. Frequency must include number of seizures and the time frame. Fasting blood sugar test Hemoglobin A1c 2-hour glucose tolerance test Measure can be used for QI only Seizure frequency is XX Number of seizures since last visit Unable to give frequency Axon 03 epilepsy who were screened for depression and anxiety. This measure is an AND condition to screen for both depression and anxiety. Measure can be used for QI only Must document depression AND anxiety screening at each visit. Depression component: PHQ-2 (followed by numerical PHQ-9 (followed by numerical SDQ (followed by numerical Anxiety component: GAD-2 (followed by numerical GAD-7 (followed by numerical SDQ (followed by numerical Axon 20 QPP 268 Percentage of patients or givers counseled at least once a year about how epilepsy and its treatment may affect contraception and/or pregnancy. This measure has changed significantly from the previous specifications. It no requires specific counseling on multiple components. Must have counseling on at least 2 of 3 components. Folic acid supplementation component: Talked about folic acid supplementation Drug to drug interaction component: Drug to drug interactions with contraception medication Discussed interactions between contraceptives and antiseizure medications Anti-seizure medication effect on fetal development and/or pregnancy component: Counseled regarding potential effects of antiseizure medication on fetal development Discussion regarding medications and pregnancy Axon 41 Percentage of patients whose quality of life assessment results are maintained or improved during the measurement period. Two office visits must occur at least 4 weeks apart during the measurement period. Score must improve or be maintained to meet the numerator. QoLIE 10P improved QoLIE 10P maintained

6 Essential Tremor Axon 36 Headache Axon 13 Axon 15 QPP 435 Axon 22.1 QPP 419 Axon 25 Multiple Sclerosis Axon 23 Percentage of patients aged 18 years or older with ET whose tremor severity was assessed annually and recorded at least once in the 12-month measurement period. Percentage of patients age 12 years and older with a diagnosis of migraine who were prescribed a guideline recommended medication for acute migraine attacks within the 12-month measurement period. primary headache disorder whose health-related quality of life (HRQoL) was assessed with a tool(s) during at least two visits during the 12 month measurement period AND whose health related quality of life score stayed the same or improved Percentage of patients for whom imaging of the head (CT or MRI) is obtained for the evaluation of primary headache when clinical indications are not present. Percentage of patients age 12 years and older with a diagnosis of primary headache who were prescribed opioid or barbiturate containing medications assessed for medication overuse headache within the 12-month measurement period, and if identified as overusing opioid or barbiturate containing medication, treated or referred for treatment. Percentage of patients with MS who are counseled on the benefits of exercise and appropriate physical activity for patients with MS in the past 12 months. Document a numerical score with appropriate assessments. Including codes for the medications makes mapping easier. Prescription of a guideline recommended therapy will meet the measure Scores must be maintained or improved This is an inverse measure meaning lower scores are better. Barbiturates should not be prescribed at all. Opioids can only be prescribed for less than 3 months at a time. This only needs to be done once annually. TETRAS (followed by numerical Archimedes Spirals documented Tremor severity is described as mild, moderate or severe sumatriptan ergotamine rizatriptan Any of the below assessments followed by a numerical score MIDAS HIT-6 Other phrases: MIDAS score improved HIT-6 score maintained CT brain performed MRI of brain Imaging not recommended Assessment: Assessment for opioid overuse headache Assessment for barbiturate overuse headache Referral/Treatment Referred for treatment Overuse identified, referred for treatment Counseled on physical activity Counseled on exercise Importance of stretching counseling Axon 37 Neuro-Otology Axon 43 Percentage of patients with MS who have a MS disability scale score* documented in the medical record in the past 12 months and had appropriate follow up. Percentage of patients diagnosed with unilateral or bilateral vestibular hypofunction who were referred, prescribed, recommended for, or received vestibular rehabilitation. If assessment identifies concern, follow up must be documented. Allowable Exclusion Example: - Documentation of prior vestibular rehabilitation services provided and determines not to be effective Assessment: At least 2 measures of MS Functional Composite Score MSRS-R Follow Up: Recommendation of physical therapy Treatment plan updated Referral to OT for vestibular rehab Order for OT vestibular rehab Order for PT vestibular rehab

7 Axon 44 Percentage of patients with BPPV who had a Dix-Hallpike maneuver performed AND patients with posterior canal BPPV who had therapeutic canalith repositioning procedure (CRP) performed or who were referred for physical therapy or to a provider who can perform CRP Allowable Exclusions: - Patients diagnosed with anterior or lateral BPPV - Patients with unspecified canal BPPV Dix-Hallpike performed CRP performed No active vertigo No active dizziness Patient asymptomatic Ophthalmology Axon 38 Axon 39 Parkinson s Disease Axon 47 Axon 04 QPP 290 Percentage of patients without fellow eye involvement 1-26 weeks after initiating corticosteroids in patients with unilateral visual loss ocular myasthenia gravis who had an improvement of ocular deviation OR were absent of diplopia in primary gaze OR had functional improvement of ptosis 6 months after initial treatment Percentage of patients with PD prescribed a contraindicated dopamineblocking agent (i.e., anti-psychotic, antinausea, anti-gastroesophageal Reflux Disease (GERD)). Parkinson's disease who were assessed for psychiatric disorders or disturbances at least annually Standard discreet data fields are ideal for tracking this information. Standard discreet data fields are ideal for tracking this information. No exceptions or exclusions for this measure. All symptoms must be addressed and documented. A check box list is ideal for ensuring you met all 5 symptoms. Fellow eye involvement left eye Unilateral vision loss right eye Improvement in ocular deviation bilateral Improvement of ptosis left eye Ocular deviation right eye Prescription for dopamine blocking agent Prescription for anti-nausea medication Prescription for GERD medication All 5 symptoms must be recorded: Assessed for psychosis, depression, anxiety, apathy, AND impulse control disorder Axon 05 Axon 06.1 Parkinson s disease (PD) who were (or whose giver(s) were, as appropriate) queried about sleep disturbances at least annually. Percentage of all patients with a diagnosis of PD (or givers, as appropriate) who were queried about symptoms of autonomic dysfunction* in the past 12 months and if autonomic dysfunction identified, patient had appropriate follow-up. This measure is for quality improvement only. If symptoms are identified, follow up must be completed and documented. Queried about insomnia Queried about periodic leg movements of sleep Queried about periodic limb movement Query: Orthostatic hypotension identified Autonomic insufficiency identified Drooling identified Follow-Up: Treatment plan modified Appropriate treatment plan Axon 27 QPP 291 Axon 29 QPP 293 Percentage of all patients with a diagnosis of PD who were assessed for cognitive impairment or dysfunction in the past 12 months. Percentage of all patients with a diagnosis of PD (or giver(s), as appropriate) who had rehabilitative therapy options discussed in the past 12 months. *See measure specifications for further definitions. No exceptions or exclusions for this measure. No exceptions or exclusions for this measure. Neuropsychologist referral DRS-2 score XX M0CA score XX Counseling on PT, OT, ST Order for PT, OT, ST Must document all 3 therapies to meet the measure.