Quality ID #154 (NQF: 0101): Falls: Risk Assessment National Quality Strategy Domain: Patient Safety
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1 Quality ID #154 (NQF: 0101): Falls: Risk Assessment National Quality Strategy Domain: Patient Safety 2018 OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY MEASURE TYPE: Process DESCRIPTION: Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months INSTRUCTIONS: This measure is to be submitted a minimum of once per performance period for patients seen during the performance period. There is no diagnosis associated with this measure. This measure is appropriate for use in all non-acute settings (with the exception of emergency departments and acute care hospitals). This measure may be submitted by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. Measure Submission: The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data. DENOMINATOR: All patients aged 65 years and older who have a history of falls (history of falls is defined as 2 or more falls in the past year or any fall with injury in the past year). Documentation of patient reported history of falls is sufficient Denominator Criteria (Eligible Cases): Patients aged 65 years on date of encounter AND Patient encounter during the performance period (CPT or HCPCS): 92540, 92541, 92542, 92548, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0402, G0438, G0439 AND Patient screened for future fall risk; documentation of two or more falls in the past year or any fall with injury in the past year: 1100F AND NOT DENOMINATOR EXCLUSIONS: Hospice services for patient provided any time during the measurement period: G9718 NUMERATOR: Patients who had a risk assessment for falls completed within 12 months Numerator Instructions: All components do not need to be completed during one patient visit, but should be documented in the medical record as having been performed within the past 12 months. Page 1 of 8
2 Definitions: Fall A sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, or the ground, other than as a consequence of sudden onset of paralysis, epileptic seizure, or overwhelming external force. Risk Assessment Comprised of balance/gait AND one or more of the following: postural blood pressure, vision, home fall hazards, and documentation on whether medications are a contributing factor or not to falls within the past 12 months. Balance/gait Assessment - Medical record must include documentation of observed transfer and walking or use of a standardized scale (e.g., Get Up & Go, Berg, Tinetti) or documentation of referral for assessment of balance/gait. Postural blood pressure - Documentation of blood pressure values in supine and then standing positions. Vision Assessment - Medical record must include documentation that patient is functioning well with vision or not functioning well with vision based on discussion with the patient or use of a standardized scale or assessment tool (e.g., Snellen) or documentation of referral for assessment of vision. Home fall hazards Assessment - Medical record must include documentation of counseling on home falls hazards or documentation of inquiry of home fall hazards or referral for evaluation of home fall hazards. Medications Assessment - Medical record must include documentation of whether the patient s current medications may or may not contribute to falls. OR OR Numerator Options: Performance Met: Denominator Exception: Performance Not Met: Falls risk assessment documented (3288F) Documentation of medical reason(s) for not completing a risk assessment for falls (i.e., patient is not ambulatory, bed ridden, immobile, confined to chair, wheelchair bound, dependent on helper pushing wheelchair, independent in wheelchair or minimal help in wheelchair (3288F with 1P) Falls risk assessment not completed, reason not otherwise specified (3288F with 8P) RATIONALE: Screening for specific medical conditions may direct the therapy. Although the clinical guidelines and supporting evidence calls for an evaluation of many factors, it was felt that for the purposes of measuring performance and facilitating implementation this initial measure must be limited in scope. For this reason, the work group defined an evaluation of balance and gait as a core component that must be completed on all patients with a history of falls as well as four additional evaluations at least one of which must be completed within the 12 month period. Data elements required for the measure can be captured and the measure is actionable by the physician. CLINICAL RECOMMENDATION STATEMENTS: Older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment. This assessment should be performed by a health care professional with appropriate skills and experience, normally in the setting of a specialist falls service. This assessment should be part of an individualized, multifactorial intervention. (NICE) (Grade C) Multifactorial assessment may include the following: Identification of falls history Assessment of gait, balance and mobility, and muscle weakness Page 2 of 8
3 Assessment of osteoporosis risk Assessment of the older person s perceived functional ability and fear relating to falling Assessment of visual impairment Assessment of cognitive impairment and neurological examination Assessment of urinary incontinence Assessment of home hazards Cardiovascular examination and medication review (nice) (grade c) A falls risk assessment should be performed for older persons who present for medical attention because of a fall, report recurrent falls in the past year, report difficulties in walking or balance or fear of falling, or demonstrate unsteadiness or difficulty performing a gait and balance test. The falls risk evaluation should be performed by a clinician with appropriate skills and experience. [C] A falls risk assessment is a clinical evaluation that should include the following, but are not limited to: A history of fall circumstances Review of all medications and doses Evaluation of gait and balance, mobility levels and lower extremity joint function Examination of vision Examination of neurological function, muscle strength, proprioception, reflexes, and tests of cortical, extrapyramidal, and cerebellar function Cognitive evaluation Screening for depression Assessment of postural blood pressure Assessment of heart rate and rhythm Assessment of heart rate and rhythm, and blood pressure responses to carotid sinus stimulation if appropriate Assessment of home environment The falls risks assessment should be followed by direct intervention on the identified risk. [A] (AGS) COPYRIGHT: This Physician Performance Measure (Measure) and related data specifications have been developed by the PCPI(R) Foundation (PCPI[R]) and the National Committee for Quality Assurance (NCQA). This Measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications. The Measure, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, eg, use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain. Commercial uses of the Measure require a license agreement between the user and the PCPI(R) or NCQA. Neither the American Medical Association (AMA), nor the former AMA-convened Physician Consortium for Performance Improvement(R), PCPI, NCQA nor its members shall be responsible for any use of the Measure. (C) 2017 National Committee for Quality Assurance and PCPI (R) Foundation. All Rights Reserved. Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. NCQA disclaims all liability for use or accuracy of any CPT or other codes contained in the specifications. CPT(R) contained in the Measure specifications is copyright American Medical Association. LOINC(R) copyright Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright International Health Terminology Standards Development Organisation. ICD-10 copyright 2017 Page 3 of 8
4 World Health Organization. All Rights Reserved. The performance Measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications. THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND. Page 4 of 8
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7 2018 Registry Individual Measure Flow #154 NQF #0101: Falls: Risk Assessment Please refer to the specific section of the Measure Specification to identify the denominator and numerator information for use in submitting this Individual Measure. This measure flow is for registry submission. 1. Start with Denominator 2. Check Patient Age: a. If the Age is greater than or equal to 65 years of age on Date of Service and equals No during the Measurement Period, do not include in Eligible Patient Population. Stop Processing. b. If the Age is greater than or equal to 65 years of age on Date of Service and equals Yes during the Measurement Period, proceed to check Encounter Performed 3. Check Encounter Performed: a. If Encounter as Listed in the Denominator equals No, do not include in Eligible Patient Population. Stop Processing. b. If Encounter as Listed in the Denominator equals Yes, check Documentation of Two or More Falls or Any Fall with Injury in the Past Year. 4. Check Documentation of Two or More Falls or Any Fall with Injury in the Past Year: a. If Documentation of Two or More Falls or Any Fall with Injury in the Past Year equals No, do not include in Eligible Patient Population. Stop Processing. b. If Documentation of Two or More Falls or Any Fall with Injury in the Past Year equals Yes, proceed to check Hospice Services Provided Any Time During the Measurement Period 5. Check Hospice Services Provided Any Time During the Measurement Period: a. If Hospice Services Provided Any Time During the Measurement Period equals No, include in Eligible Population. b. If Hospice Services Provided Any Time During the Measurement Period equals Yes, do not include in Eligible Patient Population. Stop Processing. 6. Denominator Population: a. Denominator Population is all Eligible Patients in the Denominator. Denominator is represented as Denominator in the Sample Calculation listed at the end of this document. Letter d equals 80 patients in the Sample Calculation. 7. Start Numerator 8. Check Risk Assessment for Falls Documented: a. If Risk Assessment for Falls Documented equals Yes, include in Data Completeness Met and Performance Met. b. Data Completeness Met and Performance Met is represented as Data Completeness and Performance Rate in the Sample Calculation listed at the end of this document. Letter a equals 40 patients in the Page 7 of 8
8 Sample Calculation. c. If Risk Assessment for Falls documented equals No, proceed to Risk Assessment for Falls Not Completed, Medical Reason. 9. Check Risk Assessment for Falls Not Completed, Medical Reason: a. If Risk Assessment for Falls Not Completed, Medical Reason equals Yes, include in Data Completeness Met and Denominator Exception. b. Data Completeness Met and Denominator Exception is represented as Data Completeness and Performance Rate in the Sample Calculation listed at the end of this document. Letter b equals 10 patients in the Sample Calculation. c. If Risk Assessment for Falls documented equals No, proceed to Risk Assessment for Falls Not Completed, Reason Not Otherwise Specified. 10. Check Risk Assessment for Falls Not Completed, Reason Not Otherwise Specified: a. If Risk Assessment for Falls Not Completed, Reason Not Otherwise Specified equals Yes, include in the Data Completeness Met and Performance Not Met. b. Data Completeness Met and Performance Not Met is represented as Data Completeness in the Sample Calculation listed at the end of this document. Letter c equals 20 patients in the Sample Calculation. c. If Risk Assessment for Falls Not Completed, Reason Not Otherwise Specified equals No, proceed to Data Completeness Not Met. 11. Check Data Completeness Not Met: a. If Data Completeness Not Met equals No, Quality Data Code or equivalent not submitted. 10 patients have been subtracted from the Data Completeness Numerator in the Sample Calculation. SAMPLE CALCULATIONS: Data Completeness= Performance Met (a=40 patients) + Denominator Exception (b=10 patients) + Performance Not Met (c=20 patients) = 70 patients = 87.50% Eligible Population / Denominator (d=80 patients) = 80 patients Performance Rate= Performance Met (a=40 patients) = 40 patients = 66.67% Data Completeness Numerator (70 patients) Denominator Exception (b=10 patients) = 60 patients Page 8 of 8
Measure #154 (NQF: 0101): Falls: Risk Assessment National Quality Strategy Domain: Patient Safety
Measure #154 (NQF: 0101): Falls: Risk Assessment National Quality Strategy Domain: Patient Safety 2017 OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS ONLY MEASURE TYPE: Process This is a two-part measure which
DENOMINATOR: All female patients aged 65 years and older with a visit during the measurement period
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Measure #155 (NQF: 0101): Falls: Plan of Care National Quality Strategy Domain: Communication and Care Coordination
Measure #155 (NQF: 0101): Falls: Plan of Care National Quality Strategy Domain: Communication and Care Coordination 2017 OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS ONLY MEASURE TYPE: Process This is a two-part
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2016 PQRS OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
Measure #260: Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2) National Quality Strategy Domain: Patient Safety
2017 OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY. MEASURE TYPE: Outcome
Measure #258: Rate of Open Repair of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7) National Quality
Patient is unable to communicate and caregiver/informant is unavailable to provide information. Risk
Falls Outcome for Patients with Parkinson s Disease Measure Description Percentage of patients with PD who experienced a fall in the preceding six months. Note: A lower score is desirable. Measure Components
Quality ID #343: Screening Colonoscopy Adenoma Detection Rate National Quality Strategy Domain: Effective Clinical Care
Quality ID #343: Screening Colonoscopy Adenoma Detection Rate National Quality Strategy Domain: Effective Clinical Care 2018 OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY MEASURE TYPE: Outcome DESCRIPTION:
2017 OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY. MEASURE TYPE: Outcome
Measure #165 (NQF 0130): Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate National Quality Strategy Domain: Effective Clinical Care 2017 OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY
**Please read the DQA Measures User Guide prior to implementing this measure.**
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DQA Measure Specifications: Administrative Claims-Based Measures Periodontal Evaluation in Adults with Periodontitis
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**Please read the DQA Measures User Guide prior to implementing this measure.**
**Please read the DQA Measures User Guide prior to implementing this measure.** DQA Measure Technical Specifications: Administrative Claims-Based Measures Prevention: Sealants for 6 9 year-old Children
If multiple KRAS mutation tests have been performed, refer to the most recent test results.
Measure #452 (NQF 1860): Patients with Metastatic Colorectal Cancer and KRAS Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies National Quality Strategy
**Please read the DQA Measures User Guide prior to implementing this measure.**
**Please read the DQA Measures User Guide prior to implementing this measure.** DQA Measure Technical Specifications: Administrative Claims-Based Measures Prevention: Topical Fluoride for Children at Elevated
WOUND CARE QUALITY IMPROVEMENT COLLABORATIVE
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Obstructive Sleep Apnea Physician Performance Measurement Set
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Childhood Immunization Status
emeasure Title emeasure Identifier (Measure Authoring Tool) Childhood Immunization Status 117 emeasure Version number 5.1.000 NQF Number 0038 GUID b2802b7a-3580-4be8-9458- 921aea62b78c Measurement Period
Quality ID #257 (NQF 1519): Statin Therapy at Discharge after Lower Extremity Bypass (LEB) National Quality Strategy Domain: Effective Clinical Care
Quality ID #257 (NQF 1519): Statin Therapy at Discharge after Lower Extremity Bypass (LEB) National Quality Strategy Domain: Effective Clinical Care 2018 OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
2017 OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY. MEASURE TYPE: Process
Measure #449 (NQF 1857): HER2 Negative or Undocumented Breast Cancer Patients Spared Treatment with HER2-Targeted Therapies National Quality Strategy Domain: Efficiency and Cost Reduction 2017 OPTIONS
National Committee for Quality Assurance / The Physician Consortium for Performance Improvement
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**Please read the DQA Measures User Guide prior to implementing this measure.** DQA Measure Technical Specifications: Administrative Claims-Based Measures: Ambulatory Care Sensitive Emergency Department
DQA Measure Technical Specifications: Administrative Claims-Based Measures Preventive Services for Children at Elevated Caries Risk, Dental Services
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Measure #425: Photodocumentation of Cecal Intubation National Quality Strategy Domain: Effective Clinical Care
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NQF-Endorsed Measures for Endocrine Conditions: Cycle 2, 2014
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Multifactorial risk assessments and evidence-based interventions to address falls in primary care. Objectives. Importance
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Objectives. Definition: Screen. Definition: Assessment 10/30/2013. Falls: Screens vs. Assessments vs. Outcome Measures
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Briefing Document on Medication use and Falls
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Fall Prevention (STEADI) Training for EMS Providers Alameda County Emergency Medical Services Senior Injury Prevention Program
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Normal Parameters: Age 65 years and older BMI 23 and < 30 kg/m 2 Age years BMI 18.5 and < 25 kg/m 2
Measure #128 (NQF 0421): Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan National Quality Strategy Domain: Community/Population Health 2015 PQRS OPTIONS F INDIVIDUAL MEASURES:
GUIDELINES: PEER REVIEW TRAINING BOD G [Amended BOD ; BOD ; BOD ; Initial BOD ] [Guideline]
GUIDELINES: PEER REVIEW TRAINING BOD G03-05-15-40 [Amended BOD 03-04-17-41; BOD 03-01-14-50; BOD 03-99-15-48; Initial BOD 06-97-03-06] [Guideline] I. Purpose Guidelines: Peer Review Training provide direction
2017 MSSP Clinical Quality Measures
*The information contained in this document relies heavily on information supplied by CMS. GPRO CARE-1 (NQF 0097): Medication Reconciliation Post-Discharge DESCRIPTION: Percentage of discharges from any
Measure #131 (NQF 0420): Pain Assessment and Follow-Up National Quality Strategy Domain: Community/Population Health*
Measure #131 (NQF 0420): Pain Assessment and Follow-Up National Quality Strategy Domain: Community/Population Health* *Please note that PQRS 131 is incorrectly listed under the Communication and Care Coordination
emeasure Title emeasure Identifier (Measure Authoring Tool) 621 emeasure Version number
emeasure Title emeasure Identifier (Measure Authoring Tool) Measurement That Matters 621 emeasure Version number 0.0.013 NQF Number GUID a81691e2-4be1-4725-b279- a07448a74bcd Measurement Period Measure
Preventive Care and Screening: Screening for Depression and Follow-Up Plan
emeasure Title Preventive Care and Screening: Screening for Depression and Follow-Up Plan emeasure Identifier (Measure Authoring Tool) 2 emeasure Version number 6.3.000 NQF Number 0418 GUID 9a031e24-3d9b-11e1-8634-
Denominator Exceptions
MEASURE #5: Screening for Psychiatric or Behavioral Health Disorders Measure Description Percent of all visits for patients with a diagnosis of epilepsy where the patient was screened for psychiatric or
Clinical Policy: Implantable Miniature Telescope for Age Related Macular Degeneration Reference Number: CP.MP.517
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Possible Denominator Codes Applicable to OMS * Le Fort Fractures 21346, 21347, 21348, 21422, 21423, 21432, 21433, 21435, 21436
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