2015 Physician Quality Reporting System (PQRS) Measure Specifications Manual for Claims and Registry Reporting of Individual Measures

Transcription

1 2015 Physician Quality Reporting System (PQRS) Measure Specifications Manual for Claims and Registry Reporting of Individual Measures Utilized by Individual Eligible Professionals for Claims and Registry Reporting and Clinical Practices Participating in Group Practice Reporting Option (GPRO) for Registry Reporting 11/10/ /10/2014 Page 1 of 593

2 PQRS Introduction The measure specifications contained in this manual are intended for individual eligible professionals reporting via claims or registry and group practices reporting via registry for the 2015 Physician Quality Reporting System (PQRS). Measure specifications for measures groups reporting are included in a separate manual, 2015 Physician Quality Reporting System Measures Groups Specifications Manual, which can be accessed at: Instruments/PQRS/MeasuresCodes.html Group practices electing to participate in the PQRS group practice reporting option (GPRO) reporting PQRS via GPRO Web-Interface may access the GPRO Web Interface Narrative Specifications at: Instruments/PQRS/GPRO_Web_Interface.html Meaningful Use measure specifications can access electronic clinical quality measures (ecqms) at: Guidance/Legislation/EHRIncentivePrograms/ClinicalQualityMeasures.html Information regarding CG-CAHPS may be found at: Please note that this link is directed to the Accredited Care Organization webpage. Each measure is assigned a unique number. Measure numbers for 2015 PQRS represents a continuation in numbering from the 2014 measures. For 2015 PQRS measures that are continuing forward in the 2015 PQRS, measure specifications have been updated. In addition to the measure specifications manual, please refer to the 2015 Physician Quality Reporting System Implementation Guide for additional information essential in assisting eligible professionals understanding and submission of measures. This document can be accessed at: Those who report satisfactorily for the 2015 program year may avoid the 2017 payment adjustment. Additional information on how to avoid future PQRS payment adjustments can be found through supporting documentation available on the CMS website: Assessment-Instruments/PQRS/. Eligible Professionals Eligible professionals submitting billable services on Part B claims for allowable Medicare Physician Fee Schedule (PFS) charges may report the quality action for selected PQRS quality measure(s). Providers not defined as eligible professionals in the Tax Relief and Health Care Act of 2006 or the Medicare Improvements for Patients and Providers Act of 2008 are not eligible to participate in PQRS. A list of eligible professionals can be found on the PQRS website at: Instruments/PQRS/How_To_Get_Started.html. Frequency and Performance Timeframes The measure instructions limit the frequency of reporting necessary in certain circumstances, such as for patients with chronic illness for whom a particular process of care is provided only periodically. Each individual eligible professional or group practices participating in 2015 PQRS should report according to the frequency and timeframe listed within each measure specification. 10/10/2014 Page 17 of 593

3 Denominator Codes (Eligible Cases) and Numerator Quality-Data Codes Quality measures consist of a numerator and a denominator that permit the calculation of the percentage of a defined patient population that receive a particular process of care or achieve a particular outcome. The denominator population may be defined by demographic information, certain International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis (01/01/2015-9/30/2015), International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis (10/01/ /31/2015), Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes specified in the measure that are submitted by individual eligible professionals as part of a claim for covered services under the PFS for claims-based reporting. This same criteria is also applied for individual eligible professionals and group practices who chose to report via a registry although this data is not necessarily submitted via a claim. If the specified denominator codes for a measure are not included on the patient s claim (for the same date of service) as submitted by the individual eligible professional, then the patient does not fall into the denominator population, and the PQRS measure does not apply to the patient. Likewise, if the specified denominator codes for a measure are not associated with a patient for an individual eligible professional or group practice submitting to a registry, then the patient does not fall into the denominator population, and the PQRS measure does not apply to the patient. Some measure specifications are adapted as needed for implementation in PQRS in agreement with the measure developer. For example, CPT codes for non-covered services such as preventive visits are not included in the denominator. PQRS measure specifications include specific instructions regarding CPT Category I modifiers, place of service codes, and other detailed information. Each eligible professional and group practice should carefully review the measure s denominator coding to determine whether codes submitted on a given claim or to a registry meet denominator inclusion criteria. If the patient does fall into the denominator population, the applicable Quality Data Codes or QDCs (CPT Category II codes or G-codes) that define the numerator should be submitted to satisfactorily report quality data for a measure for claims based reporting. When a patient falls into the denominator, but the measure specifications define circumstances in which a patient may be appropriately excluded, CPT Category II code modifiers such as 1P, 2P and 3P or quality-data codes are available to describe medical, patient, system, or other reasons for performance exclusion. When the performance exclusion does not apply, a measure-specific CPT Category II reporting modifier 8P or quality-data code may be used to indicate that the process of care was not provided for a reason not otherwise specified. Each measure specification provides detailed reporting information. Although a registry may or may not utilize these same QDCs, the numerator clinical concepts described for each measure are to be followed when submitting to a registry. G-codes that are associated with billable charges and found within the denominator, within this reporting program, are referred to as HCPCS coding. G-codes that describe clinical outcomes or results and are found within the denominator are generally described as QDC s. For eligible professionals reporting individually, PQRS measures, including patient-level measure(s), may be reported for the same patient by multiple eligible professionals practicing under the same Tax Identification Number (TIN). If a patient sees multiple providers during the reporting period, that patient can be counted for each individual NPI reporting if the patient encounter(s) meet denominator inclusion. The following is an example of two provider NPIs (National Provider Identifiers), billing under the same TIN who are intending to report PQRS Measure #6: Coronary Artery Disease (CAD): Antiplatelet Therapy. Provider A sees a patient on February 2, 2015 and prescribes an aspirin and reports the appropriate quality-data code (QDC) for measure #6. Provider B sees the same patient at an encounter on July 16, 2015 and verifies that the patient has been prescribed and is currently taking an aspirin. Provider B must also report the appropriate QDCs for the patient at the July encounter to receive credit for reporting measure #6. 10/10/2014 Page 18 of 593

4 Eligible professionals reporting under a group practice selecting to participate in the PQRS group practice reporting option (GPRO) under the same Tax Identification Number (TIN), should be reporting on the same patient, when instructed within the chosen measure. For example, if reporting measure #130: Documentation of Current Medications in the Medical Record all eligible professionals under the same TIN would report each denominator eligible instance as instructed by this measure. If the group practice choses a measure that is required to be reported once per reporting period, then this measure should be reported at least once during the measure period by at least one eligible professional under the TIN. Measure #6: Coronary Artery Disease (CAD): Antiplatelet Therapy is an example of a measure that would be reported once per reporting period under the TIN. CMS recommends review of any measures that an individual eligible professional or group practice intend to report. Below is an example measure specification that will assist with satisfactorily reporting. For additional assistance please contact the QualityNet Help Desk at the following: QualityNet Help Desk Available Monday Friday; 7:00 AM 7:00 PM CST Phone: Qnetsupport@hcqis.org Measure Specification Format (Refer to the Example Measure Specification Below) Measure title and domain Reporting option available for each measure (claims-based and/or registry) Measure description Instructions on reporting including frequency, timeframes, and applicability Denominator statement and coding Numerator statement and coding options Definition(s) of terms where applicable Rationale statement for measure Clinical recommendations or evidence forming the basis for supporting criteria for the measure The Rationale and Clinical Recommendation Statements sections provide limited supporting information regarding the quality actions described in the measure. Please contact the measure owner for section references and further information regarding the clinical rational and recommendations for the described quality action. Measure owner contact information is located on the last page of the Measures List document, which can be accessed at: CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. Version /10/2014 Page 19 of 593

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8 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: CLAIMS, REGISTRY DESCRIPTION: Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter Normal Parameters: Age 65 years and older BMI 23 and < 30 kg/m 2 Age years BMI 18.5 and < 25 kg/m 2 INSTRUCTIONS: There is no diagnosis associated with this measure. This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. This measure may be reported by eligible professionals who perform the quality actions described in the measure based on the services provided at the time of the qualifying visit and the measure-specific denominator coding. The BMI may be documented in the medical record of the provider or in outside medical records obtained by the provider. If the most recent documented BMI is outside of normal parameters, then a follow-up plan must be documented during the encounter or during the previous six months of the current encounter. The documented follow-up plan must be based on the most recent document BMI outside of normal parameters, example: Patient referred to nutrition counseling for BMI above normal parameters (See Definitions for examples of a follow-up plan treatments). If more than one BMI is reported during the measure period, the most recent BMI will be used to determine if the performance has been met. Measure Reporting via Claims: CPT codes or HCPCS codes, and patient demographics are used to identify patients who are included in the measure s denominator. Quality-data codes are used to report the numerator of the measure. When reporting the measure via claims, submit the listed CPT or HCPCS codes, and the appropriate numerator quality-data code. All measure-specific coding should be reported on the claim(s) representing the eligible encounter. Measure Reporting via Registry: CPT codes or HCPCS codes, and patient demographics are used to identify patients who are included in the measure s denominator. The listed numerator options are used to report the numerator of 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. DENOMINAT: All patients aged 18 years and older NUMERAT: Denominator Criteria (Eligible Cases): Patients aged 18 years on date of encounter AND Patient encounter during the reporting period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90839, 96150, 96151, 96152, 97001, 97003, 97802, 97803, 98960, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, D7140, D7210, G0101, G0108, G0270, G0271, G0402, G0438, G0439, G /10/2014 Page 198 of 593

9 Patients with a documented BMI during the encounter or during the previous six months, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter Numerator Instructions: Height and Weight - An eligible professional or their staff is required to measure both height and weight. Both height and weight must be measured within six months of the current encounter and may be obtained from separate encounters. Self-reported values cannot be used. Follow-Up Plan If the most recent documented BMI is outside of normal parameters, then a follow-up plan is documented during the encounter or during the previous six months of the current encounter. The documented follow-up plan must be based on the most recent documented BMI outside of normal parameters, example: Patient referred to nutrition counseling for BMI above normal parameters. (See Definitions for examples of a follow-up plan treatments) Performance Met for G8417 & G8418 If the provider documents a BMI and a follow-up plan at the current visit If the patient has a documented BMI within the previous six months of the current encounter, the provider documents a follow-up plan at the current visit If the patient has a documented BMI within the previous six months of the current encounter AND the patient has a documented follow-up plan for a BMI outside normal parameters within the previous six months of the current visit Definitions: BMI Body mass index (BMI), is a number calculated using the Quetelet index: weight divided by height squared (W/H 2 ) and is commonly used to classify weight categories. BMI can be calculated using: Metric Units: BMI = Weight (kg) / (Height (m) x Height (m)) English Units: BMI = Weight (lbs) / (Height (in) x Height (in)) x 703 Follow-Up Plan Proposed outline of treatment to be conducted as a result of a BMI out of normal parameters. A follow-up plan may include but is not limited to: Documentation of education Referral (eg, a registered dietitian/nutritionist, occupational therapist, physical therapist, primary care provider, exercise physiologist, mental health professional, or surgeon) Pharmacological interventions Dietary supplements Exercise counseling Nutrition counseling Not Eligible for BMI Calculation or Follow-Up Plan A patient is not eligible if one or more of the following reasons are documented: Patient is receiving palliative care Patient is pregnant Patient refuses BMI measurement (refuses height and/or weight) Any other reason documented in the medical record by the provider why BMI measurement was not appropriate 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 10/10/2014 Page 199 of 593

10 Numerator Quality-Data Coding Options for Reporting Satisfactorily: BMI Documented as Normal, No Follow-Up Plan Required (One quality-data code [G8417, G8418 or G8420] is required on the claim form to submit this numerator option) Performance Met: G8420: BMI is documented within normal parameters and no follow-up plan is required BMI Documented as Above Normal Parameters, AND Follow-Up Documented Performance Met: G8417: BMI is documented above normal parameters and a follow-up plan is documented BMI Documented as Below Normal Parameters, AND Follow-Up Documented Performance Met: G8418: BMI is documented below normal parameters and a follow-up plan is documented BMI not Documented, Patient not Eligible (One quality-data code [G8422 or G8938] is required on the claim form to submit this numerator option) Other Performance Exclusion: G8422: BMI not documented, documentation the patient is not eligible for BMI calculation BMI Documented Outside of Normal Limits, Follow-up Plan not Documented, Patient not Eligible Other Performance Exclusion: G8938: BMI is documented as being outside of normal limits, follow-up plan is not documented, documentation the patient is not eligible BMI not Documented, Reason not Given (One quality-data code [G8419 or G8421] is required on the claim form to submit this numerator option) Performance Not Met: G8421: BMI not documented and no reason is given BMI Documented Outside of Normal Parameters, Follow-Up Plan not Documented, Reason not Given Performance Not Met: G8419: BMI documented outside normal parameters, no followup plan documented, no reason given RATIONALE: Normal Parameters for Age 65 Years and Older Winter et al. (2014) performed a meta-analysis looking at the relationship between BMI and all-cause mortality among adults 65 and older. They identified a higher risk of mortality among those with a BMI <23 kg/m 2 and recommended monitoring weight status in this group to address any modifiable causes of weight loss promptly with due consideration of individual comorbidities. Dahl et al. (2013) reported that old persons (70-79) who were overweight had a lower mortality risk than old persons who were of normal weight, even after controlling for weight change and multimorbidity. The study also shows that persons who increased or decreased in BMI had a greater mortality risk than those who had a stable BMI, particularly those aged 70 to 79. Their results provide support to the belief that the World Health Organization guidelines for BMI are overly restrictive in old age. BMI Above Upper Parameters Obesity continues to be a costly public health concern in the United States. The Centers for Disease Control and Prevention (CDC, 2010) reported in 2009, no state met the Healthy People 2010 obesity target of 15 percent and the self-reported overall prevalence of obesity among adults had increased 1.1 percentage points in 2007 to 26.7 percent (2010).Ogden, Carroll, Kit and Flegal (2013) reported the prevalence of BMI-defined obesity in adults is high and continues to exceed 30% in most sex-age groups (34.9% overall). They also stated the overall prevalence of obesity 10/10/2014 Page 200 of 593

11 did not differ between men and women in ; however, among non-hispanic black adults, 56.6% of women were obese compared with 37.1% of men. In addition to the continued high prevalence rate for adults in general, Flegal, Carroll & Kit (2012) report a significant increase for men and for non-hispanic black and Mexican American women over the 12-year period from 1999 through 2010 (2012). Moyer (2012) reported: Obesity is associated with such health problems as an increased risk for coronary artery disease, type 2 diabetes, various types of cancer, gallstones and disability. These comorbid medical conditions are associated with higher use of health care services and costs among obese patients (p. 373). Obesity is also associated with an increased risk of death, particularly in adults younger than age 65 years and has been shown to reduce life expectancy by 6 to 20 years depending on age and race (LeBlanc et al., 2011). Masters, et al. (2013) also showed mortality due to obesity varied by race and gender. They estimated adult deaths between 1986 and 2006 associated with overweight and obesity was 5.0% and 15.6% for Black and White men, and 26.8% and 21.7% for Black and White women, respectively. They also found a stronger association than previous research demonstrated between obesity and mortality risk at older ages. Finkelstein, Trogdon, Cohen and Dietz (2009) found that in 2006, across all payers, per capita medical spending for the obese is $1,429 higher per year, (42 percent) than for someone of normal weight. Using 2008 dollars, this was estimated to be equivalent to $147 billion dollars in medical care costs related to obesity. Padula, Allen and Nair (2014) examined data from a commercial claims and encounters database to estimate the cost for obesity and associated comorbidities among working-age adults who had a claim with a primary or secondary diagnosis of obesity in The mean net expenditure for inpatient and outpatient claims was $1,907 per patient per visit. The increases in cost for comorbidities ranged from $527 for obesity with CHF to $15,733 for the combination of obesity, diabetes mellitus, hypertension and depression. In addition to a high prevalence rate of obesity, less than 50% of obese adults in 2010 received advice to exercise or perform physical activity (Barnes & Schoenborn, 2012). BMI Below Normal Parameters In the National Center for Health Statistics (NCHS) Health E-Stat, Fryer and Ogden (2012) reported that poor nutrition or underlying health conditions can result in underweight. Results from the National Health and Nutrition Examination Survey (NHANES), using measured heights and weights, indicate an estimated 1.7% of U.S. adults are underweight with women more likely to be underweight than men (2012). In a cohort study conducted by Borrell and Lalitha (2014), data from NHANES III ( ) was linked to the National Death Index mortality file with follow-up to 2006, and showed that when compared to their normal weight counterparts (BMI kg/m 2 ), underweight (BMI <18.5 kg/m 2 ) had significantly higher death rates (Hazard Ratio= 2.27; 95% confidence interval (CI) = 1.78, 2.90). Ranhoff, Gjoen and Mowe (2005) recommended using BMI < 23 kg/m 2 for the elderly to identify positive results with malnutrition screens and poor nutritional status. CLINICAL RECOMMENDATION STATEMENTS: Although multiple clinical recommendations addressing obesity have been developed by professional organizations, societies and associations, two recommendations have been identified which exemplify the intent of the measure and address the numerator and denominator. The US Preventive Health Services Task Force (USPSTF) recommends screening all adults (aged 18 years and older) for obesity. Clinicians should offer or refer patients with a BMI of 30 or higher to intensive, multicomponent behavioral interventions. This is a B recommendation (Moyer, 2012). As cited in Wilkinson et al. (2013), Institute for Clinical Systems Improvement (ICSI) Preventive Services for Adults, Obesity Screening (Level II) Recommendation provides the following guidance: 10/10/2014 Page 201 of 593

12 Record height, weight and calculate body mass index at least annually Clinicians should consider waist circumference measurement to estimate disease risk for patients who have BMI scores indicative of overweight or obesity class I. For adult patients with a BMI of 25 to 34.9 kg/m 2, sex-specific waist circumference cutoffs should be used in conjunction with BMI to identify increased disease risk. A BMI greater or equal to 30 is defined as obese A BMI of is defined as overweight Intensive intervention for obese individuals, based on BMI, is recommended by the U.S. Preventive Services to help control weight. Similarly, the 2013 joint report/guideline from the American Heart Association, American College of Cardiology and The Obesity Society also recommend measuring height and weight and calculating BMI at annual visits or more frequently, using the current cutpoints for overweight (BMI> kg/m 2 ) and obesity (BMI 30 kg/m 2 ) to identify adults who may be at elevated risk of CVD and the current cutpoints for obesity to identify adults who may be at elevated risk of mortality from all causes. They also recommend counseling overweight and obese individuals on their increased risk for CVD, type 2 diabetes, all-cause mortality and need for lifestyle changes. 10/10/2014 Page 202 of 593

13 Measure #130 (NQF 0419): Documentation of Current Medications in the Medical Record National Quality Strategy Domain: Patient Safety 2015 PQRS OPTIONS F INDIVIDUAL MEASURES: CLAIMS, REGISTRY DESCRIPTION: 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. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications name, dosage, frequency and route of administration INSTRUCTIONS: This measure is to be reported each visit during the 12 month reporting period. Eligible professionals meet the intent of this measure by making their best effort to document a current, complete and accurate medication list during each encounter. There is no diagnosis associated with this measure. This measure may be reported by eligible professionals who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. Measure Reporting via Claims: CPT or HCPCS codes and patient demographics are used to identify visits that are included in the measure s denominator. Quality-data codes are used to report the numerator of the measure. When reporting the measure via claims, submit the CPT or HCPCS codes, and the appropriate numerator qualitydata code. All measure-specific coding should be reported on the claim(s) representing the eligible encounter. Measure Reporting via Registry: CPT or HCPCS codes and patient demographics are used to identify visits that are included in the measure s denominator. The listed numerator options are used to report the numerator of 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. DENOMINAT: All visits for patients aged 18 years and older Denominator Criteria (Eligible Cases): Patients aged 18 years on date of encounter AND Patient encounter during the reporting period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90839, 90957, 90958, 90959, 90960, 90962, 90965, 90966, 92002, 92004, 92012, 92014, 92507, 92508, 92526, 92541, 92542, 92543, 92544, 92545, 92547, 92548, 92557, 92567, 92568, 92570, 92585, 92588, 92626, 96116, 96150, 96151, 96152, 97001, 97002, 97003, 97004, 97532, 97802, 97803, 97804, 98960, 98961, 98962, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99495, 99496, G0101, G0108, G0270, G0402, G0438, G0439 NUMERAT: Eligible professional attests to documenting, updating or reviewing a patient s current medications using all immediate resources available on the date of encounter. This list must include ALL known prescriptions, over-the counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications name, dosages, frequency and route of administration 10/10/2014 Page 203 of 593

14 Definitions: Current Medications Medications the patient is presently taking including all prescriptions, over-thecounters, herbals and vitamin/mineral/dietary (nutritional) supplements with each medication s name, dosage, frequency and administered route. Route Documentation of the way the medication enters the body (some examples include but are not limited to: oral, sublingual, subcutaneous injections, and/or topical) Not Eligible A patient is not eligible if the following reason is documented: 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 NUMERAT NOTE: The eligible professional must document in the medical record they obtained, updated, or reviewed a medication list on the date of the encounter. Eligible professionals reporting this measure may document medication information received from the patient, authorized representative(s), caregiver(s) or other available healthcare resources. G8427 should be reported if the eligible professional documented that the patient is not currently taking any medications Numerator Quality-Data Coding Options for Reporting Satisfactorily: Current Medications Documented Performance Met: G8427: Eligible professional attests to documenting in the medical record they obtained, updated, or reviewed the patient s current medications Current Medications not Documented, Patient not Eligible Other Performance Exclusion: G8430: Eligible professional attests to documenting in the medical record the patient is not eligible for a current list of medications being obtained, updated, or reviewed by the eligible professional Current Medications with Name, Dosage, Frequency, or Route not Documented, Reason not Given Performance Not Met: G8428: Current list of medications not documented as obtained, updated, or reviewed by the eligible professional, reason not given RATIONALE: In the American Medical Association s (AMA) Physician s Role in Medication Reconciliation (2007), critical patient information, including medical and medication histories, current medications the patient is receiving and taking, and sources of medications, is essential to the delivery of safe medical care. However, interruptions in the continuity of care and information gaps in patient health records are common and significantly affect patient outcomes. Consequently, clinical judgments may be based on incomplete, inaccurate, poorly documented or unavailable information about the patient and his or her medication. Medication safety efforts have primarily focused on hospitals; however, the majority of health care services are provided in the outpatient setting where two-thirds of physician visits result in writing at least one prescription (Stock et al., 2009). Chronically ill patients are increasingly being treated as outpatients, many of whom take multiple medications requiring close monitoring (Nassaralla et al., 2007). Adverse drug events (ADEs) prove to be more fatal in outpatient settings (1 of 131 outpatient deaths) than in hospitals (1 of 854 inpatient deaths) (Nassaralla et al., 2007). According to The Commonwealth Fund report (2010) about 11 to 15 of every 1,000 Americans visit a health care provider because of ADEs in a given year, representing about three to four of every 1,000 patient visits during 1995 to The total number of visits to treat ADEs increased from 2.9 million in 1995 to 4.3 million visits in /10/2014 Page 204 of 593

15 ADEs in the ambulatory setting substantially increased the healthcare costs of elderly persons and estimated costs were $1,983 per case. Further findings of The Commonwealth Fund studies additionally identified 11% to 28% of the 4.3 million visit related ADEs (VADEs) in 2001 might have been prevented with improved systems of care and better patient education, yielding an estimate of 473,000 to 1.2 million potentially preventable VADEs annually and potential cost-savings of $946 million to $2.4 billion. In the Institute for Safe Medication Practices, The White Paper on Medication Safety in the U.S. and the Roles of Community Pharmacists (2007), the American Pharmaceutical Association identified that Americans spend more than $75 billion per year on prescription and nonprescription drugs. Unnecessary costs include: improper use of prescription medicines due to lack of knowledge costs the economy an estimated $ billion per year; American businesses lose an estimated 20 million workdays per year due to incorrect use of medicines prescribed for heart and circulatory diseases alone; failure to have prescriptions dispensed and/or renewed has resulted in an estimated cost of $8.5 billion for increased hospital admissions and physician visits, nearly one percent of the country's total health care expenditures. In 2005, the rate of medication errors during hospitalization was estimated to be 52 per 100 admissions, or 70 per 1,000 patient days. Emerging research suggests the scope of medication-related errors in ambulatory settings is as extensive as or more extensive than during hospitalization. Ambulatory visits result in a prescription for medication 50 to 70% of the time. One study estimated the rate of ADEs in the ambulatory setting to be 27 per 100 patients. It is estimated that between 2004 and 2005 in the United States, 701,547 patients were treated for ADEs in emergency departments, and 117,318 patients were hospitalized for injuries caused by an ADE. Individuals aged 65 years and older are more likely than any other population group to require treatment in the emergency department for ADEs (AMA, 2007). A Systematic Review on Prevalence of Adverse Drug Events in Ambulatory Care finds that The median ADE prevalence rate for retrospective studies was 3.3% (interquartile range [IQR] %) vs 9.65% (IQR %) for prospective studies. Median preventable ADE rates in ambulatory care-based studies were 16.5%, and 52.9% for hospital-based studies. Median prevalence rates by age group ranged from 2.45% for children to 5.27% for adults, 16.1% for elderly patients, and 3.45% for studies including all ages (Tache et al., 2011). The Agency for Healthcare Research and Quality s (AHRQ) The National Healthcare Disparities Report (2011) identified the rate of adverse drug events (ADE) among Medicare beneficiaries in ambulatory settings as 50 per 1,000 person-years. In 2005, AHRQ reported data on adults age 65 and over who received potentially inappropriate prescription medicines in the calendar year, by race, ethnicity, income, education, insurance status, and gender. The disparities were identified as follows: older Asians were more likely than older whites to have inappropriate drug use (20.3% compared with 17.3%); older Hispanics were less likely than older non-hispanic Whites to have inappropriate drug use (13.5% compared with 17.6%); older women were more likely than older men to have inappropriate drug use (20.2% compared with 14.3%); there were no statistically significant differences by income or education. Weeks et al. (2010) noted that fragmented medication records across the health care continuum, inaccurate reporting of medication regimens by patients, and provider failure to acquire all of the necessary elements of medication information from the patient or record, present significant obstacles to obtaining an accurate medication list in the ambulatory care setting. Because these obstacles require solutions demonstrating improvements in access to information and communication, the Institute of Medicine and others have encouraged the incorporation of IT solutions in the medication reconciliation process. In a survey administered to office-based physicians with high rates of EMR use, Weeks, et al found there is an opportunity for universal medication lists utilizing health IT. CLINICAL RECOMMENDATION STATEMENTS: The Joint Commission s 2014 Ambulatory Care National Patient Safety Goals guide providers to maintain and communicate accurate patient medication information. Specifically, the section Use Medicines Safely NPSG includes the following: Record and pass along correct information about a patient s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure 10/10/2014 Page 205 of 593

16 the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-todate list of medicines every time they visit a doctor. The National Quality Forum s 2010 update of the Safe Practices for Better Healthcare, states healthcare organizations must develop, reconcile, and communicate an accurate patient medication list throughout the continuum of care. Improving the safety of healthcare delivery saves lives, helps avoid unnecessary complications, and increases the confidence that receiving medical care actually makes patients better, not worse. Every healthcare stakeholder group should insist that provider organizations demonstrate their commitment to reducing healthcare error and improving safety by putting into place evidence-based safe practices. The AMA s published report, The Physician s Role in Medication Reconciliation, identified the best practice medication reconciliation team as one that is multidisciplinary and in all settings of care will include physicians, pharmacists, nurses, ancillary health care professionals and clerical staff. The team s variable requisite knowledge, skills, experiences, and perspectives are needed to make medication reconciliation work as safely and smoothly as possible. Team members may have access to vital information or data needed to optimize medication safety. Because physicians are ultimately responsible for the medication reconciliation process and subsequently accountable for medication management, physician leadership and involvement in all phases of developing and initiating a medication reconciliation process or model is important to its success. 10/10/2014 Page 206 of 593

17 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 domain in the CY 2015 PFS Final Rule. PQRS 131 was finalized in the CY 2013 PFS Final Rule under the Community and Population Health domain and will therefore remain under the Community and Population Health domain for PQRS OPTIONS F INDIVIDUAL MEASURE: CLAIMS, REGISTRY DESCRIPTION: Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present INSTRUCTIONS: This measure is to be reported each visit occurring during the reporting period for patients seen during the reporting period. There is no diagnosis associated with this measure. This measure may be reported by eligible professionals who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. The documented follow-up plan must be related to the presence of pain, example: Patient referred to pain management specialist for back pain or Return in two weeks for re-assessment of pain. Measure Reporting via Claims: CPT or HCPCS codes and patient demographics are used to identify visits included in the measure s denominator. Quality-data codes are used to report the numerator of the measure. When reporting the measure via claims, submit the listed CPT or HCPCS codes, and the appropriate numerator quality-data code. All measure-specific coding should be reported on the claim(s) representing the eligible encounter. Measure Reporting via Registry: CPT or HCPCS codes and patient demographics are used to identify visits included in the measure s denominator. The listed numerator options are used to report the numerator of 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. DENOMINAT: All visits for patients aged 18 years and older Denominator Criteria (Eligible Cases): Patients aged 18 years on date of encounter AND Patient encounter during the reporting period (CPT or HCPCS): 90791, 90792, 92002, 92004, 92012, 92014, 92507, 92508, 92526, 96116, 96118, 96150, 96151, 97001, 97002, 97003, 97004, 97532, 98940, 98941, 98942, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, D7140, D7210, G0101, G0402, G0438, G0439 NUMERAT: Patient visits with a documented pain assessment using a standardized tool(s) AND documentation of a follow-up plan when pain is present Definitions: 10/10/2014 Page 207 of 593

18 Pain Assessment Documentation of a clinical assessment for the presence or absence of pain using a standardized tool is required. A multi-dimensional clinical assessment of pain using a standardized tool may include characteristics of pain; such as: location, intensity, description, and onset/duration. Standardized Tool An assessment tool that has been appropriately normalized and validated for the population in which it is used. Examples of tools for pain assessment, include, but are not limited to: Brief Pain Inventory (BPI), Faces Pain Scale (FPS), McGill Pain Questionnaire (MPQ), Multidimensional Pain Inventory (MPI), Neuropathic Pain Scale (NPS), Numeric Rating Scale (NRS), Oswestry Disability Index (ODI), Roland Morris Disability Questionnaire (RMDQ), Verbal Descriptor Scale (VDS), Verbal Numeric Rating Scale (VNRS) and Visual Analog Scale (VAS). Follow-Up Plan A documented outline of care for a positive pain assessment is required. This must include a planned follow-up appointment or a referral, a notification to other care providers as applicable indicate the initial treatment plan is still in effect. These plans may include pharmacologic and/or educational interventions. Not Eligible A patient is not eligible if one or more of the following reason(s) is documented: Severe mental and/or physical incapacity where the person is unable to express himself/herself in a manner understood by others. For example, cases where pain cannot be accurately assessed through use of nationally recognized standardized pain assessment tools 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 NUMERAT NOTE: The standardized tool used to assess the patient s pain must be documented in the medical record (exception: A provider may use a fraction such as 5/10 for Numeric Rating Scale without documenting this actual tool name when assessing pain for intensity) Numerator Quality-Data Coding Options for Reporting Satisfactorily: Pain Assessment Documented as Positive AND Follow-Up Plan Documented (One quality-data code [G8730 or G8731] is required on the claim form to submit this numerator option) Performance Met: G8730: Pain assessment documented as positive using a standardized tool AND a follow-up plan is documented Pain Assessment Documented as Negative, No Follow-Up Plan Required Performance Met: G8731: Pain assessment using a standardized tool is documented as negative, no follow-up plan required Pain Assessment not Documented Patient not Eligible (One quality-data code [G8442 or G8939] is required on the claim form to submit this numerator option) Other Performance Exclusion: G8442: Pain assessment NOT documented as being performed, documentation the patient is not eligible for a pain assessment using a standardized tool Pain Assessment Documented as Positive, Follow-Up Plan not Documented, Patient not Eligible Other Performance Exclusion: G8939: Pain assessment documented as positive, follow-up plan not documented, documentation the patient is not eligible Pain Assessment not Documented, Reason not Given (One quality-data code [G8732 or G8509] is required on the claim form to submit this numerator option) Performance Not Met: G8732: No documentation of pain assessment, reason not given Pain Assessment Documented as Positive, Follow-Up Plan not Documented, Reason not Given 10/10/2014 Page 208 of 593

19 Performance Not Met: G8509: Pain assessment documented as positive using a standardized tool, follow-up plan not documented, reason not given RATIONALE: Several provisions from the National Pain Care Policy Act (H.R. 756/S. 660) have been included in the Affordable Care Act (ACA) of 2010 to improve pain care. The legislation includes: Mandating an Institute of Medicine (IOM) conference on pain to address key medical and policy issues affecting the delivery of quality pain care. Establishing a training program to improve the skills of health care professionals to assess and treat pain. Enhancing the pain research agenda for the National Institute of Health (NIH). The American Pain Foundation (2009) identified pertinent facts related to the impact of pain as follows: Approximately 76.5 million Americans suffer from pain. Pain affects more Americans than diabetes, heart disease and cancer combined. It is the number one reason people seek medical care. Uncontrolled pain is a leading cause of disability and diminishes quality of life for patients, survivors, and their loved ones. It interferes with all aspects of daily activity, including sleep, work, social and sexual relations. Under-treated pain drives up costs estimated at $100 billion annually in healthcare expenses, lost income, and lost productivity extending length of hospital stays, as well as increasing emergency room trips and unplanned clinic visits. Medically underserved populations endure a disproportionate pain burden in all health care settings. Disparities exist among racial and ethnic minorities in pain perception, assessment, and treatment for all types of pain, whether chronic or acute. The Institute Of Medicine s (IOM) Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research (2011) report suggests that chronic pain rates will continue to increase as a result of: More Americans will experience a disease in which chronic pain is associated (diabetes, cardiovascular disease, etc.). Increase in obesity which is associated with chronic conditions that have painful symptoms. Progress in lifesaving techniques for catastrophic injuries for people who would have previously died leads to a group of young people at risk for lifelong chronic pain. Surgical patients are at risk for acute and chronic pain. The public has a better understanding of chronic pain syndromes and new treatments and therefore may seek help when they may not have sought help in the past. Persistent chronic pain costs $560 to $635 billion in the USA. Additional healthcare costs due to pain range from $261 to $300 billion. Lost productive time amounts to $299 to $334 billion. Productivity is affected by number of days missed, number of annual hours worked and hourly wages (Gaskin, 2012). Stewart et al. (2003) identified almost thirteen percent of the total workforce experienced a loss in productive time during a two-week period due to a common pain condition: 5.4% for headache; 3.2% for back pain; 2.0% for arthritis pain; 2.0% for other musculoskeletal pain. There are no current estimates of the total cost of poorly controlled pain in today s dollars. Viewed from the perspective of health care inflation at levels of more than 40% during the past decade (President s Council of 10/10/2014 Page 209 of 593

20 Economic Advisors, 2009), the cost of health care due to pain is estimated to be between $261 to $300 billion. The value of lost productivity based on estimates of days of work missed is $11.6 to 12.7 billion, hours of work lost is $95.2 to $96.5 billion and lower wages is $190.6 to $226.3 billion. Total financial cost of pain to society, combining healthcare cost estimates and productivity estimates, ranges from $560 to $635 billion in 2010 dollars (Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research, Appendix C, 2011). Medical care, specifically specialty care, rather than primary care, chiropractic care, or physical therapy is responsible for the rising costs of ambulatory care for spine conditions (Davis, 2012). Medical Expenditures Panel (MEP) data from show that prevalence of back pain has increased by 29% and chronic back pain has increased 64%. Inflation adjusted ($2010) biennial expenditures on ambulatory services for chronic back pain increased by 129% from $15.6 billion in to $35.7 billion in (Smith, 2013). Chronic pain is defined as pain without biological values that has persisted beyond the normal time and despite the usual customary efforts to diagnose and treat the original condition and injury. If a patient s pain has persisted for six weeks (or longer than the anticipated healing time), a thorough evaluation for the course of the chronic pain is warranted (ICSI, 2013). Chronic pain affects approximately 100 million adults in the USA. (Gaskin, 2012). It is clear the enormous painrelated costs represent both a great challenge and an opportunity in terms of improving the quality and costeffectiveness of care (Mayday Fund, 2009). Research also shows gender differences in the experience and treatment of pain. Most chronic pain conditions are more prevalent among women; however, women s pain complaints tend to be poorly assessed and undertreated (Green, 2003; Chronic Pain Research Alliance 2011, Weimer 2013). Although women may have higher baseline pain, differences in pain levels may not persist at one month (Peterson, 2012). A growing body of research reveals even more extensive gaps in pain assessment and treatment among racial and ethnic populations, with minorities receiving less care for pain than non-hispanic whites (Burgess, 2013; Green, 2003; Green, 2007; Green et al., 2011; Todd et al., 2004; Todd et al., 2007). Differences in pain care occur across all types of pain (eg, acute, chronic, cancer-related) and medical settings (eg, emergency departments and primary care) (Green, 2003; Green, 2007; Todd et al., 2007). Even when income, insurance status and access to health care are accounted for, minorities are still less likely than whites to receive necessary pain treatments (Green, 2003; Green, 2007; Paulson et al., 2007). Black race is associated with neighborhood socio-economic status (SES) and race plays a role in pain outcomes beyond SES (Green, 2012). CLINICAL RECOMMENDATION STATEMENTS: Chronic pain assessment should include determining the mechanisms of pain through documentation of pain location, intensity, quality and onset/duration; functional ability and goals; and psychological/social factors such as depression or substance abuse. A patient-centered, multifactorial, comprehensive care plan is necessary; one that includes biopsychosocial factors, as well as spiritual and cultural issues. It is important to have an interdisciplinary team approach which includes the primary care physician and specialty areas of psychology and physical rehabilitation. The Institute for Clinical Systems Improvement (ICSI, 2013) Assessment and Management of Chronic Pain Guideline, Sixth Edition is based on a very broad foundation of evidence addressing a wide range of clinical conditions. It was chosen because it addresses the key factors of the comprehensive plan of care which incorporates self-management and active input from the patient and primary care clinician, pain assessment outcomes and referral to a pain medicine specialist or pain medicine specialty clinic. 10/10/2014 Page 210 of 593