2016 Physician Quality Reporting System Data Collection Form: Multiple Chronic Conditions (for patients aged 66 and older)

Transcription

1 2016 Physician Quality Reporting System Data Collection Form: Multiple Chronic Conditions (for patients aged 66 and older) IMPORTANT: Any measure with a 0% performance rate (100% for inverse measures) is not considered satisfactory reporting. Review your PQRS Submission Summary report, available after entering your data, to ensure this is not an issue. Each measure answer is identified as Performance Met (PM), Performance Not Met (PNM) or Performance Exclusion (PE). More information on this rule is available within the Covisint PQRS Web Application. Patient sample criteria for the Multiple Chronic Conditions Measure Group are: patients aged 66 years and older with at least of the two conditions as listed in the Chronic Conditions Data Warehouse (CCW) document accompanied by a specific patient encounter: One of the following patient encounter codes: 99487, For purposes of the 2016 Multiple Chronic Conditions Measures Group submission of specific diagnosis codes are not required. This measures group contains one or more inverse measures. An inverse measure is a measure that represents a poor clinical quality action as meeting performance for the measure. For these measures, a lower performance rate indicates a higher quality of clinical care. Composite codes for measures groups that contain inverse measures are only utilized when the appropriate quality clinical care is given. Note: Refer to the Covisint PQRS2016 Applicable Measure Group Codes document which contains a list of diagnosis, encounter, and procedure codes for each measures group. Not all measures groups require all 3 code types. REFER TO THE MULTIPLE CHRONIC CONDITIONS MEASURES GROUP WITHIN THE CMS 2016 PQRS MEASURES GROUPS SPECIFICATIONS MANUAL FOR CLINICAL RECOMMENDATIONS AND FURTHER INFORMATION.

2 Page 2 of 11 Physician Name: Patient Name: Last First MI Date of Birth: / / mm dd yyyy Gender: M F Practice Medical Record Number: Patient Insured - Traditional Medicare*: Medicare Advantage: Other: *Note: A minimum of 11 patients must be Traditional Medicare Part B Appointment Date: / / (1/1/16 12/31/16) mm dd yyyy ICD-10 Diagnosis Code: CPT Encounter (visit) Code: CPT Procedure Code: N/A

3 Page 3 of 11 Physician Quality Reporting Measure #47: Care Plan Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan Documentation that Patient did not Wish or was not able to Name a Surrogate Decision Maker or Provide an Advance Care Plan May also include, as appropriate, the following: That the patient s cultural and/or spiritual beliefs preclude a discussion of advance care planning, as it would be viewed as harmful to the patient's beliefs and thus harmful to the physician-patient relationship. Advance Care Planning discussed and documented; advance care plan or surrogate decision maker documented in the medical record - PM Advance Care Planning discussed and documented in the medical record; patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan - PM Advance care planning not documented, reason not otherwise specified - PNM

4 Page 4 of 11 Physician Quality Reporting Measure # 110: Preventive Care and Screening: Influenza Immunization Percentage of patients aged 50 years and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization If reporting this measure between January 1, 2016 and March 31, 2016, choose answer option Influenza immunization administered or previously received when the influenza immunization is ordered or administered to the patient during the months of August, September, October, November, and December of 2015 or January, February, and March of 2016 for the flu season ending March 31, If reporting this measure between October 1, 2016 and December 31, 2016, choose answer option Influenza immunization administered or previously received when the influenza immunization is ordered or administered to the patient during the months of August, September, October, November, and December of 2016 for the flu season ending March 31, Influenza immunizations administered during the month of August or September of a given flu season (either flu season OR flu season) can be reported when a visit occurs during the flu season (October 1 - March 31). In these cases, choose answer option Influenza immunization administered or previously received. Patient visit occurred outside of acceptable date range (i.e., April 1 through September 30, 2016) patient not eligible Influenza immunization administered or previously received PM Influenza immunization was not administered for reasons documented by clinician (e.g., patient allergy or other medical reason, patient declined or other patient reasons, vaccine not available or other system reasons) - PE Document reason in medical chart Influenza immunization was not administered, reason not given - PNM Previous Receipt - Receipt of the current season s influenza immunization from another provider OR from same provider prior to the visit to which the measure is applied (typically, prior vaccination would include influenza vaccine given since August 1st).

5 Page 5 of 11 Physician Quality Reporting Measure # 128 : Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-up Percentage of patients aged 18 years and older with a documented BMI during the current 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 encounter An eligible professional or their staff is required to measure both height and weight. Both the height and the weight must be measured within six months of the encounter and may be obtained from separate encounters. Self-reported values cannot be used. The documentation of a follow-up plan must be based on the most recent documented BMI within the previous six months. NOTE: BMI normal parameters are as follows: age BMI 18.5 and < 25 kg/m2; age 65 and older BMI 23 and < 30 kg/m2 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 education, a referral (e.g., a registered dietician, nutritionist, occupational therapist, physical therapist, primary care provider, exercise physiologist, mental health professional, or surgeon), pharmacological interventions, dietary supplements, exercise counseling, or 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 calculation or follow-up plan 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. BMI is documented within normal parameters and no follow-up plan is required - PM BMI is documented above normal parameters and a follow-up plan is documented - PM BMI is documented below normal parameters and a follow-up plan is documented - PM BMI or follow-up plan not documented, documentation the patient is not eligible for BMI calculation - PE BMI not documented and no reason is given OR BMI documented outside normal parameters, no follow-up plan documented, no reason given -PNM

6 Page 6 of 11 Physician Quality Reporting Measure #130: Documentation of Current Medications in the Medical Record 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. 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 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. Eligible professional attests to documenting in the medical record they obtained, updated, or reviewed the patient s current medications including no medications - PM 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 - PE Current list of medications not documented as obtained, updated, or reviewed by the eligible professional, reason not given - PNM For definitions and further information refer to the measures groups specifications manual

7 Page 7 of 11 Physician Quality Reporting Measure #131: Pain Assessment and Follow-Up 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 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 followup appointment or a referral, a notification to other care providers as applicable OR 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 Pain assessment documented as positive using a standardized tool AND a follow-up plan is documented - PM Pain assessment using a standardized tool is documented as negative, no follow-up plan required - PM Pain assessment NOT documented as being performed, documentation the patient is not eligible for a pain assessment using a standardized tool - PE Pain assessment documented as positive, follow-up plan not documented, documentation the patient is not eligible - PE No documentation of pain assessment, reason not given - PNM Pain assessment documented as positive using a standardized tool, follow-up plan not documented, reason not given - PNM 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)

8 Page 8 of 11 Physician Quality Reporting Measure # 134: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan Percentage of patients aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen Standardized Depression Screening Tool A normalized and validated depression screening tool developed for the patient population in which it is being utilized. The name of the age appropriate standardized depression screening tool utilized must be documented in the medical record. Examples of depression screening tools include but are not limited to: Adult Screening Tools (18 years and older)patient Health Questionnaire (PHQ-9), Beck Depression Inventory (BDI orbdi-ii), Center for Epidemiologic Studies Depression Scale (CES-D),Depression Scale (DEPS), Duke Anxiety- Depression Scale (DADS),Geriatric Depression Scale (GDS), Cornell Scale Screening, and PRIMEMD-PHQ2 Follow-Up Plan Documented follow-up for a positive depression screening must include one or more of the following: Additional evaluation for depression, Suicide Risk Assessment Referral to a practitioner who is qualified to diagnose and treat depression, Pharmacological interventions, Other interventions or follow-up for the diagnosis or treatment of depression NOTE: The follow up plan must be related to a positive depression screening, example: Patient referred for psychiatric evaluation due to positive depression screening. Not Eligible A patient is not eligible if one or more of the following conditions are documented: Patient refuses to participate 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 Situations where the patient s functional capacity or motivation to improve may impact the accuracy of results of standardized depression assessment tools. For example: certain court appointed cases or cases of delirium Patient has an active diagnosis of Depression Patient has a diagnosed Bipolar Disorder Screening for clinical depression is documented as being positive AND a follow-up plan is documented - PM Screening for clinical depression is documented as negative, a follow-up plan is not required - PM Screening for clinical depression not documented, documentation stating the patient is not eligible PE Screening for clinical depression documented as positive, a follow-up plan not documented, documentation stating the patient is not eligible - PE Clinical depression screening not documented, reason not given - PNM Screening for clinical depression documented as positive, follow-up plan not documented, reason not given - PNM

9 Page 9 of 11 Physician Quality Reporting Measure #154: Falls: Risk Assessment Percentage of patients aged 65 years and older with a history of falls who had a risk assessment for falls completed within 12 months 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. 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. NOTE: 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. Falls risk assessment documented 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 - PM Documentation of medical reason(s) for not completing a risk assessment for falls (ie, 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) 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 - PE Patient screened for future fall risk; documentation of no falls in the past year or only one fall without injury in the past year - PE No documentation of falls status - PE Falls risk assessment not completed, reason not otherwise specified 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 - PNM

10 Page 10 of 11 Physician Quality Reporting Measure #155: Falls: Plan of Care Percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months 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. Plan of Care Must include: 1) consideration of vitamin D supplementation AND 2) balance, strength, and gait training. Consideration of Vitamin D Supplementation Documentation that vitamin D supplementation was advised or considered or documentation that patient was referred to his/her physician for vitamin D supplementation advice. Balance, Strength, and Gait Training Medical record must include: documentation that balance, strength, and gait training/instructions were provided OR referral to an exercise program, which includes at least one of the three components: balance, strength or gait OR referral to physical therapy. Falls plan of care documented - PM Documentation of medical reason(s) for no plan of care for falls (ie, 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) - PE Plan of care not documented, reason not otherwise specified - PNM No history of falls, patient not eligible 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. NOTE: 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.

11 Page 11 of 11 Physician Quality Reporting Measure #238: Use of High-Risk Medications in the Elderly Percentage of patients aged 66 years and older who were ordered at least one high-risk medication. A high-risk medication is identified by either of the following: A prescription for medications classified as high risk at any dose and for any duration listed in Table 18 Prescriptions for medications classified as high risk at any dose with greater than a 90 day cumulative medication duration listed in Table 19*. One high-risk medication ordered - PM One high-risk medication not ordered - PNM *Refer to the measures group specifications manual for definitions and further information on this measure. NOTE: This is an Inverse Measure - A lower calculation performance rate for this measure indicates better clinical care or control.