2014 Physician Quality Reporting System Data Collection Form: Oncology (for patients aged 18 and older)

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Mervin Fitzgerald
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1 2014 Physician Quality Reporting System Data Collection Form: Oncology (for patients aged 18 and older) Physician Name: Patient Name: Last First MI Date of Birth: / / mm dd yyyy Gender: M F Medical Record Number: Patient Insured - Traditional Medicare*: Medicare Advantage: Other: *Note: A minimum of 11 patients must be Traditional Medicare Part B **Note: Currently, ICD-10 codes are not required. You may choose to use either the ICD-9 codes listed in each data collection form, or the ICD- 10 codes in the document: PQRS2014 Applicable Measure Group Codes. This document also contains a list of ICD-9, encounter, and procedure codes. Not all measures groups require all 3 code types. Appointment Date: / / (1/1/14 12/31/14) mm dd yyyy ICD-9 (or ICD-10) Diagnosis Code**: Encounter Code: Procedure Code: Patient sample criteria for the Oncology Measures Group are: patients aged 18 years and older with specific surgical procedures performed: Oncology ICD-9, Encounter and Procedure codes: Full list of applicable ICD-9, encounter, and procedure codes--and notes related to these codes--are located at the end of this document PLEASE REFER TO THE ONCOLOGY MEASURES GROUP IN THE CMS 2014 PQRS MEASURES GROUPS SPECIFICATIONS MANUAL F FURTHER INFMATION.

2 Patient Name: Page 2 of 9 Physician Quality Reporting Measure # 71 : Breast Cancer: Hormonal Therapy for Stage IC - IIIC Estrogen Receptor/ Progesterone Receptor (ER/PR) Positive Breast Cancer Percentage of female patients aged 18 years and older with Stage IC through IIIC, ER or PR positive breast cancer who were prescribed tamoxifen or aromatase inhibitor (AI) during the 12-month reporting period Prescribed Prescribed may include prescription given to the patient for tamoxifen or aromatase inhibitor (AI) at one or more visits in the 12-month period patient already taking tamoxifen or aromatase inhibitor (AI) as in the current medication list. Tamoxifen or Aromatase Inhibitor Prescribed AJCC Breast Cancer Stage I: T1C (tumor size > 1 cm to 2 cm)- AJCC Breast Cancer Stage II- AJCC Breast Cancer Stage III- Estrogen receptor (ER) or progesterone receptor (PR) positive breast cancer Tamoxifen or Aromatase Inhibitor not Prescribed for Medical; Patient; or System Reasons AJCC Breast Cancer Stage I: T1C (tumor size > 1 cm to 2 cm)- AJCC Breast Cancer Stage II- AJCC Breast Cancer Stage III- Estrogen receptor (ER) or progesterone receptor (PR) positive breast cancer Medical Reason Patient Reason System Reason NOTE: Measure #71 only needs to be reported when the patient is female and has the following diagnosis code indicating breast cancer: ICD-9-CM: 174.0, 174.1, 174.2, 174.3, 174.4, 174.5, 174.6, 174.8, Not Eligible Patient not Stage IC through IIIC Breast Cancer AJCC Breast Cancer Stage 0- AJCC Breast Cancer Stage I: T1 mic, T1a or T1b (tumor size 1 cm)- AJCC Breast Cancer Stage IV- Not Eligible Patient is ER and PR negative cancer stage is not ER/PR status not patient is not female Tamoxifen or Aromatase Inhibitor not Prescribed- Reason not Otherwise Specified AJCC Breast Cancer Stage I: T1C (tumor size > 1 cm to 2 cm)- AJCC Breast Cancer Stage II- AJCC Breast Cancer Stage III- Estrogen receptor (ER) or progesterone receptor (PR) positive breast cancer

3 Patient Name: Page 3 of 9 Physician Quality Reporting Measure # 72 : Colon Cancer: Chemotherapy for AJCC Stage 3 Colon Cancer Patients Percentage of patients aged 18 through 80 years with AJCC Stage 3 colon cancer who are referred for adjuvant chemotherapy, prescribed adjuvant chemotherapy, or have previously received adjuvant chemotherapy within the 12-month reporting period Adjuvant Chemotherapy According to current NCCN guidelines, the following therapies are recommended: 5-FU/LV/oxaliplatin (mfolfox6) as the standard of care (category 1); bolus 5- FU/LV/oxaliplatin (FLOX, category 1); capecitabine/oxaliplatin (CapeOx, category 1); or single agent capecitabine (category 2A) or 5-FU/LV (category 2A) in patients felt to be inappropriate for oxaliplatin therapy (NCCN, 2012). See clinical recommendation statement for cases where leucovorin is not available. Prescribed May include prescription ordered for the patient for adjuvant chemotherapy at one or more visits in the 12 month period patient already receiving adjuvant chemotherapy as in the current medication list. NOTE: Measure #72 only needs to be reported when the patient is 18 through 80 years old and has the following diagnosis code indicating colon cancer: ICD-9-CM: 153.0, 153.1, 153.2, 153.3, 153.4, 153.6, 153.7, 153.8, Adjuvant Chemotherapy Referred- Prescribed or Previously Received for AJCC Stage 3 Colon Cancer AJCC Colon Cancer Stage 3- Adjuvant Chemotherapy not Prescribed or Previously Received for Documented Reasons Document reason in medical chart AJCC Colon Cancer Stage 3- Not Eligible Patient not Stage 3 colon cancer AJCC Colon Cancer Stage 0- AJCC Colon Cancer Stage 1- AJCC Colon Cancer Stage 2- AJCC Colon Cancer Stage 4- Not Eligible No documentation of cancer stage Adjuvant Chemotherapy not Prescribed or Previously Received- Reason not Given AJCC Colon Cancer Stage 3-

4 Patient Name: Page 4 of 9 Physician Quality Reporting Measure # 110: Preventive Care and Screening: Influenza Immunization Percentage of patients aged 18 and older seen for a visit between October 1 and March 31 who received an influenza immunization who reported previous receipt of an influenza immunization If reporting this measure between January 1, 2014 and March 31, 2014, 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 2013 or January, February, and March of 2014 for the flu season ending March 31, If reporting this measure between October 1, 2014 and December 31, 2014, 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 2014 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 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. Influenza immunization visit occurred outside of acceptable date range (i.e., April 1 through September 30, 2014) patient not eligible Influenza immunization administered or previously received Influenza immunization was not ordered or administered for reasons by clinician (e.g., patient allergy or other medical reason, patient declined or other patient reasons, or other system reasons) Document reason in medical chart Influenza immunization ordered or recommended (to be given at alternate location or alternate provider); vaccine not available at time of visit Influenza immunization was not ordered or administered, reason not given Previous Receipt - Receipt of the current season s influenza immunization from another provider 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 Patient Name: Page 5 of 9 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. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements must contain the medications name, dosage, frequency and route of administration For this measure, the 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 prescriptions, over-the counters, herbals, and vitamin/mineral/dietary (nutritional) supplements must contain the medications name, dosages, frequency and route of administration Current Medications Medications the patient is presently taking including all prescriptions, over-the-counters, herbals and vitamin/mineral/dietary (nutritional) supplements with each medication s name, dosage, frequency and administered route. Eligible professional attests to documenting in the medical record they obtained, updated, or reviewed the patient s current medications 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 list of medications not as obtained, updated, or reviewed by the eligible professional, reason not given 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 in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient s health status. 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. Answer option Eligible professional attests to documenting in the medical record that they obtained should be chosen if the eligible professional that the patient is not currently taking any medications.

6 Patient Name: Page 6 of 9 Physician Quality Reporting Measure # 143 : Oncology: Medical and Radiation Pain Intensity Quantified Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified Pain intensity should be quantified using a standard instrument, such as a 0-10 numeric rating scale, a categorical scale, or the pictorial scale. Pain severity quantified; pain present Pain severity quantified; no pain present Pain severity not, reason not otherwise specified Physician Quality Reporting Measure # 144 : Oncology: Medical and Radiation Plan of Care for Pain Percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a plan of care to address pain A plan of care may include: use of opioids, non-opioid analgesics, psychological support, patient and/or family education, referral to a pain clinic, or reassessment of pain at an appropriate time interval. Plan of care to address pain Plan of care for pain not, reason not otherwise specified Not eligible, No pain present NOTE: Measure #144 only needs to be reported when patients are identified in Measure #143 with pain present

7 Patient Name: Page 7 of 9 Physician Quality Reporting Measure # 194 : Oncology: Cancer Stage Documented Percentage of patients, regardless of age, with a diagnosis of cancer who are seen in the ambulatory setting who have a baseline AJCC cancer stage or documentation that the cancer is metastatic in the medical record at least once within 12 months American Joint Committee on Cancer (AJCC) stage and reviewed Cancer stage in medical record as metastatic and reviewed For certain malignancies, staging or classification systems included in the AJCC Staging Manual would also satisfy the requirements of this measure (e.g., Ann Arbor). Cancer stage refers to stage at diagnosis. Documentation that the cancer is metastatic at diagnosis would also satisfy the requirements of the measure. Cancer Stage not Documented, Reason not Otherwise Specified Physician Quality Reporting Measure # 226 : Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months who received cessation counseling intervention if identified as a tobacco user NOTE: In the event that a patient is screened for tobacco use and identified as a user but did not receive tobacco cessation counseling, choose answer option tobacco screening tobacco cessation intervention not performed, reason not otherwise specified. Tobacco Use includes any type of tobacco. Cessation Counseling Intervention includes brief counseling (3 minutes or less) and/or pharmacotherapy. Patient screened for tobacco use received tobacco cessation intervention (counseling, pharmacotherapy, or both), if identified as a tobacco user Current tobacco non-user Documentation of medical reason(s) for not screening for tobacco use (eg, limited life expectancy, other medical reasons) Tobacco screening tobacco cessation intervention not performed, reason not otherwise specified

8 Patient Name: Page 8 of 9 FULL LIST OF PROCEDURE ENCOUNTER CODES F THIS MEASURE GROUP: Patient sample criteria for the Oncology Measures Group are patients aged 18 years and older with a specific diagnosis of cancer, accompanied by a specific patient encounter: One of the following diagnosis codes indicating cancer ICD-9-CM: 140.0, 140.1, 140.3, 140.4, 140.5, 140.6, 140.8, 140.9, 141.0, 141.1, 141.2, 141.3, 141.4, 141.5, 141.6, 141.8, 141.9, 142.0, 142.1, 142.2, 142.8, 142.9, 143.0, 143.1, 143.8, 143.9, 144.0, 144.1, 144.8, 144.9, 145.0, 145.1, 145.2, 145.3, 145.4, 145.5, 145.6, 145.8, 145.9, 146.0, 146.1, 146.2, 146.3, 146.4, 146.5, 146.6, 146.7, 146.8, 146.9, 147.0, 147.1, 147.2, 147.3, 147.8, 147.9, 148.0, 148.1, 148.2, 148.3, 148.8, 148.9, 149.0, 149.1, 149.8, 149.9, 150.0, 150.1, 150.2, 150.3, 150.4, 150.5, 150.8, 150.9, 151.0, 151.1, 151.2, 151.3, 151.4, 151.5, 151.6, 151.8, 151.9, 152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 153.0, 153.1, 153.2, 153.3, 153.4, 153.5, 153.6, 153.7, 153.8, 153.9, 154.0, 154.1, 154.2, 154.3, 154.8, 155.0, 155.1, 155.2, 156.0, 156.1, 156.2, 156.8, 156.9, 157.0, 157.1, 157.2, 157.3, 157.4, 157.8, 157.9, 158.0, 158.8, 158.9, 159.0, 159.1, 159.8, 159.9, 160.0, 160.1, 160.2, 160.3, 160.4, 160.5, 160.8, 160.9, 161.0, 161.1, 161.2, 161.3, 161.8, 161.9, 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 163.0, 163.1, 163.8, 163.9, 164.0, 164.1, 164.2, 164.3, 164.8, 164.9, 165.0, 165.8, 165.9, 170.0, 170.1, 170.2, 170.3, 170.4, 170.5, 170.6, 170.7, 170.8, 170.9, 171.0, 171.2, 171.3, 171.4, 171.5, 171.6, 171.7, 171.8, 171.9, 172.0, 172.1, 172.2, 172.3, 172.4, 172.5, 172.6, 172.7, 172.8, 172.9, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 174.0, 174.1, 174.2, 174.3, 174.4, 174.5, 174.6, 174.8, 174.9, 175.0, 175.9, 176.0, 176.1, 176.2, 176.3, 176.4, 176.5, 176.8, 176.9, 179, 180.0, 180.1, 180.8, 180.9, 181, 182.0, 182.1, 182.8, 183.0, 183.2, 183.3, 183.4, 183.5, 183.8, 183.9, 184.0, 184.1, 184.2, 184.3, 184.4, 184.8, 184.9, 185, 186.0, 186.9, 187.1, 187.2, 187.3, 187.4, 187.5, 187.6, 187.7, 187.8, 187.9, 188.0, 188.1, 188.2, 188.3, 188.4, 188.5, 188.6, 188.7, 188.8, 188.9, 189.0, 189.1, 189.2, 189.3, 189.4, 189.8, 189.9, 190.0, 190.1, 190.2, 190.3, 190.4, 190.5, 190.6, 190.7, 190.8, 190.9, 191.0, 191.1, 191.2, 191.3, 191.4, 191.5, 191.6, 191.7, 191.8, 191.9, 192.0, 192.1, 192.2, 192.3, 192.8, 192.9, 193, 194.0, 194.1, 194.3, 194.4, 194.5, 194.6, 194.8, 194.9, 195.0, 195.1, 195.2, 195.3, 195.4, 195.5, 195.8, 196.0, 196.1, 196.2, 196.3, 196.5, 196.6, 196.8, 196.9, 197.0, 197.1, 197.2, 197.3, 197.4, 197.5, 197.6, 197.7, 197.8, 198.0, 198.1, 198.2, 198.3, 198.4, 198.5, 198.6, 198.7, , , , 199.0, 199.1, 199.2, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , (CONTINUED, NEXT PAGE)

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2015 Physician Quality Reporting System Data Collection Form: Oncology (for patients aged 18 and older)

2015 Physician Quality Reporting System Data Collection Form: Oncology (for patients aged 18 and older) IMPORTANT: Any measure with a 0% performance rate (100% for inverse measures) is not considered satisfactory