Patient sample criteria for the Preventive Care Measure Group are patients aged 50 years and older with a specific patient encounter:

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1 2016 Physician Quality Reporting System Data Collection Form: Preventive Care (for patients aged 50 and older) NOTE: Individual measures may have more restrictive age and gender requirements. 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 Preventive Care Measure Group are patients aged 50 years and older with a specific patient encounter: One of the following patient encounter codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, Some measures are applicable to women only; and some measures require a specific age range. **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.

2 Demographics Page 2 of 10 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**: N/A CPT Encounter (visit) Code: CPT Procedure Code**: N/A PLEASE REFER TO THE PREVENTIVE CARE MEASURES GROUP IN THE CMS 2016 PQRS MEASURES GROUPS SPECIFICATIONS MANUAL FOR CLINICAL RECOMMENDATIONS AND FURTHER INFORMATION.

3 Page 3 of 10 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. 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). 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

4 Page 4 of 10 Physician Quality Reporting Measure # 111 : Pneumonia Vaccination Status for Older Adults For men or women aged 65 and older Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine Pneumococcal vaccine administered or previously received - PM Pneumococcal vaccine not administered or previously received, reason not otherwise specified - PNM Physician Quality Reporting Measure # 113 : Colorectal Cancer Screening For men or women aged Percentage of patients 50 through 75 years of age who had appropriate screening for colorectal cancer Appropriate screenings are defined by any one of the following criteria below: Fecal occult blood test (FOBT) during the measurement period Flexible sigmoidoscopy during the measurement period or the four years prior to the measurement period Colonoscopy during the measurement period or the nine years prior to the measurement period Colorectal cancer screening results documented and reviewed - PM Documentation of medical reason(s) for not performing a colorectal cancer screening (i.e., diagnosis of colorectal cancer or total colectomy) - PE Document reason in medical chart Colorectal cancer screening results were not documented and reviewed, reason not otherwise specified - PNM

5 Page 5 of 10 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 10 Physician Quality Reporting Measure # 134: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan Percentage of patients aged 50 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 followup 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

7 Page 7 of 10 Physician Quality Reporting Measure # 431 : Preventive Care and Screening: Unhealthy Alcohol Use Screening & Brief Counseling Percentage of patients aged 50 years and older who were screened for unhealthy alcohol use at least once within 24 months using a systematic screening method AND who received brief counseling if identified as an unhealthy alcohol user Patient identified as an unhealthy alcohol user when screened for unhealthy alcohol use using a systematic screening method and received brief counseling - PM Unhealthy Alcohol Use Covers a spectrum that is associated with varying degrees of risk to health. Categories representing unhealthy alcohol use include risky use, problem drinking, harmful use, and alcohol abuse, and the less common but more severe alcoholism and alcohol dependence. Risky use is defined as > 7 standard drinks per week or > 3 drinks per occasion for women and persons > 65 years of age; > 14 standard drinks per week or > 4 drinks per occasion for men 65 years of age. Systematic Screening Method For purposes of this measure, one of the following systematic methods to assess unhealthy alcohol use must be utilized. Systematic screening methods and thresholds for defining unhealthy alcohol use include: AUDIT Screening Instrument (score 8) AUDIT-C Screening Instrument (score 4 for men; score 3 for women) Single Question Screening - How many times in the past year have you had 5 (for men) or 4 (for women and all adults older than 65 years) or more drinks in a day? (response 2) Brief counseling - Brief counseling for unhealthy alcohol use refers to one or more counseling sessions, a minimum of 5-15 minutes, which may include: feedback on alcohol use and harms; identification of high risk situations for drinking and coping strategies; increased motivation and the development of a personal plan to reduce drinking. Patient not identified as an unhealthy alcohol user when screened for unhealthy alcohol use using a systematic screening method - PM Documentation of medical reason(s) for not screening for unhealthy alcohol use (e.g., limited life expectancy, other medical reasons) - PE Document reason in medical chart Patient not screened for unhealthy alcohol screening using a systematic screening method OR patient did not receive brief counseling, reason not given - PNM

8 Page 8 of 10 Physician Quality Reporting Measure # 226 : Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Percentage of patients aged 50 years and older who were screened for tobacco use one or more times within 24 months AND 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 OR 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 AND received tobacco cessation intervention (counseling, pharmacotherapy, or both), if identified as a tobacco user - PM Current tobacco non-user - PM Documentation of medical reason(s) for not screening for tobacco use (e.g., limited life expectancy, other medical reasons) - PE Tobacco screening OR tobacco cessation intervention not performed, reason not otherwise specified - PNM

9 Page 9 of 10 FEMALE PATIENTS ONLY: Physician Quality Reporting Measure # 39 : Screening or Therapy for Osteoporosis for Women Aged Years of Age For women aged only Percentage of female patients aged years of age who have ever had a central dual-energy X-ray absorptiometry (DXA) to check for osteoporosis The number of women who have documentation in their medical record of having received a DXA test of the hip or spine Patient with documented results of a central DXA ever being performed - PM Clinician documented that patient was not an eligible candidate for screening - PE Patient with central DXA results not documented, reason not given - PNM

10 Page 10 of 10 Physician Quality Reporting Measure # 48 : Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older For women aged 65 and older only Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months Urinary Incontinence Any involuntary leakage of urine. Presence or absence of urinary incontinence assessed - PM Presence or absence of urinary incontinence not assessed for medical reason - PE Document reason in medical chart Presence or absence of urinary incontinence not assessed, reason not otherwise specified - PNM Physician Quality Reporting Measure # 112 : Breast Cancer Screening For women aged 50 through 74 only Percentage of women 50 through 74 years of age who had a mammogram to screen for breast cancer within 27 months NOTE: The measure's 27-month look back period applies to women ages (the numerator looks for a mammogram any time on or between October 1, 27 months prior to the measurement period, and December 31 of the measurement period in order to capture women who have had a mammogram every 24 months per clinical guidelines, with a 3-month grace period). Therefore, women ages are included in the measure if they had a visit and a mammogram since age 50, but the 27-month look back period only applies to patients age For patients that are 51 years of age during the measurement period look back only to age 50. Screening mammography results documented and reviewed - PM Documentation of medical reason(s) for not performing a mammogram (i.e., women who had a bilateral mastectomy or two unilateral mastectomies) - PE Document reason in medical chart Screening mammography results were not documented and reviewed, reason not otherwise specified - PNM