2017 Data Collection Form: Orthopedics Advanced

Transcription

1 2017 Data Collection Form: Orthopedics Advanced Physician Name: The following Quality measures are included in this ADVANCED specialty set: o 21 Perioperative - Selection of Prophylactic Antibiotic o 23 Perioperative - Venous Thromboembolism (VTE) Prophylaxis o 109 Osteoarthritis: Function and Pain Assessment o 226 Smoking o 350 TKR Shared Decision Making o 352 TKR Preoperative Antibiotic Infusion with Proximal Tourniquet CMS final rule for MACRA s Merit-Based Incentive Payment System (MIPS) allows for an Eligible Clinician to pick your pace by reporting a minimal amount of data to avoid penalty OR report more data for a 90-day period for the possibility of earning a small positive payment adjustment. With this in mind, Covisint has created this easy to use form giving you the option to report some data using a BASIC measure set for avoidance of penalty only or choose to report the ADVANCED measure set designed to maximize scoring*. In either case refer to the Individual Measure specifications for measure requirement criteria. Patient Name: Last First MI Date of Birth: / / mm dd yyyy Gender: M F Patient Insured - Traditional Medicare: Medicare Advantage: Other: Practice Medical Record Number(optional): Appointment Date: / / (1/1/17 12/31/17) mm dd yyyy *To maximize potential incentives Eligible Clinicians must report at least six (6) quality measures including an Outcome or High Priority measure at a 50% reporting rate for 90-days along with other category reporting requirements.

2 Measure #21 (NQF 0268): Perioperative Care: Selection of Prophylactic Antibiotic First OR Second Generation Cephalosporin National Quality Strategy Domain: Patient Safety. Measure Type: Process Page 2 of 7 This measure is to be reported each time a procedure is performed during the performance period for patients who undergo surgical procedures with the indications for a first or second generation cephalosporin prophylactic antibiotic. There is no diagnosis associated with this measure. It is anticipated that eligible clinicians who perform the listed surgical procedures as specified in the denominator coding will submit this measure. Registry Quality Measure # 21: Perioperative Care: Selection of Prophylactic Antibiotic First OR Second Generation Cephalosporin Description: Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic who had an order for a first OR second generation cephalosporin for antimicrobial prophylaxis Numerator Instructions: There must be documentation of an order (written order, verbal order, or standing order/protocol) for a first OR second generation cephalosporin for antimicrobial prophylaxis OR documentation that a first OR second generation cephalosporin was given. Documentation of order for first OR second generation cephalosporin for antimicrobial prophylaxis - PM Documentation of medical reason(s) for not ordering a first OR second generation cephalosporin for antimicrobial prophylaxis (e.g., patients enrolled in clinical trials, patients with documented infection prior to surgical procedure of interest, patients who were receiving antibiotics more than 24 hours prior to surgery [except colon surgery patients taking oral prophylactic antibiotics], patients who were receiving antibiotics within 24 hours prior to arrival [except colon surgery patients taking oral prophylactic antibiotics], other medical reason(s)) - Denominator exception Order for first OR second generation cephalosporin for antimicrobial prophylaxis was not documented, reason not given - PNM

3 Page 3 of 7 Measure #23 (NQF 0239): Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) National Quality Strategy Domain: Patient Safety. Measure Type: Process This measure is to be reported each time a procedure is performed during the performance period for all patients who undergo surgical procedures for which VTE prophylaxis is indicated. There is no diagnosis associated with this measure. It is anticipated that eligible clinicians who perform the listed surgical procedures as specified in the denominator coding will submit this measure. Registry Quality Measure # 23: Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) Description: Percentage of surgical patients aged 18 years and older undergoing procedures for which venous thromboembolism (VTE) prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low- Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time Numerator Instructions: There must be documentation of order (written order, verbal order, or standing order/protocol) for VTE prophylaxis OR documentation that VTE prophylaxis was given. Definition: Mechanical Prophylaxis Does not include TED hose. Documentation that an order was given for venous thromboembolism (VTE) prophylaxis to be given within 24 hours prior to incision time or 24 hours after surgery end time- PM Documentation of medical reason(s) for patient not receiving any form of VTE prophylaxis (LMWH, LDUH, adjusted-dose warfarin, fondaparinux or mechanical prophylaxis) within 24 hours prior to incision time or 24 hours after surgery end time - Denominator exception Order was not given for venous thromboembolism (VTE) prophylaxis to be given within 24 hours prior to incision time or 24 hours after surgery end time, reason not otherwise specified - PNM

4 Page 4 of 7 Measure #109: Osteoarthritis (OA): Function and Pain Assessment National Quality Strategy Domain: Person and Caregiver-Centered Experience and Outcomes. Measure Type: Process This measure is to be reported at each denominator eligible visit occurring during the performance period for patients with osteoarthritis seen during the performance period. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. Registry Quality Measure #109: Osteoarthritis (OA): Function and Pain Assessment Description: Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain NUMERATOR: Patient visits with assessment for level of function and pain documented (may include the use of a standardized scale or the completion of an assessment questionnaire, such as an SF-36, AAOS Hip & Knee Questionnaire) NOTE: For the purposes of this measure, the method for assessing function and pain is left up to the discretion of the individual eligible clinician and based on the needs of the patient. The assessment may be done via a validated instrument (though one is not required) that measures pain and various functional elements including a patient s ability to perform activities of daily living (ADLs). Osteoarthritis symptoms and functional status assessed (may include the use of a standardized scale or the completion of an assessment questionnaire, such as the SF-36, AAOS Hip & Knee Questionnaire) - PM Osteoarthritis symptoms and functional status not assessed, reason not otherwise specified - PNM

5 Page 5 of 7 Measure #226 (NQF 0028): Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention National Quality Strategy Domain: Community / Population Health. Measure Type: Process This measure is to be reported once per performance period for patients seen during the performance period. This measure is intended to reflect the quality of services provided for preventive screening for tobacco use. Registry Quality Measure # 226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Description: Percentage of patients aged 18 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 Tobacco Use includes any type of tobacco. Cessation Counseling Intervention includes brief counseling (3 minutes or less) and/or pharmacotherapy. 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. 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) Denominator exception Tobacco screening OR tobacco cessation intervention not performed, reason not otherwise specified - PNM

6 Page 6 of 7 Measure #350: Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy National Quality Strategy Domain: Communication and Care Coordination. Measure Type: Process This measure is to be reported each time a procedure for total knee replacement is performed during the performance period. There is no diagnosis associated with this measure. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. Registry Quality Measure #350: Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy Percentage of patients regardless of age or gender undergoing a total knee replacement with documented shared decision-making with discussion of conservative (non-surgical) therapy (e.g. NSAIDS, analgesics, weight loss, exercise, injections) prior to the procedure Patients with documented shared decision-making including discussion of conservative (non-surgical) therapy prior to the procedure (e.g., NSAIDS, analgesics, weight loss, exercise, injections) prior to the procedure - PM Shared decision-making including discussion of conservative (non-surgical) therapy (e.g. NSAIDS, analgesics, weight loss, exercise, injections) prior to the procedure not documented, reason not given - PNM

7 Page 7 of 7 Measure #352: Total Knee Replacement: Preoperative Antibiotic Infusion with Proximal Tourniquet National Quality Strategy Domain: Patient Safety. Measure Type: Process This measure is to be reported each time a procedure for total knee replacement is performed during the performance period. There is no diagnosis associated with this measure. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. Registry Quality Measure # 352 : Total Knee Replacement (TKR): Preoperative Antibiotic Infusion with Proximal Tourniquet Percentage of patients regardless of age or gender undergoing a total knee replacement who had the prophylactic antibiotic completely infused prior to the inflation of the proximal tourniquet Patients who had the prophylactic antibiotic completely infused prior to the inflation of the proximal tourniquet - PM Documentation of medical reason(s) for not completely infusing the prophylactic antibiotic prior to the inflation of the proximal tourniquet (e.g., a tourniquet was not used) Denominator exception Prophylactic antibiotic not completely infused prior to the inflation of the proximal tourniquet, reason not given - PNM