2014 Physician Quality Reporting System Data Collection Form: Inflammatory Bowel Disease (IBD) (for patients aged 18 and older)
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1 2014 Physician Quality Reporting System Data Collection Form: Inflammatory Bowel Disease (IBD) (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: N/A Patient sample criteria for the IBD Measures Group are: patients aged 18 and older with a specific diagnosis of IBD, accompanied by a specific patient encounter: One of the following ICD-9 diagnosis codes indicating IBD: 555.0, 555.1, 555.2, 555.9, 556.0, 556.1, 556.2, 556.3, 556.4, 556.5, 556.6, 556.8, one of the following patient encounter codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99401, 99402, 99403, 99404, 99406, PLEASE REFER TO THE INFLAMMATORY BOWEL DISEASE MEASURES GROUP IN THE CMS 2014 PQRS MEASURES GROUPS SPECIFICATIONS MANUAL FOR FURTHER INFORMATION.
2 Patient Name: Page 2 of 7 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 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 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 OR tobacco cessation intervention not performed, reason not otherwise specified Physician Quality Reporting Measure # 269 : Inflammatory Bowel Disease (IBD): Type, Anatomic Location and Activity All Documented diagnosis of inflammatory bowel disease who have documented the disease type, anatomic location and activity, at least once during the reporting year Patients are considered to have appropriate documentation of inflammatory bowel disease type, anatomic location, and activity if all of the following are documented: a. Type of inflammatory bowel disease (Crohn s, ulcerative colitis or IBD-unclassified) Type, anatomic location, and activity all documented Documentation of patient reason(s) for not being able to assess (e.g. patient refuses endoscopic and/or radiologic assessment) No documentation of disease type, anatomic location and activity, reason not otherwise specified b. Anatomic location of disease based on current or historic endoscopic and/or radiologic data (Note: this element does not prescribe frequency of studies). c. Luminal disease activity (quiescent, mild, moderate, severe) and presence of extraintestinal manifestations
3 Patient Name: Page 3 of 7 Physician Quality Reporting Measure # 270 : Care: Corticosteroid Sparing Therapy diagnosis of inflammatory bowel disease who have been managed by corticosteroids greater than or equal to 10 mg/day for 60 or greater consecutive days that have been prescribed corticosteroid sparing therapy in the last reporting year Corticosteroids Prednisone equivalents used expressly for the treatment of IBD and not for other indications (including premedication before anti-tnf therapy, non-ibd indications) can be determined using the following: 1 mg of prednisone = 1 mg of prednisolone; 5 mg of cortisone; 4 mg of hydrocortisone; 0.8 mg of triamcinolone; 0.8 mg of methylprednisolone; 0.15 mg of dexamethasone; 0.15 mg of betamethasone. for 60 consecutive days Corticosteroid sparing therapy prescribed Patient not receiving corticosteroids 10 for 60consecutive days Corticosteroid sparing therapy not prescribed, medical reason (e.g. benefits of continuing steroid therapy outweigh the risk of weaning patient off steroids and initiating steroid sparing therapy; patient refuses to initiate steroid sparing therapy) for 60consecutive days Documentation of patient reason(s) for not treating with corticosteroid sparing therapy (eg, patient refuses to initiate steroid sparing therapy) for 60 consecutive days Corticosteroid sparing therapy not prescribed, reason not otherwise specified
4 Patient Name: Page 4 of 7 Physician Quality Reporting Measure # 271 : Care: Corticosteroid Related Iatrogenic Injury Bone Loss Assessment diagnosis of inflammatory bowel disease who have received dose of corticosteroids greater than or equal to 10 mg/day for 60 or greater consecutive days and were assessed for risk of bone loss once per the reporting year Corticosteroids Prednisone equivalents used expressly for the treatment of IBD and not for other indications (including premedication before anti-tnf therapy, non-ibd indications) can be determined using the following: 1 mg of prednisone = 1 mg of prednisolone; 5 mg of cortisone; 4 mg of hydrocortisone; 0.8 mg of triamcinolone; 0.8 mg of methylprednisolone; 0.15 mg of dexamethasone; 0.15 mg of betamethasone. Assessed Documentation that an assessment for risk of bone loss has been performed or ordered. This includes, but is not limited to, review of systems and medication history, and ordering of Central Dual-energy X-Ray Absorptiometry (DXA) scan. Patient receiving corticosteroids 10 Central Dual-energy X-Ray Absorptiometry (DXA) ordered or documented, review of systems and medication history or pharmacologic therapy (other than minerals/vitamins) for osteoporosis prescribed Patient not receiving corticosteroids 10 Patient receiving corticosteroids 10 Patients not assessed for risk of bone loss, reason not otherwise specified
5 Patient Name: Page 5 of 7 Physician Quality Reporting Measure # 272 : Care: Influenza Immunization Percentage of patients aged 18 years and older with inflammatory bowel disease for whom influenza immunization was recommended, received during the reporting year Influenza immunization recommended, ordered or administered Influenza immunization not recommended, ordered, received for documented reason System Reason Influenza immunization not recommended, ordered or administered, reason not otherwise specified Physician Quality Reporting Measure # 273 : Care: Pneumococcal Immunization diagnosis of inflammatory bowel disease that had pneumococcal vaccination received Pneumococcal vaccine received Pneumococcal vaccine not received, for Document reason in medical char Pneumococcal vaccine not received, reason not specified
6 Patient Name: Page 6 of 7 Physician Quality Reporting Measure # 274 : Inflammatory Bowel Disease (IBD): Testing for Latent Tuberculosis (TB) Before Initiating Anti- TNF (Tumor Necrosis Factor) Therapy diagnosis of inflammatory bowel disease (IBD) for whom a tuberculosis (TB) screening was performed and results interpreted within six months prior to receiving a first course of anti-tnf (tumor necrosis factor) therapy First Course of anti-tnf therapy the first (ever) course of anti-tnf therapy Documentation that tuberculosis (TB) screening test performed and results interpreted Patients receiving a first course of anti-tnf therapy Patient not receiving a first course of anti-tnf (tumor necrosis factor) therapy TB screening test not performed within 6 months prior to receiving a first course of anti-tnf therapy received for Patient receiving a first course of anti-tnf (tumor necrosis factor) therapy TB screening test not performed within 6 months prior to receiving a first course of anti-tnf therapy received, reason not specified Patient receiving a first course of anti-tnf (tumor necrosis factor) therapy
7 Patient Name: Page 7 of 7 Physician Quality Reporting Measure # 275 : Inflammatory Bowel Disease (IBD): Assessment of Hepatitis B Virus (HBV) Status Before Initiating Anti-TNF (Tumor Necrosis Factor) Therapy diagnosis of inflammatory bowel disease (IBD) who had Hepatitis B Virus (HBV) status assessed and results interpreted within one year prior to receiving a first course of anti-tnf (tumor necrosis factor) therapy HBV status must be assessed by one of the following: HBsAG, HBsAG neutralization, HBcAb total, HBcAB IgM, HBsAB First Course of anti-tnf therapy the first (ever) course of anti-tnf therapy Hepatitis B Virus (HBV) status assessed and results interpreted within one year prior to receiving a first course of anti-tnf (tumor necrosis factor) therapy Patient has documented immunity to hepatitis B and is receiving a first course of anti- TNF therapy Hepatitis B vaccine injection received and is receiving a first course of anti-tnf therapy Patient not receiving a first course of anti-tnf therapy Hepatitis B virus not assessed for Hepatitis B virus not assessed and results interpreted within one year prior to receiving a first course of anti-tnf (tumor necrosis factor) therapy, reason not specified
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