2013 Physician Quality Reporting System Data Collection Form: Inflammatory Bowel Disease (IBD) (for patients 18 and older)

Transcription

1 2013 Physician Quality Reporting System Data Collection Form: Inflammatory Bowel Disease (IBD) (for patients 18 and older) Physician Name: Patient Name: Last First MI Date of Birth: / / mm dd yyyy Gender: M F Patient Insured - Traditional Medicare*: Medicare Advantage: Other: Medical Record Number: App t Date: ICD-9 : / / mm dd yyyy Encounter: *Note: A minimum of 11 patients must be Traditional Medicare Part B Patient sample criteria for the IBD Measures Group is for patients aged 18 and older with a specific diagnosis of IBD accompanied by a specific patient encounter: One of the following 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, Accompanied by one of the following patient encounter codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99401, 99402, 99403, 99404, 99406, The appointment date must be between Jan 1 through Dec 31, Each measure needs to have been assessed at least once during the 12 m reporting period. If more than one assessment; record the most recent information. PLEASE REFER TO THE INFLAMMATORY BOWEL DISEASE USER GUIDE FOR FURTHER INFORMATION

2 Patient Name: Page 2 of 7 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 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. Patient receiving corticosteroids 10 mg/day for 60 consecutive days Corticosteroid sparing therapy prescribed Patient not receiving corticosteroids 10 Patient receiving corticosteroids 10 mg/day 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) Patient receiving corticosteroids 10 mg/day for 60consecutive days Corticosteroid sparing therapy not prescribed, reason not 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 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, administered or previously 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 specified

5 Patient Name: Page 5 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 Reporting Frequency: patient must be screened for tobacco use one or more times within 24 months and reported once during the reporting period. Tobacco Use Includes any type of tobacco Cessation Counseling Intervention Includes counseling or pharmacotherapy Patient screened for tobacco use received tobacco cessation intervention (counseling pharmacotherapy or both) if identified as a tobacco user Patient screened for tobacco use and identified as a tobacco non-user Tobacco screening not performed - Tobacco screening OR tobacco cessation not performed - 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) 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) 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 Patient not receiving a first Hepatitis B virus not assessed for Hepatitis B virus not assessed, reason not specified