2016 Physician Quality Reporting System Data Collection Form: Total Knee Replacement

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1 2016 Physician Quality Reporting System Data Collection Form: Total Knee Replacement 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 Total Knee Replacement (TKR) Measures Group are patients, regardless of age, who had a TKR procedure: One of the following procedure codes indicating Total Knee Replacement (TKR): 27438, 27442, 27446, **Note: Currently, ICD-10 codes are not required for this measures group. Not all measures groups require all 3 code types. 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 Code: N/A CPT Procedure Code: PLEASE REFER TO THE TOTAL KNEE REPLACEMENT MEASURES GROUP IN THE CMS 2016 PQRS MEASURES GROUPS SPECIFICATIONS MANUAL FOR CLINICAL RECOMMENDATIONS AND FURTHER INFORMATION.

2 Page 2 of 5 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. 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 known prescriptions, over-the counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications name, dosages, frequency and route of administration Not Eligible - A patient is not eligible if the following reason is documented: 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. Eligible professional attests to documenting in the medical record they obtained, updated, or reviewed the patient s current medications - PM 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 - PE Current list of medications not documented as obtained, updated, or reviewed by the eligible professional, reason not given - PNM For definitions and further information refer to the measures groups specifications manual

3 Page 3 of 5 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 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 Physician Quality Reporting Measure # 350: Total Knee Replacement: Shared Decision- Making: Trial of Conservative (Non-surgical) Therapy 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 decisionmaking 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

4 Page 4 of 5 Physician Quality Reporting Measure # 351 : Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation undergoing a total knee replacement who are evaluated for the presence or absence of venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure (e.g. history of Deep Vein Thrombosis, Pulmonary Embolism, Myocardial Infarction, Arrhythmia and Stroke) Patients who are evaluated for venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure (e.g. history of DVT, PE, MI, arrhythmia and stroke) - PM Patients who are not evaluated for venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure including (e.g. history of DVT, PE, MI, arrhythmia and stroke, reason not given) - PNM Physician Quality Reporting Measure # 352 : Total Knee Replacement (TKR): Preoperative Antibiotic Infusion with Proximal Tourniquet 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) - PE Prophylactic antibiotic not completely infused prior to the inflation of the proximal tourniquet, reason not given - PNM

5 Page 5 of 5 Physician Quality Reporting Measure # 353 : Total Knee Replacement (TKR): Identification of Implanted Prosthesis in Operative Report undergoing a total knee replacement whose operative report identifies the prosthetic implant specifications including the prosthetic implant manufacturer, the brand name of the prosthetic implant and the size of each prosthetic implant Operative report identifies the prosthetic implant specifications including the prosthetic implant manufacturer, the brand name of the prosthetic implant and the size of each prosthetic implant - PM Operative report does not identify the prosthetic implant specifications including the prosthetic implant manufacturer, the brand name of the prosthetic implant and the size of each prosthetic implant, reason not given - PNM