2013 Physician Quality Reporting System Data Collection Form: Hepatitis C (For patients aged 18 and over)

Transcription

1 2013 Physician Quality Reporting System Data Collection Form: (For patients aged 18 and over) Physician Name: Patient Name: Last First MI Gender: Patient Insured - M F Traditional Medicare*: Medicare Advantage: Other: Date of Birth: / / mm dd yyyy Medical Record Number: App t Date: / / mm dd yyyy ICD-9 : Encounter: *Note: A minimum of 11 patients must be Traditional Medicare Part B Patient sample criteria for the Measures Group are patients aged 18 years and older with a specific diagnosis of chronic hepatitis C accompanied by a specific patient encounter: The following diagnosis code indicating chronic hepatitis C: Accompanied by one of the following patient encounter codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 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 HEPATITIS C USER GUIDE FOR FURTHER INFORMATION

2 Patient Name: Page 2 of 5 Physician Quality Reporting Measure # 84 : : Ribonucleic Acid (RNA) Testing Before Initiating Treatment treatment for whom quantitative HCV RNA testing was performed within 6 months prior to initiation of antiviral treatment RNA testing performed within 6 months RNA testing not performed within 6 months for medical reason Document reason(s) in medical chart (e.g if patient is first seen by physician after initiation of treatment) RNA testing not performed within 6 months, reason unspecified Patient not Receiving Antiviral Treatment for Physician Quality Reporting Measure # 85 : : HCV Genotype Testing Prior to Treatment genotype testing documented as performed prior to initiation of antiviral treatment for genotype testing performed prior to the initiation of antiviral treatment Genotype testing not performed, reason unspecified Patient not receiving antiviral treatment for

3 Patient Name: Page 3 of 5 Physician Quality Reporting Measure # 86 : : Antiviral Treatment Prescribed diagnosis of chronic hepatitis C who were prescribed at a minimum peginterferon and ribavirin therapy within the 12-month reporting period Prescribed May include prescription given to the patient for at a minimum peginterferon and ribavirin therapy at one or more visits in the 12-month period OR patient already taking at a minimum peginterferon and ribavirin therapy as documented in current medication list (i.e., may include additional antiviral therapy, as appropriate). therapy prescribed therapy not prescribed for- therapy not prescribed, reason unspecified System Reason Physician Quality Reporting Measure # 87 : : HCV Ribonucleic Acid (RNA) Testing at Week 12 of Treatment treatment for whom quantitative HCV RNA testing was performed at no greater than 12 weeks from the initiation of antiviral treatment Quantitative RNA Testing at 12 weeks treatment for Quantitative RNA Testing not performed at 12 weeks for treatment for documented Quantitative RNA Testing not performed at 12 weeks, reason unspecified treatment for documented Patient not Receiving Antiviral Treatment for

4 Patient Name: Page 4 of 5 Physician Quality Reporting Measure # 89 : : Counseling Regarding Risk of Alcohol Consumption diagnosis of hepatitis C who were counseled about the risks of alcohol use at least once within 12-months Patient counseled about risks of alcohol use Patient counseled about risks of alcohol use not performed, reason not specified Counseling May include documentation of a discussion regarding the risks of alcohol, or notation to decrease or abstain from alcohol intake. Physician Quality Reporting Measure # 90 : : Counseling Regarding Use of Contraception Prior to Antiviral Therapy Percentage of female patients aged 18 through 44 years and all men aged 18 years and older with a treatment who were counseled regarding contraception prior to the initiation of treatment Counseling regarding contraception received prior to initiation of antiviral treatment Counseling regarding contraception not received for medical reason Counseling regarding contraception not Not Eligible patient is Female and older than age 44 Patient not receiving antiviral treatment for

5 Patient Name: Page 5 of 5 Physician Quality Reporting Measure # 183 : : Hepatitis A Vaccination in Patients with HCV diagnosis of hepatitis C who received at least one injection of hepatitis A vaccine, or who have documented immunity to hepatitis A administered or previously received Patient has documented immunity to Hepatitis A received for Physician Quality Reporting Measure # 184 : : Hepatitis B Vaccination in Patients with HCV diagnosis of hepatitis C who received at least one injection of hepatitis B vaccine, or who have documented immunity to hepatitis B administered or previously received Patient has documented immunity to Hepatitis B received for