PQRI MEASURE CODING AND REPORTING PRINCIPLES

Transcription

1 PQRI MEASURE CODING AND REPORTING PRINCIPLES PQRI Measure Denominators and Numerators Each PQRI measure consists of two major components: 1. A denominator that describes the eligible cases for a measure (the eligible patient population associated with a measure s numerator) 2. A numerator that describes the clinical action required by the measure for reporting and performance measure denominators and numerators are further specified by specific codes, usually ICD-9 and CPT Category I codes for denominators and CPT Category II codes or G codes (where CPT Category II codes are not yet available) for numerators. Each measure is unique, so it is important to review and understand each measure s specifications, which provide definitions and specific instructions for coding and reporting measure components. Use of CPT II Modifiers CPT II modifiers are unique to CPT II codes and may be used to report PQRI measures by appending the appropriate modifier to a CPT II code if allowed for a given measure. The modifiers for a code are mutually exclusive and their use is guided by the measure s coding instructions, which are included in the numerator coding section of the PQRI Measure Specifications. Use of the modifiers is unique to CPT II codes and may not be used with other types of CPT codes. Descriptions of each modifier are provided below to help identify circumstances when the use of an exclusion modifier may be appropriate. Note that in a payfor-reporting model, accurate reporting on all selected applicable measures counts the same, whether reporting that the clinical action was performed or not. CPT II code modifiers fall into two categories, exclusion modifiers and the 8P reporting modifier. 1. Exclusion modifiers may be appended to a CPT II code to indicate that an action specified in the measure was not provided due to medical, patient, or system reason(s) documented in the medical record. These modifiers serve as denominator exclusions for the purpose of measuring performance. Some measures do not provide for performance exclusions. Reasons for appending a performance measure exclusion modifier fall into one of three categories: 1P exclusion modifier due to medical reasons Examples include: not indicated (absence of organ/limb, already received/performed); contraindicated (patient allergic history, potential adverse drug interaction) 2P exclusion modifier due to patient reasons Examples include: patient declined; economic, social, or religious reasons 3P exclusion modifier due to system reasons Examples include: resources to perform the services not available; insurance or coverage/payer-related limitations; other reasons attributable to health care delivery system 2. Reporting modifier 8P is available for use only with CPT II codes to facilitate reporting an eligible case when an action described in a measure is not performed and the reason is not specified. Instructions for appending this modifier to CPT Category II codes are included in applicable measures. Use of the 8P reporting modifier indicates that the patient is eligible for the measure; however, there is no indication in the record that the action described in the measure was performed, nor was there any documented reason attributable to the exclusion modifiers. 8P reporting modifier - action not performed, reason not otherwise specified The 8P modifier facilitates reporting an eligible case on a given measure when the clinical action does not apply to a specific encounter. Eligible professionals can use the 5-1

2 8P modifier to receive credit for successful reporting but will not receive credit for performance. For example, a patient with diabetes may present to a clinician for reasons that do not involve glycemic control, hypertension, or cholesterol management. However, the claim for services for that encounter will contain ICD-9 and CPT codes that will draw the patient into the diabetes measures denominator during analysis. The 8P modifier serves to include the patient in the numerator when reporting rates are calculated for PQRI. Reporting Frequency and Performance Timeframes Each measure includes a reporting frequency requirement for each denominator-eligible patient seen during the reporting period. The reporting frequency is described in the instructions: Report one-time only Report once for each procedure performed Report once for each acute episode A measure s performance timeframe is defined in the measure s description and is distinct from the reporting frequency requirement. The performance timeframe, unique to each measure, delineates the timeframe in which the clinical action described in the numerator may be accomplished. Performance timeframes may be stated as within 12 months, or most recent. This means that: 1. The clinical action in the numerator need be performed only once during a 12-month period for each patient seen during the reporting period 2. The quality code need be reported only one time for each patient by each eligible professional caring for the patient who has chosen to report that measure during the reporting period If the measure calls for a clinical test result, then the most recent test result only needs to be obtained, assessed, and reported one time per reporting period. A test does not need to have been performed within the reporting period, nor does it need to have been performed by the same eligible professional. Performance timeframes may also be tied to a specific clinical event that requires reporting each time the event occurs within the reporting period. The following are examples of measures reported each time the clinical action described by the measure numerator is taken: Procedure-related measures require reporting each time the procedure is performed and have distinct performance timeframes tied to them. The date of service is the date that is used to report the measure. Examples are perioperative care or imaging measures. Chronic care measures, such as those that call for prescribing a medication, require the eligible professional to verify whether the medication is current and being taken by the patient. A new prescription is not required to meet the measure requirement unless it is clinically indicated. Acute care measures are tied to specific episodes of acute care and require reporting each time an acute event occurs. Examples are measures related to hospitalizations, fractures and osteoporosis management, or stroke measures. Claims-Based Reporting Principles The following principles apply to the reporting of quality-data codes for PQRI measure The CPT Category II code, which supplies the numerator, must be reported on the same claim form as the payment codes, usually ICD-9 and CPT Category I codes, which supply the denominator. Quality-data codes must be submitted with a line item charge of zero dollars ($0.00) at the time the associated covered service is performed.! The submitted charge field cannot be blank. 5-2

3 ! The line item charge should be $0.00.! If a system does not allow a $0.00 line item charge, use a small amount such as $0.01! Entire claims with a zero charge will be rejected. (Total charge for the claim cannot be $0.00)! Quality data code line items will be denied for payment, but are then passed through the claims processing system for PQRI analysis. Multiple eligible professionals quality-data codes can be reported on the same claim. Multiple CPT Category II codes for multiple measures that are applicable to a patient visit can be reported on the same claim, as long as the corresponding denominator codes are also line items on that claim. The individual NPI of the participating eligible professional(s) must be properly used on the claim. Timeliness of Quality Data Submission Claims processed by the Carrier/MAC must reach the national Medicare claims system data warehouse (National Claims History file) by February 29, 2008 to be included in the analysis. Claims for services furnished toward the end of the reporting period should be filed promptly. Claims that are resubmitted only to add quality-data codes will not be included in the analysis. Successful Reporting The 2007 PQRI incentive payment is an all-or-nothing bonus (subject to cap) based on successful reporting. Eligible professionals need not enroll or file an intent to participate for the PQRI. Eligible professionals can participate by reporting the appropriate quality measure data on claims submitted to their Medicare claims processing contractor. In order to satisfactorily meet the requirements of the program and receive the bonus payment, certain reporting thresholds must be met. When four or more measures are applicable to the services provided by an eligible professional, the 80% threshold must be met on at least three of the measures reported. Good news for those physicians practicing in a group practice, not all physicians in the group must participate in PQRI to be eligible for the bonus payment. Individual analysis will be done using the individual physician s national provider identifier (NPI) to determine satisfactory reporting and the bonus payment calculation. Thus, physicians must bill with an NPI to participate in PQRI. The potential 1.5 percent incentive payment will be paid in mid-2008 as a lump-sum bonus payment made to the practice at the Taxpayer Identification Number (TIN) level. According to the CMS website, the NPI is the only unique provider enumerator that can be used by the CMS PQRI analysis contractor to properly identify eligible physicians at the individual-physician level. The performing professional s NPI must be used for the quality-data codes and related services. For claims submitted via the ASC X12N 837 professional health care claim transaction, the group practice NPI is placed in the provider billing segment, loop 2010AA, and the performing professional s NPI is placed in loop 2420A. For claims submitted via the CMS 1500 form, the performing professional s NPI is placed on the individual line item. Placing the performing eligible professional s NPI on the individual line item will allow the analysis of successful reporting and the bonus payment calculation to be performed at the individual level, though payment will be made at the TIN level. Bonus Payment Participating eligible professionals who successfully report may earn a 1.5% bonus, subject to cap. The potential 1.5% bonus will be based on allowed charges for covered professional services: 5-3

4 1. Furnished during the reporting period of July 1 through December 31, 2007, 2. Received into the CMS National Claims History (NCH) file by February 29, 2008 (Joy s comment: claim should be received by the Carrier no later than February 28, 2008), and 3. Paid under the Medicare Physician Fee Schedule (Joy s comment: HCPCS J codes for drugs are not subject to the bonus). Because claims processing times may vary by time of the year and Medicare Carrier/Medicare Administrative Contractor (MAC), physicians should submit claims from the end of 2007 promptly, so that those claims will reach the NCH file by February 29, Bonuses will be paid as a lump sum in mid There is no beneficiary copayment or notice to the beneficiary regarding the bonus payments. A payment cap that would reduce the potential bonus below 1.5% of allowed charges may apply in situations where a physician reports relatively few instances of quality measure data. The physician s cap will be calculated by multiplying: (1) the physician s total instances of reporting quality data for all measures (not limited only to measures meeting the 80% threshold), by (2) a constant of 300%, and by (3) the national average per measure payment amount. The national average per measure payment amount is one value for all measures and all participants that is calculated by dividing: (1) the total amount of allowed charges under the Physician Fee Schedule for all covered professional services furnished during the reporting period on claims for which quality measures were reported by all participants in the program by (2) the total number of instances for which data were reported by all participants in the program for all measures during the reporting period. (Note that the national average per measure payment amount calculation only takes into account the charges on claims for which quality measures were reported, whereas the individual bonus calculation takes into account charges for all services furnished during the reporting period.) While the purpose of the cap is clear, it is not possible to determine the impact of the cap until the national average per measure payment amount can be calculated after the end of the reporting period. CMS recommends that physicians report on every quality measure that is applicable to their patient populations to: (1) increase the likelihood that they will reach the 80% satisfactorily reporting requirement for the requisite number of measures and (2) increase the likelihood that they will not be affected by the bonus payment cap Physician Quality Reporting Initiative Measures - Not All Inclusive 1) Hemoglobin A1c Poor Control in Type 1 or 2 Diabetes Mellitus - Percentage of patients aged years with diabetes (type 1 or type 2) who had most recent hemoglobin A1c greater than 9.0% - This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. The performance period for this measure is 12 months. It is anticipated that clinicians who provide services for the primary management of diabetes mellitus will submit this measure ICD-9: , and CPT: (office/outpatient visit) (office/outpatient visit); (home visit); (nursing facility); (domiciliary); and G0270-G0271 (nutrition therapy) Most recent hemoglobin A1c level > 9.0% (3046F) Most recent hemoglobin A1c level < 7.0% (3044F) Most recent hemoglobin A1c level 7.0% to 9.0% (3045F) Hemoglobin A1c not performed during last 12 months reason not specified (3046F-8P) 2) Low Density Lipoprotein Control in Type 1 or 2 Diabetes Mellitus - Percentage of patients aged years with diabetes (type 1 or type 2) who had most recent LDL-C level in control (less than 100 mg/dl) - This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. The performance period for this measure is 12 months. It is anticipated that clinicians who provide services for the primary management of diabetes mellitus will submit this measure. 5-4

5 ICD-9: , and CPT: (office/outpatient visit) (office/outpatient visit); (home visit); (nursing facility); (domiciliary); and G0270-G0271 (nutrition therapy) Most recent LDL-C < 100 mg/dl (3048F) Most recent LDL-C mg/dl (3049F) Most recent LDL-C 130 mg/dl (3050F) LDL-C level not performed during last 12 months reason not specified (3048F-8P) 3) High Blood Pressure Control in Type 1 or 2 Diabetes Mellitus - Percentage of patients aged years with diabetes (type 1 or type 2) who had most recent blood pressure in control (less than 140/80 mm Hg) - This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. The performance period for this measure is 12 months. It is anticipated that clinicians who provide services for the primary management of diabetes mellitus will submit this measure. ICD-9: , and CPT: (office/outpatient visit); (home visit); (nursing facility); (domiciliary); and G0270-G0271 (nutrition therapy) Systolic codes Most recent systolic blood pressure < 130 mm Hg (3074F) Most recent systolic blood pressure 130 to 139 mm Hg (3075F) Most recent systolic blood pressure > 140 mm Hg (3077F) AND Diastolic codes Most recent diastolic blood pressure < 80 mm Hg (3078F) Most recent diastolic blood pressure mm Hg (3079F) Most recent diastolic blood pressure > 90 mm Hg (3080F) OR Blood pressure measurement not performed, reason not specified (2000F-8P) 4) Screening for Future Fall Risk - Percentage of patients aged 65 years and older who were screened for future fall risk (patients are considered at risk for future falls if they have had 2 or more falls in the past year or any fall with injury in the past year) at least once within 12 months - This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. This measure is appropriate for use in all nonacute settings (excludes emergency departments and acute care hospitals). It is anticipated that clinicians who provide primary care for the patient will submit this measure. ICD-9: None specified - CPT: (PT eval); (office/outpatient visit), (nursing facility), (domiciliary), (domiciliary), (home visits), and (preventive), (preventive counseling), Definition: A fall is defined as a sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, or the ground, other than as a consequence of sudden onset of paralysis, epileptic seizure, or overwhelming external force (Tinetti). Screening for future fall risk; documentation of 2 or more falls in the past year or any fall with injury in the past year (1100F) Screening for future fall risk; documentation of no falls in the past year or only 1 fall without injury in the past year (1101F) Screening for future fall risk not performed for medical reasons (1100F-1P) Screening for future fall risk not performed, reason not specified (1100F-8P) 5) Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) - Percentage of patients aged 18 years and older with a diagnosis of heart failure and left ventricular systolic dysfunction (LVSD) who were prescribed ACE inhibitor or ARB therapy - This measure is to be reported a minimum of once per reporting period for all heart failure patients seen during the reporting period. The left ventricular systolic dysfunction may be 5-5

6 determined by quantitative or qualitative assessment. Examples of a quantitative or qualitative assessment may include an echocardiogram: 1) that provides a numerical value of left ventricular systolic dysfunction or 2) that uses descriptive terms such as moderately or severely depressed left ventricular dysfunction. It is anticipated that clinicians who provide primary management of patients with heart failure will submit this measure. ICD-9: , , ; , , , , , ; 428.0, 428.1, , , , and CPT: (office/outpatient visit), 99238, (discharge), (office/outpatient consult), (nursing facility), (domiciliary), (home visit) OR AND ACE inhibitor or ARB therapy prescribed and left ventricular ejection fraction (LVEF) <40% or documentation of moderately or severely depressed left ventricular systolic function (4009F and 3021F) ACE inhibitor or ARB therapy not prescribed for medical reason (4009F-1P) ACE inhibitor or ARB therapy not prescribed for patient reasons (4009F-2P) ACE inhibitor or ARB therapy not prescribed for system reasons (4009F-3P) Left ventricular ejection fraction (LVEF) <40% or documentation of moderately or severely depressed left ventricular systolic function (3021F) Left ventricular ejection fraction (LVEF) >40% or documentation as normal or mildly depressed left ventricular systolic function (3022F) Left ventricular ejection fraction (LVEF) was not performed or documented reason not otherwise specified (3021F-8P) OR ACE inhibitor or ARB therapy not prescribed reason not specified and left ventricular ejection fraction <40% or documentation of moderately or severely depressed left ventricular systolic dysfunction (4009F- 8P and 3021F) 6) Oral Antiplatelet Therapy Prescribed for Patients with Coronary Artery Disease - Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease who were prescribed oral antiplatelet therapy - This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. It is anticipated that clinicians who provide the primary management of patients with coronary artery disease will submit this measure. - Oral antiplatelet therapy consists of aspirin, clopidogrel/plavix, or combination of aspirin and dipyridamole/aggrenox. ICD-9: , 414.8, 414.9, ; 412, , , V45.81, V45.82 and CPT (office/outpatient visit); 99238, (discharge), (office/outpatient consult), (nursing facility), (domiciliary), (home visit) Oral antiplatelet therapy prescribed (4011F) Documentation of medical reason(s) for not prescribing oral antiplatelet therapy (4011F-1P) Documentation of patient reason(s) for not prescribing oral antiplatelet therapy (4011F-2P) Documentation of system reason(s) for not prescribing oral antiplatelet therapy (4011F-3P) Oral antiplatelet therapy not prescribed reason not specified (4011F-8P) 7) Beta-blocker Therapy for Coronary Artery Disease Patients with Prior Myocardial Infarction (MI) - Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease and prior myocardial infarction (MI) who were prescribed beta-blocker therapy - This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. It is anticipated that clinicians who provide the primary management of patients with coronary artery disease with prior myocardial infarction (MI) will submit this measure. ICD-9: , 414.8, 414.9, 411.0, 411.1, , , 413.0, 413.1, 413.9, V45.81, V45.82, *, 412* and Patients who had a prior MI at any time ICD-9: , 412 and CPT (office/outpatient visit), 99238, (discharge), (office/outpatient consult), (nursing facility), (domiciliary), (home visit) *Denominator inclusion for this measure requires the presence of a prior MI diagnosis AND at least one E/M code during the measurement period. Diagnosis codes for Coronary Artery Disease (which include MI diagnosis codes) may also accompany the MI diagnosis code, but are not required for inclusion in the measure. 5-6

7 Beta-blocker therapy prescribed (4006F) Documentation of medical reason(s) for not prescribing beta-blocker therapy (4006F-1P) Documentation of patient reason(s) for not prescribing beta-blocker therapy (4006F-2P) Documentation of system reason(s) for not prescribing beta-blocker therapy (4006F-3P) Beta-blocker therapy not prescribed, reason not specified (4006F-8P) 8) Heart Failure: Beta-blocker Therapy for Left Ventricular Systolic Dysfunction - Percentage of patients aged 18 years and older with a diagnosis of heart failure who also have left ventricular systolic dysfunction (LVSD) and who were prescribed beta-blocker therapy - This measure is to be reported a minimum of once per reporting period for all heart failure patients seen during the reporting period. The left ventricular systolic dysfunction may be determined by quantitative or qualitative assessment. Examples of a quantitative or qualitative assessment may include an echocardiogram: 1) that provides a numerical value of left ventricular systolic dysfunction or 2) that uses descriptive terms such as moderately or severely depressed left ventricular dysfunction. It is anticipated that clinicians who provide primary management of patients with heart failure will submit this measure. ICD-9: , , ; , , , , , ; 428.0, 428.1, , , , and CPT: (office/outpatient visit), (office/outpatient consult), (home visit), (nursing facility), (domiciliary) Beta blocker therapy prescribed and left ventricular ejection fraction (LVEF) < 40% or documentation of moderately or severely depressed left ventricular systolic function (4006F and 3021F) OR Documentation of medical reason(s) for not prescribing beta-blocker therapy (4006F-1P) Documentation of patient reason(s) for not prescribing beta-blocker therapy (4006F-2P) Documentation of system reason(s) for not prescribing beta-blocker therapy (4006F-3P) AND Left ventricular ejection fraction (LVEF) < 40% or documentation of moderately or severely depressed left ventricular systolic function (3021F) Left ventricular ejection fraction (LVEF) 40% or documentation as normal or mildly depressed left ventricular systolic function (3022F) Left ventricular ejection fraction (LVEF) was not performed or documented, reason not otherwise specified (3021F-8P) OR Beta-blocker therapy was not prescribed, reason not otherwise specified and left ventricular ejection fraction (LVEF) < 40% or documentation of moderately or severely depressed left ventricular systolic function (4006F-8P and 3021F) 9) Antidepressant Medication During Acute Phase for Patients with New Episode of Major Depression - Percentage of patients aged 18 years and older diagnosed with new episode of major depressive disorder (MDD) and documented as treated with antidepressant medication during the entire 84-day (12 week) acute treatment phase - This measure is to be reported for each occurrence of MDD during the reporting period. It is anticipated that clinicians who provide the primary management of patients with major depressive disorder (MDD) will submit this measure. ICD-9: , , 298.0, 300.4, 309.1, 311 and CPT: (office/outpatient visit); 90801, 90802, , (psychiatry) Definition: A new episode is defined as a patient with major depression who has not been seen or treated for major depression by any practitioner in the prior 4 months. A new episode can either be a recurrence for a patient with prior major depression or a patient with a new onset of major depression. 5-7

8 Report G8126: 1) For all patients with a diagnosis of Major Depression, New Episode who were prescribed a full 12 week course of antidepressant medication OR 2) At the completion of a 12 week course of antidepressant medication. Patient with new episode of MDD documented as being treated with antidepressant medication during the entire 12 week acute treatment phase (G8126) Patient with new episode of MDD not documented as being treated with antidepressant medication during the entire 12 week acute treatment phase (G8127) Clinician documented that patient with a new episode of MDD was not an eligible candidate for antidepressant medication treatment or patient did not have a new episode of MDD (G8128) 39) Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older - Percentage of female patients aged 65 years and older who have a central dual-energy X-ray absorptiometry (DXA) measurement ordered or performed at least once since age 60 or pharmacologic therapy prescribed within 12 months - This measure is to be reported a minimum of once during the reporting period for patients seen during the reporting period. Female patients aged 65 years and older should have a central DXA measurement ordered or performed at least once since the time they turned 60 years or have pharmacologic therapy prescribed to prevent or treat osteoporosis. It is anticipated that clinicians who provide primary care or care for treatment of fracture or osteoporosis will submit this measure. ICD-9: No specific diagnosis codes and CPT: (office/outpatient visit), and (preventive), (preventive counseling) Definition: Pharmacologic Therapy: U.S. Food and Drug Administration approved pharmacologic options for osteoporosis prevention and/or treatment of postmenopausal osteoporosis include, in alphabetical order: bisphosphonates (alendronate, ibandronate, and risedronate), calcitonin, estrogens (estrogens and/or hormone therapy), parathyroid hormone [PTH (1-34), teriparatide], and selective estrogen receptor modules or SERMs (raloxifene). Central Dual-energy X-Ray Absorptiometry (DXA) ordered (3096F) Central Dual-energy X-Ray Absorptiometry (DXA) results documented (3095F) Pharmacologic therapy (other than minerals/vitamins) for osteoporosis prescribed (4005F) Documentation of medical reason(s) for not ordering or performing a central dual energy X-ray absorptiometry (DXA) measurement or not prescribing pharmacologic therapy for osteoporosis (3096F-1P) Documentation of patient reason(s) for not ordering or performing central dual energy X-ray absorptiometry (DXA) measurement or not prescribing pharmacologic therapy for osteoporosis (3096F-2P) Documentation of system reason(s) for not ordering or performing central dual energy X-ray absorptiometry (DXA) measurement or not prescribing pharmacologic therapy for osteoporosis (3096F-3P) Central dual energy X-ray absorptiometry (DXA) measurement was not ordered or performed and a pharmacologic therapy for osteoporosis was not prescribed reason not otherwise specified (3096F-8P) 40) Osteoporosis: Management Following Fracture - Percentage of patients aged 50 years and older with fracture of the hip, spine, or distal radius who had a central dual-energy X-ray absorptiometry (DXA) measurement ordered or performed or pharmacologic therapy prescribed - This measure is to be reported after each occurrence of a fracture during the reporting period. Patients with a fracture of the hip, spine, or distal radius should have a central DXA measurement ordered or performed or pharmacologic therapy prescribed. The management (DXA ordered or performed or pharmacologic therapy prescribed) should occur within three months of the initial visit with the reporting clinician following the fracture. Patients with documentation of prior central DXA measurement or already receiving pharmacologic therapy would automatically meet the intent of this measure. It is anticipated that clinicians who manage the primary or ongoing care for osteoporosis or osteoporosis related fracture(s) will submit this measure. ICD-9: , , , 805.2, 805.4, 805.6, 805.8, , , , , , , , , , and CPT: (office/outpatient visit), (office consult) 5-8

9 Definition: Pharmacologic Therapy: U.S. Food and Drug Administration approved pharmacologic options for osteoporosis prevention and/or treatment of postmenopausal osteoporosis include, in alphabetical order: bisphosphonates (alendronate, ibandronate, and risedronate), calcitonin, estrogens (estrogens and/or hormone therapy), parathyroid hormone [PTH (1-34), teriparatide], and selective estrogen receptor modules or SERMs (raloxifene). Central dual energy X-ray absorptiometry (DXA) ordered (3096F) Central dual energy X-ray absorptiometry (DXA) results documented (3095F) Pharmacologic therapy (other than minerals/vitamins) for osteoporosis prescribed (4005F) Documentation of medical reason(s) for not ordering or performing a central dual energy X-ray absorptiometry (DXA) measurement or not prescribing pharmacologic therapy for osteoporosis (3096F-1P) Documentation of patient reason(s) for not ordering or performing a central dual energy X-ray absorptiometry (DXA) measurement or not prescribing pharmacologic therapy for osteoporosis (3096F-2P) Documentation of system reason(s) for not ordering or performing a central dual energy X-ray absorptiometry (DXA) measurement or not prescribing pharmacologic therapy for osteoporosis (3096F-3P) Central dual energy X-ray absorptiometry (DXA) measurement was not ordered or performed and a pharmacologic therapy for osteoporosis was not prescribed reason not otherwise specified (3096F-8P) 41) Osteoporosis: Pharmacologic Therapy - Percentage of patients aged 50 years and older with a diagnosis of osteoporosis who were prescribed pharmacologic therapy within 12 months - This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. Patients with a diagnosis of osteoporosis should be prescribed pharmacologic therapy to treat osteoporosis. It is anticipated that clinicians who provide services for patients with the diagnosis of osteoporosis will submit this measure. ICD-9: , and CPT: (office/outpatient visit), (office/outpatient consult), and (preventive), (preventive counseling) Definition: Pharmacologic Therapy: U.S. Food and Drug Administration approved pharmacologic options for osteoporosis prevention and/or treatment of postmenopausal osteoporosis include, in alphabetical order: bisphosphonates (alendronate, ibandronate, and risedronate), calcitonin, estrogens (estrogens and/or hormone therapy), parathyroid hormone [PTH (1-34), teriparatide], and selective estrogen receptor modules or SERMs (raloxifene). 1P) Pharmacologic therapy (other than minerals/vitamins) for osteoporosis prescribed (4005F) Documentation of medical reason(s) for not prescribing pharmacologic therapy for osteoporosis (4005F- Documentation of patient reason(s) for not prescribing pharmacologic therapy for osteoporosis (4005F-2P) Documentation of system reason for not prescribing pharmacologic therapy for osteoporosis (4005F-3P) Pharmacologic therapy for osteoporosis was not prescribed reason not otherwise specified (4005F-8P) 42) Osteoporosis: Counseling for Vitamin D, Calcium Intake, and Exercise - Percentage of patients, regardless of age, with a diagnosis of osteoporosis who are either receiving both calcium and vitamin D or have been counseled regarding both calcium and vitamin D intake, and exercise at least once within 12 months - This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. Patients with a diagnosis of osteoporosis should be receiving both calcium and vitamin D or had counseling regarding their use and counseled on exercise. It is anticipated that clinicians who provide services for patients with the diagnosis of osteoporosis will submit this measure. ICD-9: , and CPT: (office/outpatient visit), (office/outpatient consult), and (preventive), (preventive counseling) Documentation of receipt of counseling on exercise AND either both calcium and vitamin D use or counseling regarding both calcium and vitamin D use (4019F) Documentation of medical reason(s) for patient not receiving both calcium and vitamin D or and not needing counseling regarding both calcium and vitamin D intake, and exercise (e.g., patient has dementia and is unable to receive counseling) (4019F-1P) Receipt of counseling on exercise AND either both calcium and vitamin D use or counseling regarding both calcium and vitamin D use was not documented reason not otherwise specified (4019F-8P) 5-9

10 46) Medication Reconciliation - Percentage of patients aged 65 years and older discharged from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) and seen within 60 days following discharge in the office by the physician providing on-going care who had a reconciliation of the discharge medications with the current medication list in the medical record documented - This measure is to be reported at an office visit occurring within 60 days of each inpatient facility discharge during the reporting period. This measure is appropriate for use in the ambulatory setting only. It is anticipated that clinicians who provide primary on-going care will submit this measure when a patient is seen in the office within 60 days following discharge from any inpatient facility. If a patient has not been discharged within the 60-day timeframe from an inpatient facility, there are no reporting requirements for this measure. ICD-9: No specific diagnosis code and CPT: (office/outpatient visit), and (preventive), (preventive counseling) Patient discharged from an inpatient facility within the last 60 days and discharge medications reconciled with the current medication list in outpatient medical record (1110F and 1111F) Patient discharged from an inpatient facility within the last 60 days and discharge medication not reconciled with current medication list in the medical record, reason not specified (1110F and 1111F-8P) 47) Advance Care Plan - Percentage of patients aged 65 years and older with documentation of a surrogate decision-maker or advance care plan in the medical record - This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. This measure is appropriate for use in all healthcare settings. It is anticipated that clinicians who provide primary care services for the patient will submit this measure. ICD-9: No specific diagnosis codes and CPT: (office/outpatient visit), (observation services), (initial inpatient), (subsequent inpatient), (admit and discharge on the same day), (ED services), (critical care), (nursing facility), (domiciliary/rest home), (home visits), and (preventive services), (preventive counseling) Surrogate decision maker or advance care plan documented in the medical record (1080F) Surrogate decision maker or advance directive not documented for patient reasons (1080F-2P) Surrogate decision maker or advance directive not documented, reason not specified (1080F-8P) (Joy s Comment: For successful reporting of this measure, primary care physicians will have to report on this measure at least one time for every Medicare patient.) 48) Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older - Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months - This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. This measure is appropriate for use in the ambulatory setting only. It is anticipated that clinicians who provide primary care for the patient will submit this measure. ICD-9: No specific codes and CPT: (office/outpatient visit), and (preventive), (preventive counseling) Definition: Urinary incontinence is defined as any involuntary leakage of urine. Presence or absence of urinary incontinence assessed (1090F) Presence or absence of urinary incontinence not assessed for medical reasons (1090F-1P) Presence or absence of urinary incontinence not assessed reason not specified (1090F-8P) 49) Characterization of Urinary Incontinence in Women Aged 65 Years and Older - Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence whose urinary incontinence was characterized at least once within 12 months - This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. This measure is appropriate for use in the ambulatory setting only. It is anticipated that clinicians who provide services for patients with the diagnosis of urinary incontinence will submit this measure. ICD-9: 307.6, 625.6, and CPT: (office/outpatient visit), (office/outpatient consult), and (preventive), (preventive counseling) 5-10

11 Definition: Characterization includes, but is not limited to, (frequency, volume, timing, type of symptoms, how bothersome) Urinary incontinence characterized (1091F) Urinary incontinence not characterized reason not specified (1091F-8P) 50) Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older - Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months - This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. This measure is appropriate for use in the ambulatory setting only. It is anticipated that clinicians who provide services for patients with the diagnosis of urinary incontinence will submit this measure. ICD-9: 307.6, 625.6, and CPT: (office/outpatient visit), (office/outpatient consult), and (preventive), (preventive counseling) Definition: Plan of care may include behavioral interventions (e.g., bladder training, pelvic floor muscle training, prompted voiding), referral to specialist, surgical treatment, reassess at follow-up visit, lifestyle interventions, addressing co-morbid factors, modification or discontinuation of medications contributing to urinary incontinence, or pharmacologic therapy. Urinary incontinence plan of care documented (0509F) Plan of care for urinary incontinence not documented reason not specified (0509F-8P) 51) Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation - Percentage of patients aged 18 years and older with a diagnosis of COPD who had spirometry evaluation results documented - This measure is to be reported a minimum of once per reporting period using the most recent spirometry results in the patient record for patients seen during the reporting period. It is anticipated that clinicians who provide primary care services for the patient will submit this measure. ICD-9: 491.0, 491.1, , 491.8, 491.9, 492.0, 492.8, 496 and CPT: (office/outpatient visit), (office/outpatient consult), , (preventive), (preventive counseling) Instructions: Look for most recent documentation of spirometry evaluation results in the medical record; do not limit the search to the reporting period. Spirometry results documented and reviewed (3023F) Spirometry results not documented medical reason(s) (3023F-1P) Spirometry results not documented for patient reasons (3023F-2P) Spirometry results not documented for system reasons (3023F-3P) Spirometry results not documented, reason not specified (3023F-8P) 52) Chronic Obstructive Pulmonary Disease (COPD): Bronchodilator Therapy - Percentage of patients aged 18 years and older with a diagnosis of COPD and who have an FEV1/FVC less than 70% and have symptoms who were prescribed an inhaled bronchodilator - This measure is to be reported a minimum of once per reporting period for all COPD patients seen during the reporting period. It is anticipated that clinicians who provide primary care services for the patient will submit this measure. ICD-9: 491.0, 491.1, , 491.8, 491.9, 492.0, 492.8, 496 and CPT: (office/outpatient visit), (office/outpatient consult), , (preventive), (preventive counseling) Inhaled bronchodilator prescribed and spirometry test results demonstrate FEV 1 /FVC < 70% with COPD symptoms (e.g., dyspnea, cough/sputum, wheezing) (4025F and 3025F) Documentation of medical reason(s) for not prescribing an inhaled bronchodilator and spirometry test results demonstrate FEV 1 /FVC < 70% with COPD symptoms (e.g., dyspnea, cough/sputum, wheezing) (4025F-1P and 3025F) Documentation of patient reason(s) for not prescribing an inhaled bronchodilator and spirometry test results demonstrate FEV 1 /FVC < 70% with COPD symptoms (e.g., dyspnea, cough/sputum, wheezing) (4025F-2P and 3025F) 5-11

12 Documentation of system reason(s) for not prescribing an inhaled bronchodilator and spirometry test results demonstrate FEV 1 /FVC < 70% with COPD symptoms (e.g., dyspnea, cough/sputum, wheezing) (4025F-3P and 3025F) Spirometry results demonstrate FEV 1 /FVC 70% or patient does not have COPD symptoms (3027F) Spirometry test not performed or documented (3025F-8P) Inhaled bronchodilator not prescribed, reason not specified and spirometry test results demonstrate FEV 1 /FVC < 70% with COPD symptoms (e.g., dyspnea, cough/sputum, wheezing) (4025F-8P and 3025F) 53) Asthma: Pharmacologic Therapy - Percentage of patients aged 5 to 40 years with a diagnosis of mild, moderate, or severe persistent asthma who were prescribed either the preferred long-term control medication (inhaled corticosteroid) or an acceptable alternative treatment - This measure is to be reported a minimum of once per reporting period for all asthma patients seen during the reporting period. It is anticipated that clinicians who provide primary care services for the patient will submit this measure. ICD-9: , , , , , , and CPT: (office/outpatient visit), (office/outpatient consult), , (preventive), (preventive counseling) Definition: acceptable alternative treatment (leukotriene modifiers, cromolyn sodium, nedocromil sodium, or sustained-released methylxanthines) Persistent asthma (mild, moderate, or severe) and preferred long term control medication or acceptable alternative treatment prescribed (4015F and 1038F) Persistent asthma (mild, moderate, or severe) and preferred long-term control medication or acceptable alternative treatment not prescribed for patient reasons (4015F-2P and 1038F) Intermittent asthma (1039F) Persistent asthma (mild, moderate, or severe) and preferred long-term control medication or acceptable alternative treatment not prescribed, reason not specified (4015F-8P and 1038F) 60) Gastroesophageal Reflux Disease (GERD): Assessment for Alarm Symptoms - Percentage of patients aged 18 years and older with a diagnosis of GERD, seen for an initial evaluation, who were assessed for the presence or absence of the following alarm symptoms: involuntary weight loss, dysphagia, and GI bleeding - This measure is to be reported once for all GERD patients seen during the reporting period. Patients seen for an initial evaluation of GERD should have documentation in the medical record of the presence or absence of alarm symptoms. If the initial evaluation of GERD occurred prior to the reporting period, report the proper CPT Category II code with modifier indicated in the numerator coding indicating this is not the initial evaluation. It is anticipated that clinicians who provide care for patients with GERD will submit this measure. ICD-9: , , and CPT: (office/outpatient visit), (office/outpatient consult) Definition: Patients assessed for the presence or absence of the following alarm symptoms: involuntary weight loss, dysphagia, and GI bleeding Alarm symptoms assessed; none present (1070F) Alarm symptoms assessed; one or more present (1071F) Patient does not meet denominator inclusion because the initial evaluation of GERD occurred prior to the reporting period (1070F-8P) Alarm symptoms not assessed for medical reasons (1070F-1P) Alarm symptoms not assessed, reason not specified (1071F-8P) (Joy s Comment: For successful reporting of this measure, physicians will have to report on this measure at least one time for every Medicare patient with GERD.) 61) Gastroesophageal Reflux Disease (GERD): Upper Endoscopy for Patients with Alarm Symptoms - Percentage of patients aged 18 years and older with a diagnosis of GERD, seen for an initial evaluation, with at least one alarm symptom who were either referred for upper endoscopy or had an upper endoscopy performed - This measure is to be reported once for all GERD patients seen during the reporting period. Patients seen for an initial evaluation of GERD and at least one alarm symptom will be referred for upper endoscopy or have an upper endoscopy performed. If the initial evaluation of GERD occurred prior to the reporting period, 5-12

13 report the proper CPT II Category II code with modifier indicated in the numerator coding indicating this is not the initial evaluation. It is anticipated that clinicians who provide care for patients with GERD will submit this measure. ICD-9: , , and CPT: (office/outpatient visit), (office/outpatient consult) Definition: Alarm symptoms for GERD include involuntary weight loss, dysphagia, and GI bleeding. Upper gastrointestinal endoscopy performed (3130F) Documentation of referral for upper gastrointestinal endoscopy (3132F and 1071F) Patient does not have alarm symptoms (1070F) Initial evaluation of GERD occurred prior to the reporting period (1071F-8P) Upper endoscopy not performed or patient not referred for upper endoscopy for medical reasons (e.g., patient has already had the procedure) (3130F-1P and 1071F) Upper endoscopy not performed or patient not referred for upper endoscopy for patient reasons (3130F-2P and 1071F) Upper endoscopy not performed or patient not referred for upper endoscopy for system reasons (3130F-3P and 1071F) Upper endoscopy not performed or patient not referred for upper endoscopy, reason not specified (3130F- 8P and 1071F) (Joy s Comment: For successful reporting of this measure, physicians will have to report on this measure and measure #60 at least one time for every Medicare patient with GERD.) 63) Gastroesophageal Reflux Disease (GERD): Barium Swallow- Inappropriate Use - Percentage of patients aged 18 years and older with a diagnosis of GERD, seen for an initial evaluation, who did not have a Barium swallow test ordered - This measure is to be reported once for all GERD patients seen during the reporting period. Patients being seen for an initial evaluation of GERD should not receive a barium swallow test. If the initial evaluation of GERD occurred prior to the reporting period, report the proper CPT Category II with modifier indicated in the numerator coding indicating this is not the initial evaluation. It is anticipated that clinicians who provide care for patients with GERD will submit this measure. ICD-9: , , and CPT: (office/outpatient visit), (office/outpatient consult) Definitions: This is an overuse measure. For performance, the numerator will be calculated as the difference between patients in the denominator and patients for whom a CPT Category II code was reported for barium swallow test ordered. A higher score indicates appropriate treatment of patients with GERD (i.e., the proportion for whom a barium swallow test was not ordered). Barium swallow test ordered (3142F) Patient does not meet denominator inclusion because the initial evaluation of GERD occurred prior to the reporting period (3200F-8P) Barium swallow test ordered for medical reasons (3142F-1P) Barium swallow test not ordered (3200F) (Joy s Comment: For successful reporting of this measure, physicians will have to report on this measure and measure #60 at least one time for every Medicare patient with GERD.) 64) Asthma Assessment - Percentage of patients aged 5 to 40 years with a diagnosis of asthma who were evaluated during at least one office visit within 12 months for the frequency (numeric) of daytime and nocturnal asthma symptoms - This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. It is anticipated that clinicians who provide primary care services for the patient with a diagnosis of asthma will submit this measure. ICD-9: , , , , , , and CPT: (office/outpatient visit), (office/outpatient consult), , (preventive), (preventive counseling) Definitions: To be counted in calculations of this measure, symptom frequency must be numerically quantified. Measure may also be met by clinician documentation or patient completion of an asthma assessment 5-13