Patient sample criteria for the Preventive Care Measure Group are: patients aged 50 years and older with a specific patient encounter:

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1 2014 Physician Quality Reporting System Data Collection Form: Preventive Care (for patients aged 50 and older) NOTE: Individual measures may have more restrictive age and gender requirements. 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**: N/A Encounter Code: Procedure Code: N/A Patient sample criteria for the Preventive Care Measure Group are: patients aged 50 years and older with a specific patient encounter: One of the following patient encounter codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, NOTE: Some measures are applicable to women only; and some measures require a specific age range. PLEASE REFER TO THE PREVENTIVE CARE MEASURES GROUP IN THE CMS 2014 PQRS MEASURES GROUPS SPECIFICATIONS MANUAL FOR FURTHER INFORMATION.

2 Patient Name: Page 2 of 8 Physician Quality Reporting Measure # 110: Preventive Care and Screening: Influenza Immunization Percentage of patients aged 50 years and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization If reporting this measure between January 1, 2014 and March 31, 2014, choose answer option Influenza immunization administered or previously received when the influenza immunization is ordered or administered to the patient during the months of August, September, October, November, and December of 2013 or January, February, and March of 2014 for the flu season ending March 31, If reporting this measure between October 1, 2014 and December 31, 2014, choose answer option Influenza immunization administered or previously received when the influenza immunization is ordered or administered to the patient during the months of August, September, October, November, and December of 2014 for the flu season ending March 31, Influenza immunizations administered during the month of August or September of a given flu season (either flu season OR flu season) can be reported when a visit occurs during the flu season (October 1 - March 31). In these cases, choose answer option Influenza immunization administered or previously received. Previous Receipt - Receipt of the current season s influenza immunization from another provider OR from same provider prior to the visit to which the measure is applied (typically, prior vaccination would include influenza vaccine given since August 1st). Patient visit occurred outside of acceptable date range (i.e., April 1 through September 30, 2014) patient not eligible Influenza immunization administered or previously received Influenza immunization was not ordered or administered for reasons documented by clinician (e.g., patient allergy or other medical reason, patient declined or other patient reasons, or other system reasons) Document reason in medical chart Influenza immunization ordered or recommended (to be given at alternate location or alternate provider); vaccine not available at time of visit Influenza immunization was not ordered or administered, reason not given

3 Patient Name: Page 3 of 8 Physician Quality Reporting Measure # 111 : Pneumonia Vaccination Status for Older Adults For men or women aged 65 and older Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine Pneumococcal vaccine administered or previously received Pneumococcal vaccine not administered or previously received, reason not otherwise specified Physician Quality Reporting Measure # 113 : Colorectal Cancer Screening For men or women aged Percentage of patients 50 through 75 years of age who had appropriate screening for colorectal cancer Appropriate screenings are defined by any one of the following criteria below: Fecal occult blood test (FOBT) during the measurement period Flexible sigmoidoscopy during the measurement period or the four years prior to the measurement period Colonoscopy during the measurement period or the nine years prior to the measurement period Colorectal cancer screening results documented and reviewed Documentation of medical reason(s) for not performing a colorectal cancer screening (i.e., diagnosis of colorectal cancer or total colectomy) Document reason in medical chart Colorectal cancer screening results were not documented and reviewed, reason not otherwise specified

4 Patient Name: Page 4 of 8 Physician Quality Reporting Measure # 128 : Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-up Percentage of patients aged 18 years and older with a documented BMI during the current encounter or during the previous six months AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the encounter An eligible professional or their staff is required to measure both height and weight. Both the height and the weight must be measured within the same six months. Self-reported values cannot be used. The documentation of a follow-up plan must be based on the most recent documented BMI within the previous six months. NOTE: BMI is considered outside of normal parameters as follows: age BMI 18.5 and < 25 ; age 65 and older BMI 23 and < 30 Follow-Up Plan Proposed outline of treatment to be conducted as a result of a BMI out of normal parameters. A follow-up may include but is not limited to: documentation education, a referral (e.g., a registered dietician, nutritionist, occupational therapist, physical therapist, primary care provider, exercise physiologist, mental health professional, or surgeon), pharmacological interventions, dietary supplements, exercise counseling, or nutrition counseling. Not Eligible/Not Appropriate for BMI Measurement A patient is not eligible if one or more of the following reasons are documented: Patient is receiving palliative care Patient is pregnant Patient refuses BMI measurement (refuses height and/or weight) Any other reason documented in the medical record by the provider why BMI calculation or follow-up plan was not appropriate 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. BMI is documented within normal parameters and no follow-up plan is required BMI is documented above normal parameters and a follow-up plan is documented BMI is documented below normal parameters and a follow-up plan is documented BMI is documented as being outside of normal limits, follow-up plan is not documented, documentation the patient is not eligible BMI not documented, documentation the patient is not eligible for BMI calculation BMI not documented and no reason is given BMI documented outside normal parameters, no follow-up plan documented, no reason given

5 Patient Name: Page 5 of 8 Physician Quality Reporting Measure # 173 : Preventive Care and Screening: Unhealthy Alcohol Use Screening Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use at least once within 24 months using a systematic screening method Unhealthy Alcohol Use Covers a spectrum that is associated with varying degrees of risk to health. Categories representing unhealthy alcohol use include risky use, problem drinking, harmful use, and alcohol abuse, and the less common but more severe alcoholism and alcohol dependence. Risky use is defined as > 7 standard drinks per week or > 3 drinks per occasion for women and persons > 65 years of age; > 14 standard drinks per week or > 4 drinks per occasion for men 65 years of age. Systematic Screening Method A systematic method of assessing for unhealthy alcohol use should be utilized. Systemic screening methods include but are not limited to: AUDIT Screening Instrument CAGE Screening Instrument AUDIT-C Screening Instrument Single Item Screening Instrument Alternative approaches may also include questions regarding quantity/frequency of consumption (i.e., drinks per week or drinks per occasion). Screened for unhealthy alcohol use using a systematic screening method Documentation of medical reason(s) for not screening for unhealthy alcohol use (e.g., limited life expectancy, other medical reasons) Document reason in medical chart Unhealthy alcohol use screening NOT performed, reason not otherwise specified

6 Patient Name: Page 6 of 8 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 Current tobacco non-user Documentation of medical reason(s) for not screening for tobacco use (e.g., limited life expectancy, other medical reasons) Tobacco screening OR tobacco cessation intervention not performed, reason not otherwise specified

7 Patient Name: Page 7 of 8 FEMALE PATIENTS ONLY: Physician Quality Reporting Measure # 39 : Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older For women aged 65 and older only 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 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). Prescribed Includes patients who are currently receiving medication(s) that follow the treatment plan recommended at an encounter during the reporting period, even if the prescription for that medication was ordered prior to the encounter. Patient with central DXA results documented or ordered or pharmacologic therapy (other than minerals/vitamins) for osteoporosis prescribed Clinician documented that patient was not an eligible candidate for screening or therapy Patient with central DXA results not documented or not ordered or pharmacologic therapy (other than minerals/vitamins) for osteoporosis not prescribed, reason not given

8 Patient Name: Page 8 of 8 Physician Quality Reporting Measure # 48 : Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older For women aged 65 and older only Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months Urinary Incontinence Any involuntary leakage of urine. Presence or absence of urinary incontinence assessed Presence or absence of urinary incontinence not assessed for medical reason Document reason in medical chart Presence or absence of urinary incontinence not assessed, reason not otherwise specified Physician Quality Reporting Measure # 112 : Breast Cancer Screening For women aged 50 through 74 only Percentage of women 50 through 74 years of age who had a mammogram to screen for breast cancer within 27 months NOTE: Include patients who had one or more mammograms any time on or between October 1, 27 months prior to December 31 of the measurement period, not to precede the patient s 50th birthday. Screening mammography results documented and reviewed Documentation of medical reason(s) for not performing a mammogram (i.e., women who had a bilateral mastectomy or two unilateral mastectomies) Document reason in medical chart Screening mammography results were not documented and reviewed, reason not otherwise specified