2014 Physician Quality Reporting System Data Collection Form: Hypertension (for patients aged 18 through 90)
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1 2014 Physician Quality Reporting System Data Collection Form: Hypertension (for patients aged 18 through 90) Physician Name: Patient Name: Last First MI Date of Birth: / / mm dd yyyy Gender: M F 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. Medical Record Number: Appointment Date: / / (1/1/14 12/31/14) mm dd yyyy ICD-9 (or ICD-10) Diagnosis Code**: Encounter Code: Procedure Code: N/A Patient sample criteria for the Hypertension Measures Group are: patients aged 18 through 90 years with a specific diagnosis of hypertension, and without a diagnosis of stage 5 chronic kidney disease (GFR of < 15ml/min per 1.72 m2 or end-stage kidney disease) accompanied by a specific patient encounter: One of the following ICD-9 diagnosis codes indicating Hypertension: 401.0, 401.1, 401.9, , , , , , , , , , , , , , , , AND one of the following patient encounter codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0438, G0439 AND NOT Diagnosis for stage 5 chronic kidney disease (ICD-9-CM): 585.5, 585.6, , , , , , , , **NOTE: Patients must be seen by the provider for a minimum of 2 visits during the last 24 months, with one encounter during the reporting period. PLEASE REFER TO THE HYPERTENSION 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 # 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 screening for tobacco use (e.g., limited life expectancy, other medical reasons) Tobacco screening OR tobacco cessation intervention not performed, reason not otherwise specified
3 Patient Name: Page 3 of 8 Physician Quality Reporting Measure # 295 : Hypertension: Appropriate Use of Aspirin or Other Antithrombotic Therapy Percentage of patients aged 30 through 90* years old with a diagnosis of hypertension and are eligible for aspirin or other antithrombotic therapy who were prescribed aspirin or other antithrombotic therapy Oral antithrombotic therapy consists of aspirin, warfarin, clopidogrel, dabigatran, rivaroxaban, apixaban or combination of aspirin and extended release dipyridamole or prasugrel. Diagnosis of prior coronary heart disease (CHD), prior ischemic stroke or transient ischemic attack (TIA), prior peripheral artery disease (PAD), and Framingham risk assessment for estimating 10-year risk of developing CHD are used to determine if a patient should be recommended/prescribed aspirin or other antithrombotic therapy or if the patient is at low risk and therefore aspirin or other antithrombotic therapy should not be recommended/prescribed. Patients who are at low risk of developing CHD, stroke or TIA, or PAD, patients with the level of risk not being sufficient to justify the use of aspirin or other antithrombotic therapy, patients whose risk from aspirin or other antithrombotic therapy exceeds the benefits, patients with a preference not to use aspirin or other antithrombotic, or patients where the treatment of hypertension with standard treatment goals is not clinically appropriate, should be excluded (check Documentation of medical reasons answer option). Prescribed - May include prescription given to the patient for aspirin or other anticoagulant/antiplatelet at one or more visits in the 12 month period OR patient already taking aspirin, warfarin, clopidogrel, dabigratan, or combination of aspirin and extended release dipyridamole as documented in current medication list. Framingham Risk Score - A risk assessment tool which uses recent data from the Framingham Heart Study to estimate 10- year risk for hard CHD outcomes (myocardial infarction and coronary death). This tool is designed to estimate risk in adults aged 20 and older who do not have heart disease or diabetes. Oral aspirin or other antithrombotic therapy prescribed prescribing oral aspirin or other antithrombotic therapy (e.g., patient documented to be low risk, or patient with palliative care goals or treatment of hypertension with standard treatment goals is not clinically appropriate, or for whom risk of aspirin or other antithrombotic therapy exceeds potential benefits such as for individuals whose blood pressure is poorly controlled) Document reason in medical chart Oral aspirin or other antithrombotic therapy was not prescribed, reason not given * Measure 295 is applicable only to patients years within the sample population, while all other measures within this group apply to all patients years.
4 Patient Name: Page 4 of 8 Physician Quality Reporting Measure # 296 : Hypertension: Complete Lipid Profile a diagnosis of hypertension who received a complete lipid profile within 60 months standard treatment goals is not clinically appropriate should be excluded (check Documentation of medical reasons box in table to the right). If LDL-C could not be calculated due to high triglycerides, count as complete lipid profile. Lipid panel results documented and reviewed (must include total cholesterol, HDL-C, triglycerides and calculated LDL-C) performing lipid profile (e.g., patients with palliative or for whom treatment of hypertension with standard treatment goals is not clinically appropriate) Lipid profile not performed, reason not given Physician Quality Reporting Measure # 297 : Hypertension: Urine Protein Test a diagnosis of hypertension who either have chronic kidney disease diagnosis documented or had a urine protein test done within 36 months This measure is looking for a urine protein screening test or evidence of existing chronic kidney disease. A urine protein test consists of tests for albuminuria, microalbuminuria, or proteinuria. standard treatment goals is not clinically appropriate should be excluded (check Documentation of medical reasons box in table to the right). Urine Protein test result documented and reviewed Documentation of diagnosis of chronic kidney disease performing urine protein test (e.g., patients with palliative or for whom treatment of hypertension with standard treatment goals is not clinically appropriate) Urine protein test was not performed, reason not given
5 Patient Name: Page 5 of 8 Physician Quality Reporting Measure # 298 : Hypertension: Annual Serum Creatinine Test a diagnosis of hypertension who had a serum creatinine test done within 12 months standard treatment goals is not clinically appropriate should be excluded (check Documentation of medical reasons box in table to the right). Serum creatinine test result documented and reviewed performing serum creatinine test (e.g., patients with palliative or for whom treatment of hypertension with standard treatment goals is not clinically appropriate) Serum creatinine test not performed, reason not given Physician Quality Reporting Measure # 299 : Hypertension: Diabetes Mellitus Screening Test a diagnosis of hypertension who had a diabetes screening test within 36 months Diabetes screening test consists of either a fasting glucose measurement, glycosylated hemoglobin test, or a two hour glucose tolerance test (three specimens). standard treatment goals is not clinically appropriate should be excluded (check Documentation of medical reasons box in table to the right). Diabetes screening test performed performing diabetes screening test (e.g., patients with palliative or for whom treatment of hypertension with standard treatment goals is not clinically appropriate, OR patients with a diagnosis of diabetes) Diabetes screening test not performed, reason not given
6 Patient Name: Page 6 of 8 Physician Quality Reporting Measure # 300 : Hypertension: Blood Pressure Control a diagnosis of hypertension whose most recent blood pressure was under control (< 140/90 mmhg) during the 12-month period If there are multiple blood pressures on the same date of service, use the lowest systolic and lowest diastolic blood pressure on that date as the representative blood pressure. To be under control, both systolic and diastolic blood pressures must be below the target values (e.g., for a patient, systolic BP =143 mmhg and diastolic BP =70 mmhg is not under control ). standard treatment goals is not clinically appropriate (e.g., patient with severe Alzheimer s disease) should be excluded by using the Documentation of medical reasons answer option. Most recent blood pressure under control Documentation of medical reason(s) for most recent blood pressure not under control (e.g., patients with palliative goals or for whom treatment of hypertension with standard treatment goals is not clinically appropriate) Most recent blood pressure not under control, results documented and reviewed No documentation of blood pressure measurement, reason not given
7 Patient Name: Page 7 of 8 Physician Quality Reporting Measure # 301 : Hypertension: Low Density Lipoprotein (LDL-C) Control a diagnosis of hypertension whose most recent LDL cholesterol level was under control (at goal) during the 60-month period Patients are considered to have most recent LDL-C level under control if any of the following are documented: Patients are considered to have most recent LDL-C level under control if any of the following are documented: < 100 mg/dl for those with coronary heart disease, OR stroke or transient ischemic attack, OR peripheral artery disease, OR diabetes < 130 mg/dl for those without conditions listed above, but with one or more additional risk factors for CHD (Low HDL (< 40 mg/dl) or on HDL-raising medication, risk age (men 45 years, women 55 years), family history of premature CHD, smoking); HDL cholesterol 60 acts as a negative risk factor < 160 mg/dl for those without conditions listed above, and without additional risk factors for CHD (Low HDL (< 40 mg/dl) or on HDL-raising medication, risk age (men 45 years, women 55 years), family history of premature CHD, smoking); HDL cholesterol 60 acts as a negative risk factor Most recent LDL-C under control, results documented and reviewed Documentation of medical reason(s) for most recent LDL-C not under control (e.g., patients with palliative goals or for whom treatment of hypertension with standard treatment goals is not clinically appropriate) Documentation of medical reason(s) for not performing LDL-C test (e.g., patients with palliative goals or for whom treatment of hypertension with standard treatment goals is not clinically appropriate) Most recent LDL-C not under control, results documented and reviewed LDL-C not performed, reason not given standard treatment goals is not clinically appropriate (e.g., patient with severe Alzheimer s disease) should be excluded (check most appropriate of the two Documentation of medical reasons boxes in table to the right).
8 Patient Name: Page 8 of 8 Physician Quality Reporting Measure # 302 : Hypertension: Dietary and Physical Activity Modifications Appropriately Prescribed a diagnosis of hypertension who received dietary and physical activity counseling at least once within 12 months Patients who have a terminal illness or for whom treatment of hypertension with standard treatment goals is not clinically appropriate should be excluded (check Documentation of medical reasons box in table to the right). For some patients, treatment of hypertension with standard goals may not be relevant, as might be the case for a patient with severe Alzheimer s disease. Counseling May include documentation of prescribing any of the following dietary modifications: dietary saturated fat and cholesterol restriction, calorie restriction as part of weight reduction program for overweight/obese patients, DASH eating plan, dietary sodium restriction, increased fruits, vegetables and/or soluble fiber; and documentation of activity status for active patients or discussion of increase exercise or physical activity for inactive patients. Counseling for diet and physical activity performed Documentation of medical reason(s) for patient not receiving counseling for diet and physical activity (e.g., patients with palliative or for whom treatment of hypertension with standard treatment goals is not clinically appropriate) Documentation of patient reason(s) for patient not receiving counseling for diet and physical activity (e.g., patient is not willing to discuss diet or exercise interventions to help control blood pressure, or the patient said he/she refused to make these changes) Counseling for diet and physical activity not performed, reason not given
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