2015 Physician Quality Reporting System Data Collection Form: Sleep Apnea (for patients aged 18 and older)

Transcription

1 2015 Physician Quality Reporting System Data Collection Form: Sleep Apnea (for patients aged 18 and older) 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 Sleep Apnea Measures Group are: patients aged 18 years and older with a specific diagnosis of Sleep Apnea accompanied by a specific patient encounter: One of the following diagnosis codes indicating Sleep Apnea: ICD-9-CM [for use 1/1/2015 9/30/2015]: , , , ICD-10-CM [for use 10/1/ /31/2015]: G47.30, G47.33 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, **Note: ICD9 codes are applicable 1/1/15-9/30/15; ICD10 codes are applicable 10/1/15-12/31/15 unless changed per CMS rule. Refer to the Covisint PQRS2015 Applicable Measure Group Codes document which contains a list of diagnosis, encounter, and procedure codes for each measures group. Not all measures groups require all 3 code types. PLEASE REFER TO THE Sleep Apnea MEASURES GROUP WITHIN THE CMS 2015 PQRS MEASURES GROUPS SPECIFICATIONS FOR FURTHER INFORMATION.

2 Page 2 of 8 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 Appointment Date: / / (1/1/15 12/31/15) mm dd yyyy ICD-9 (or ICD-10) Diagnosis Code**: Encounter Code: Procedure Code: N/A

3 Page 3 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 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 six months of the encounter and may be obtained from separate encounters. 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 plan 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 - PM BMI is documented above normal parameters and a follow-up plan is documented - PM BMI is documented below normal parameters and a follow-up plan is documented - PM BMI is documented as being outside of normal limits, follow-up plan is not documented, documentation the patient is not eligible - PE BMI not documented, documentation the patient is not eligible for BMI calculation - PE BMI not documented and no reason is given - PNM BMI documented outside normal parameters, no follow-up plan documented, no reason given - PNM

4 Page 4 of 8 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 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 theessence 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

5 Page 5 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 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 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

6 Page 6 of 8 Physician Quality Reporting Measure # 276 : Sleep Apnea: Assessment of Sleep Symptoms Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea that includes documentation of an assessment of sleep symptoms, including presence or absence of snoring and daytime sleepiness Sleep apnea symptoms assessed, including presence or absence of snoring and daytime sleepiness - PM Sleep apnea symptoms not assessed, reason documented (e.g., patient didn t have initial daytime sleepiness, patient visits between initial testing and initiation of therapy) - PE Document reason in medical chart Sleep apnea symptoms not assessed, reason not given - PNM Physician Quality Reporting Measure # 277 : Sleep Apnea: Severity Assessment at Initial Diagnosis Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) measured at the time of initial diagnosis Apnea-Hypopnea Index (AHI) for polysomnography performed in a sleep lab (Total Apneas + Hypopneas per hour of sleep); Apnea- Hypopnea Index (AHI) for a home sleep study is defined as (Total Apneas + Hypopneas per hour of monitoring); Respiratory Disturbance Index (RDI) (Total Apneas + Hypopneas + Respiratory-Effort-Related- Arousals per hour of sleep) Apnea hypopnea index (AHI) or respiratory disturbance index (RDI) measured at the time of initial diagnosis - PM Documentation of reason(s) for not measuring an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) at the time of initial diagnosis (e.g., abnormal anatomy, patient declined, financial, insurance coverage) - PE AHI or RDI not measured at the time of initial diagnosis, reason not given - PNM

7 Page 7 of 8 Physician Quality Reporting Measure # 278 : Sleep Apnea: Positive Airway Pressure Therapy Prescribed Percentage of patients aged 18 years and older with a diagnosis of moderate or severe obstructive sleep apnea who were prescribed positive airway pressure therapy Moderate or severe sleep apnea apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) greater than or equal to 15 episodes per hour of sleep Positive airway pressure therapy prescribed Moderate or severe obstructive sleep apnea (AHI or RDI 15) - PM Mild obstructive sleep apnea (AHI or RDI < 15) PE Documentation of reason(s) for not prescribing positive airway pressure therapy (e.g., patient unable to tolerate, alternative therapies used, patient declined, financial, insurance coverage) Moderate or severe obstructive sleep apnea (AHI or RDI 15) - PE Positive airway pressure therapy not prescribed, reason not specified Moderate or severe obstructive sleep apnea (AHI or RDI 15) - PNM

8 Page 8 of 8 Physician Quality Reporting Measure # 279 : Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea who were prescribed positive airway pressure therapy who had documentation that adherence to positive airway pressure therapy was objectively measured Objectively measured positive airway pressure machine-generated measurement of hours of use. Objective measurement of adherence to positive airway pressure therapy, documented Positive airway pressure therapy prescribed - PM Objective measurement of adherence to positive airway pressure therapy, documented Positive airway pressure therapy not prescribed - PE Documentation of reason(s) for not objectively measuring adherence to positive airway pressure therapy (e.g., patient didn t bring data from continuous positive airway pressure [CPAP], therapy not yet initiated, not available on machine) Positive airway pressure therapy prescribed - PE Objective measurement of adherence to positive airway pressure therapy not performed, reason not specified Positive airway pressure therapy prescribed - PNM