Simply Podiatry PQRS Measures Summary

Transcription

1 Table of Contents Introduction... 2 (NQF 0013) Hypertension: Blood Pressure Measurement... 4 (NQF 0028a) Tobacco Use Assessment (Preventive Care and Screening Measure Pair: a. Tobacco Use Assessment)... 6 (NQF 0028b) Tobacco Cessation Intervention (Preventive Care and Screening Measure Pair: b. Tobacco Cessation Intervention)... 8 (NQF 0421) Adult Weight Screening and Follow-Up - Ages 18 to 64 AND Adult Weight Screening and Follow-Up - Ages (G8553) - Adoption/Use of Medication Electronic Prescribing Measure #126 - Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy - Neurological Evaluation #127 - Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention Evaluation of Footwear #163 - Diabetes Mellitus: Foot Exam (NQF 0056) (NQF 0027) Smoking and Tobacco Use Cessation, Medical assistance (NQF 0061) Diabetes: Blood Pressure Management (NQF 0041) Preventive Care and Screening: Influenza Immunization for Patients >= 50 Years Old (NQF 0024) Weight Assessment and Counseling for Children and Adolescents (NQF 0038) Childhood Immunization Status - Four DTaP... 36

2 Introduction The Medicare Electronic Health Record (EHR) Incentive Program provides incentive payments to eligible professionals, eligible hospitals, and Critical Access Hospitals (CAHs) that successfully demonstrate meaningful use of certified EHR technology. To successfully demonstrate meaningful use, eligible professionals, eligible hospitals, and CAHs are required to report Clinical Quality Measures (CQMs) as well as meaningful use functionality measures. Beginning in 2012, eligible professionals may satisfy the meaningful use objective to report CQMs to the Centers for Medicare & Medicaid Services (CMS) by reporting them through the Medicare and Medicaid EHR Incentive Programs web-based Registration and Attestation System. Core Measures Eligible professionals participating in the Physician Quality Reporting System-Medicare EHR Incentive Pilot are required to submit information on the three Medicare EHR Incentive Program core measures in the following list: - The 3 Core Measures are: (a) PQRS Measure #237 (NQF0013): Hypertension: Blood Pressure Measurement (b) PQRS Measure #226 (NQF0028): Tobacco Use Assessment and Tobacco Cessation Intervention (c) PQRS Measure #128 (NQF0421): Adult Weight Screening and Follow-Up Alternate Core Measures If the denominator for one or more of the Medicare EHR Incentive Program core measures is zero, the eligible professional must report on up to three of the Medicare EHR Incentive Program alternate core measures in the following list: - The 3 Alternate Core Measures are: (a) PQRS Measure #110 (NQF0041): Preventive Care and Screening: Influenza Immunization (b) PQRS Measure #239 (NQF0024): Weight Assessment and Counseling for Children and Adolescents (c) PQRS Measure #240 (NQF0038): Adult Weight Screening and Follow-Up

3 Additional Measures Eligible professionals must report on three of the measures available for the Medicare EHR Incentive Program in the following list: -The 3 Additional (Podiatry Specific Measures) we have chosen to meet for Simply Podiatry are: (a) PQRS Measure #126: Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy Neurological Evaluation (b) PQRS Measure #127: Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention Evaluation of Footwear (c) PQRS Measure # 163: Diabetes Mellitus: Foot Exam **Introduction derived from MLN/MLNProducts/downloads/PQRSMdcrEHRIncnPlt-ICN pdf

4 (NQF 0013) Hypertension: Blood Pressure Measurement EMeasure Name Hypertension: Blood Pressure Measurement EMeasure Id Pending Version Number 1 Set Id Pending Available Date No information Measurement Period January 1, 20xx through December 31, 20xx Measure Steward Endorsed by American Medical Association Physician Consortium for Performance Improvement National Quality Forum Description Percentage of patient visits for patients aged 18 years and older with a diagnosis of hypertension who have been seen for at least 2 office visits, with blood pressure (BP) recorded. Measure scoring Measure type Rationale Proportion Process Effective management of blood pressure in patients with hypertension can help prevent cardiovascular events, including myocardial infarction, stroke, and the development of heart failure. Clinical Recommendation Statement Treating SBP and DBP to targets that are <140/90 mm Hg is associated with a decrease in CVD risk complications. In patients with hypertension and diabetes or renal disease, the BP goal is <130/80 mm Hg. (JNC VII, 2004). Improvement notation Measurement duration Higher score indicates better quality 12 months References Definitions Page 4

5 Measure set CLINICAL QUALITY MEASURE SET Denominator = o AND: Patient characteristic: birth date (age) >= 18 years ; o AND: Diagnosis active: hypertension ; Diagnosis for Hypertension (ICD-9-CM): 401.0, 401.1, 401.9, , , , , , , , , , , , , , , , , , , , , , , , o AND: Number of office visits with provider >=2 with one being in the reporting period. Numerator = o AND: Physical exam finding: systolic blood pressure ; (entered on Extra Tests/Notes page of Exam) o AND: Physical exam finding: diastolic blood pressure ; (entered on Extra Tests/Notes page of Exam) Summary Calculation Calculate the final denominator by adding all that meet denominator criteria. Subtract from the final denominator all that do not meet numerator criteria yet also meet exclusion criteria. Note some measures do not have exclusion criteria. The performance calculation is the number meeting numerator criteria divided by the final denominator. For measures with multiple patient populations, repeat this process for each patient population and report each result separately. For measures with multiple numerators, calculate each numerator separately within each population using the paired exclusion. Page 5

6 (NQF 0028a) Tobacco Use Assessment (Preventive Care and Screening Measure Pair: a. Tobacco Use Assessment) EMeasure Name Preventive Care and Screening Measure Pair: a. Tobacco Use Assessment EMeasure Id Pending Version Number 1 Set Id Pending Available Date No information Measurement Period January 1, 20xx through December 31, 20xx Measure Steward Endorsed By Description Measure scoring Measure type Rationale Clinical Recommendation Statement American Medical Association Physician Consortium for Performance Improvement National Quality Forum Percentage of patients aged 18 years or older who have been seen for at least 2 office visits by the physician ever, have been seen for one office visit by the physician during the reporting date range, and whose most recent Patient History record within the last 24 months indicates the Smoking Status is Current or Yes was answered for the question Do you use tobacco products? Proportion Process Tobacco use is one of the leading causes of many preventable diseases, however, not all individuals are screened for tobacco use. The USPSTF strongly recommends that clinicians screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products. (A Recommendation) (USPSTF, 2003). References Definitions Measure set CLINICAL QUALITY MEASURE SET Page 6

7 Denominator = o AND: Patient characteristic: birth date (age) >= 18 years; o AND: Number of office visits with provider >=2 with one being in the reporting period. Numerator = o AND: Patient characteristic: tobacco user before or simultaneously to the encounter as indicated by the most recent Patient History record within the last 24 months with the Smoking Status as Current or Yes was answered for the question Do you use tobacco products? ; Summary Calculation Calculation is generic to all measures: Calculate the final denominator by adding all that meet denominator criteria. Subtract from the final denominator all that do not meet numerator criteria yet also meet exclusion criteria. Note some measures do not have exclusion criteria. The performance calculation is the number meeting numerator criteria divided by the final denominator. For measures with multiple patient populations, repeat this process for each patient population and report each result separately. For measures with multiple numerators, calculate each numerator separately within each population using the paired exclusion. Page 7

8 (NQF 0028b) Tobacco Cessation Intervention (Preventive Care and Screening Measure Pair: b. Tobacco Cessation Intervention) EMeasure Name Preventive Care and Screening Measure Pair: b. Tobacco Cessation Intervention EMeasure Id Pending Version Number 1 Set Id Pending Available Date No information Measurement Period January 1, 20xx through December 31, 20xx Measure Steward Endorsed By Description Measure scoring Measure type Rationale Clinical Recommendation Statement American Medical Association Physician Consortium for Performance Improvement National Quality Forum Percentage of patients aged 18 years and older identified as tobacco users within the past 24 months, and have been seen for at least 2 office visits, who received cessation intervention (procedures with tobacco in the description). Proportion Process The USPSTF strongly recommends that clinicians screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products. The USPSTF strongly recommends that clinicians screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products. (A Recommendation) (USPSTF, 2003). References Definitions Measure set CLINICAL QUALITY MEASURE SET Page 8

9 Denominator = o AND: Patient characteristic: birth date (age) >= 18 years; o AND: Number of office visits with provider >=2 with one being in the reporting period. o AND: Patient characteristic: tobacco user <= 24 months; (encounter as indicated by the most recent Patient History record within the last 24 months with the Smoking Status as Current or Yes was answered for the question Do you use tobacco products? ) Numerator = o OR: Procedure performed: tobacco use cessation counseling <= 24 months; (procedures with tobacco in the description) o OR: Medication active: smoking cessation agents before or simultaneously to the encounter <= 24 months; o OR: Medication order: smoking cessation agents before or simultaneously to the encounter <= 24 months; Summary Calculation Calculation is generic to all measures: Calculate the final denominator by adding all that meet denominator criteria. Subtract from the final denominator all that do not meet numerator criteria yet also meet exclusion criteria. Note some measures do not have exclusion criteria. The performance calculation is the number meeting numerator criteria divided by the final denominator. For measures with multiple patient populations, repeat this process for each patient population and report each result separately. For measures with multiple numerators, calculate each numerator separately within each population using the paired exclusion Page 9

10 (NQF 0421) Adult Weight Screening and Follow-Up - Ages 18 to 64 AND Adult Weight Screening and Follow-Up - Ages 65+ EMeasure Name Adult Weight Screening and Follow-Up EMeasure Id Pending Version Number 1 Set Id Pending Available Date No information Measurement Period January 1, 20xx through December 31, 20xx Measure Steward Endorsed by Description Measure scoring Measure type Quality Insights of Pennsylvania National Quality Forum Percentage of patients aged 18 years and older with a calculated BMI in the past six months or during the current visit documented in the medical record AND if the most recent BMI is outside parameters, a follow-up plan is documented. Proportion Process Rationale Of the Medicare population, 37 percent are overweight, and 18 percent are obese. Between 1991 and 1998, the prevalence of obesity among persons age increased by 45 percent (American Obesity Association). According to a 1998 survey, only 52 percent of adults age 50 or older reported being asked during routine medical check-ups about physical activity or exercise. The likelihood of being asked about exercise during a routine check-up declined with age (Center for the Advancement of Health, 2004). Elderly patients with unintentional weight loss are at higher risk for infection, depression and death. In one study it was found that a BMI of less than 22 kg per m2 in women and less than 23.5 in men is associated with increased mortality. In another study it was found that the optimal BMI in the elderly is 24 to 29 kg per m2. (Huffman, G. B., Evaluation and Treatment of Unintentional Weight Loss in the Elderly, American Family Physician, 2002 Feb, 4: ) Page 10

11 Clinical Recommendation Statement Improvement notation The USPSTF (2009) recommends that clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults. (Level of Evidence = B, USPSTF) The clinical guideline for obesity recommends assessment of BMI at each encounter (National Heart, Lung and Blood Institute). Management of Obesity indicates that the body mass index should be calculated at least annually for screening and as needed for management (The Institute for Clinical Systems Improvement s 2009 Guideline for Prevention and Management of Obesity). Validated measure of nutrition status serves as an indicator of overnourishment and undernourishment. Nutrition Screening Initiative: Nutrition Interventions Manual for Professionals Caring for Older Americans, 2002 (Cosponsored by American Dietetic Association (ADA), AAFP and National Council on Aging, Inc.). The NSI-suggested BMI range is (values outside this range indicate Higher score indicates better quality overweight or underweight for elderly) Nutrition Screening Initiative: Nutrition Interventions Manual for Professionals Caring for Older Americans, 2002 (Co-sponsored by American Dietetic Association (ADA), AAFP and National Council on Aging, Inc.). Page 11

12 Measurement duration 12 months References Definitions Measure set CLINICAL QUALITY MEASURE SET Denominator 1= Numerator 1 = o AND: Patient characteristic: birth date (age) >= 18 years AND <= 64 years; o AND: >=1 exam in the reporting period; o OR: Physical exam finding: BMI >=18.5 kg/m² and <25 kg/m², occurring <=6 months before or simultaneously to the Encounter: outpatient encounter ; o OR: Physical Exam Finding: BMI >=25 kg/m², occurring <=6 months before or simultaneously to the Encounter: outpatient encounter ; AND plan is either: OR: Care goal: follow-up plan BMI management ; OR: Communication provider to provider: dietary consultation order ; o OR: Physical Exam Finding: BMI >=25 kg/m², occurring <=6 months before or simultaneously to the Encounter: outpatient encounter ; AND plan is either: OR: Care goal: follow-up plan BMI management ; OR: Communication provider to provider: dietary consultation order ; Denominator 2 = Numerator 2 = o AND: Patient characteristic: birth date (age) >= 65 years; o AND: >=1 exam in the reporting period; o OR: Physical exam finding: BMI >=22 kg/m² and <30 kg/m², occurring <=6 months before or simultaneously to the Encounter: outpatient encounter ; o OR: Physical Exam Finding: BMI >=30 kg/m², occurring <=6 months before or simultaneously to the Encounter: outpatient encounter ; AND Plan is either: Page 12

13 OR: Care goal: follow-up plan BMI management ; OR: Communication provider to provider: dietary consultation order ; o OR: Physical Exam Finding: BMI <22 kg/m², occurring <=6 months before or simultaneously to the Encounter: outpatient encounter ; AND plan is either: OR: Care goal: follow-up plan BMI management ; OR: Communication provider to provider: dietary consultation order ; Summary Calculation Calculation is generic to all measures: Calculate the final denominator by adding all that meet denominator criteria. Subtract from the final denominator all that do not meet numerator criteria yet also meet exclusion criteria. Note some measures do not have exclusion criteria. The performance calculation is the number meeting numerator criteria divided by the final denominator. For measures with multiple patient populations, repeat this process for each patient population and report each result separately. For measures with multiple numerators, calculate each numerator separately within each population using the paired exclusion. Page 13

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15 (G8553) - Adoption/Use of Medication Electronic Prescribing Measure Denominator = Numerator = Patients with an exam that have an exam date within the start and end dates of the Clinical Measures report, and that have a prescription related to the exam. On the CPOE page of the Exam, the user must create the medication order on the MedRX tab, and the Used E-RX System checkbox must be checked. The user can simply check the box directly, or if the practice uses Allscripts as their e-prescribe vendor they can click the eprescribe Now button to access the All Scripts login page, and this will automatically check the Used E-RX System checkbox. The prescriptions must be created for exams dated within the start and end dates of the Clinical Measures report. Page 15

16 #126 - Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy - Neurological Evaluation 2012 PHYSICIAN QUALITY REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY DESCRIPTION: Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 months INSTRUCTIONS: This measure is to be reported a minimum of once per reporting period for patients with diabetes mellitus seen during the reporting period. Evaluation of neurological status in patients with diabetes to assign risk category and therefore have appropriate foot and ankle care to prevent ulcerations and infections ultimately reduces the number and severity of amputations that occur. Risk catagorization and follow up treatment plan should be done according to the following table: Risk Categorization System: Category Risk Profile Evaluation Frequency 0 Normal Annual 1 Peripheral Neuropathy (LOPS) Semi-annual 2 Neuropathy, deformity, and/or Quarterly PAD 3 Previous ulcer or amputation Monthly to quarterly This measure may be reported by non-md/do clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. Measure Reporting via Claims: ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients who are included in the measure s denominator. G-codes are used to report the numerator of the measure. When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes, and the appropriate numerator G-code. All measure-specific coding should be reported on the claim(s) representing the eligible encounter. Measure Reporting via Registry: ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients who are included in the measure s denominator. The numerator options as described in the quality-data codes are used to report the numerator of the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data. DENOMINATOR: All patients aged 18 years and older with a diagnosis of diabetes mellitus Denominator Criteria (Eligible Cases): Patients aged 18 years on date of encounter AND Diagnosis for diabetes (ICD-9-CM): , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , AND Patient encounter during the reporting period (CPT): 11042, 11043, 11044, 11055, 11056, 11057, 11719, 11720, 11721, 11730, 11740, 97001, 97002, 97597, 97598, 97802, 97803, 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, Page 16

17 NUMERATOR: Patients who had a lower extremity neurological exam performed at least once within 12 months Definition: Lower Extremity Neurological Exam Consists of a documented evaluation of motor and sensory abilities and may include: reflexes, vibratory, proprioception, sharp/dull and 5.07 filament detection. The components listed ar250e consistent with the neurological assessment recommended by the Task Force of the Foot Care Interest Group of the American Diabetes Association. They generally recommend at least two of the listed tests be performed when evaluating for loss of protective sensation; however the clinician should perform all necessary tests to make the proper evaluation. Numerator Quality-Data Coding Options for Reporting Satisfactorily: Lower Extremity Neurological Exam Performed G8404: Lower extremity neurological exam performed and documented OR Lower Extremity Neurological Exam not Performed for Documented Reasons G8406: Clinician documented that patient was not an eligible candidate for lower extremity neurological exam measure OR Lower Extremity Neurological Exam not Performed G8405: Lower extremity neurological exam not performed RATIONALE: Foot ulceration is the most common single precursor to lower extremity amputations among persons with diabetes. Treatment of infected foot wounds accounts for up to one-quarter of all inpatient hospital admissions for people with diabetes in the United States. Peripheral sensory neuropathy in the absence of perceived trauma is the primary factor leading to diabetic foot ulcerations. Approximately 45-60% of all diabetic ulcerations are purely neuropathic. Other forms of neuropathy may also play a role in foot ulcerations. Motor neuropathy resulting in anterior crural muscle atrophy or intrinsic muscle wasting can lead to foot deformities such as foot drop, equinus, and hammertoes. In people with diabetes, 22.8% have foot problems such as amputations and numbness compared with 10% of nondiabetics. Over the age of 40 years old, 30% of people with diabetes have loss of sensation in their feet. CLINICAL RECOMMENDATION STATEMENTS: Recognizing important risk factors and making a logical, treatment-oriented assessment of the diabetic foot requires a consistent and thorough diagnostic approach using a common language. Without such a method, the practitioner is more likely to overlook vital information and to pay inordinate attention to less critical points in the evaluation. A useful examination will involve identification of key risk factors and assignment into appropriate risk category. Only then can an effective treatment plan be designed and implemented. (ACFAS/ACFAOM Clinical Practice Guidelines) Page 17

18 #127 - Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention Evaluation of Footwear 2012 PHYSICIAN QUALITY REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY DESCRIPTION: Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing INSTRUCTIONS: This measure is to be reported a minimum of once per reporting period for patients with diabetes mellitus seen during the reporting period. This measure may be reported by non-md/do clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. Measure Reporting via Claims: ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients who are included in the measure s denominator. G-codes are used to report the numerator of the measure. When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes, and the appropriate numerator G-code. All measure-specific coding should be reported on the claim(s) representing the eligible encounter. Measure Reporting via Registry: ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients who are included in the measure s denominator. The numerator options as described in the quality-data codes are used to report the numerator of the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data. DENOMINATOR: All patients aged 18 years and older with a diagnosis of diabetes mellitus Denominator Criteria (Eligible Cases): Patients aged 18 years on date of encounter AND Diagnosis for diabetes (ICD-9-CM): , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , AND Patient encounter during the reporting period (CPT): 11042, 11043, 11044, 11055, 11056, 11057, 11719, 11720, 11721, 11730, 11740, 97001, 97002, 97597, 97598, 97802, 97803, 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, NUMERATOR: Patients who were evaluated for proper footwear and sizing at least once within 12 months Definition: Evaluation for Proper Footwear Includes a foot examination documenting the vascular, neurological, dermatological, and structural/biomechanical findings. The foot should be measured using a standard measuring device and counseling on appropriate footwear should be based on risk categorization. Numerator Quality-Data Coding Options for Reporting Satisfactorily: Footwear Evaluation Performed Page 18

19 G8410: Footwear evaluation performed and documented OR Footwear Evaluation not Performed for Documented Reasons G8416: Clinician documented that patient was not an eligible candidate for footwear evaluation measure OR Footwear Evaluation not Performed G8415: Footwear evaluation was not performed RATIONALE: Foot ulceration is the most common single precursor to lower extremity amputations among persons with diabetes. Shoe trauma, in concert with loss of protective sensation and concomitant foot deformity, is the leading event precipitating foot ulceration in persons with diabetes. Treatment of infected foot wounds accounts for up to one-quarter of all inpatient hospital admissions for people with diabetes in the United States. Peripheral sensory neuropathy in the absence of perceived trauma is the primary factor leading to diabetic foot ulcerations. Approximately 45-60% of all diabetic ulcerations are purely neuropathic. In people with diabetes, 22.8% have foot problems such as amputations and numbness compared with 10% of nondiabetics. Over the age of 40 years old, 30% of people with diabetes have loss of sensation in their feet. CLINICAL RECOMMENDATION STATEMENTS: The multifactorial etiology of diabetic foot ulcers is evidenced by the numerous pathophysiologic pathways that can potentially lead to this disorder. Among these are two common mechanisms by which foot deformity and neuropathy may induce skin breakdown in persons with diabetes. The first mechanism of injury refers to prolonged low pressure over a bony prominence (i.e., bunion or hammertoe deformity). This generally causes wounds over the medial, lateral, and dorsal aspects of the forefoot and is associated with tight or ill-fitting shoes. (ACFAS/ACFAOM Clinical Practice Guidelines) Page 19

20 #163 - Diabetes Mellitus: Foot Exam (NQF 0056) 2012 PHYSICIAN QUALITY REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY DESCRIPTION: The percentage of patients aged 18 through 75 years with diabetes who had a foot examination INSTRUCTIONS: This measure is to be reported a minimum of once per reporting period for patients with diabetes mellitus seen during the reporting period. The performance period for this measure is 12 months. This measure may be reported by clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. Measure Reporting via Claims: ICD-9-CM diagnosis codes, CPT codes, G-codes, and patient demographics are used to identify patients who are included in the measure s denominator. CPT Category II codes are used to report the numerator of the measure. When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes, G-codes, and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The modifiers allowed for this measure are: 1P- medical reasons, 8P- reason not otherwise specified. All measure-specific coding should be reported on the claim(s) representing the eligible encounter. Measure Reporting via Registry: ICD-9-CM diagnosis codes, CPT codes, G-codes, and patient demographics are used to identify patients who are included in the measure s denominator. The numerator options as described in the quality-data codes are used to report the numerator of the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data. DENOMINATOR: Patients aged 18 through 75 years with a diagnosis of diabetes Denominator Criteria (Eligible Cases): Patients aged 18 through 75 years on date of encounter AND Diagnosis for diabetes (ICD-9-CM): , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 357.2, , , , , , , , , , , , , AND Patient encounter during the reporting period (CPT or HCPCS): 97802, 97803, 97804, 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, G0270, G0271 Page 20

21 NUMERATOR: Patients who received a foot exam (visual inspection, sensory exam with monofilament, or pulse exam) Numerator Quality-Data Coding Options for Reporting Satisfactorily: Foot Exam Performed CPT II 2028F: Foot examination performed (includes examination through visual inspection, sensory exam with monofilament, and pulse exam report when any of the three components are completed) OR Foot Exam not Performed for Medical Reason Append a modifier (1P) to CPT Category II code 2028F to report documented circumstances that appropriately exclude patients from the denominator. 2028F with 1P: Documentation of medical reason for not performing foot exam (i.e., patient with bilateral foot/leg amputation) OR Foot Exam not Performed, Reason not Specified Append a reporting modifier (8P) to CPT Category II code 2028F to report circumstances when the action described in the numerator is not performed and the reason is not otherwise specified. 2028F with 8P: Foot exam was not performed, reason not otherwise specified RATIONALE: The most common consequences of diabetic neuropathy are amputation and foot ulceration (ADA, 2006). In developed countries, up to five percent of diabetic patients have foot ulcers (IDF, 2005). One in every six diabetics will have an ulcer during their lifetime (IDF, 2005). Amputation and foot ulceration are also major causes of morbidity and mortality. One half to 80% of all amputations are diabetes-related (Mayfield, 1998; Reiber, 1995; ADA, 2001; Unwin, 2000).The risk of ulcers or amputations increases the longer someone has diabetes. Early recognition and management of risk factors can prevent or delay adverse outcomes. (ADA, 2006) CLINICAL RECOMMENDATION STATEMENTS: American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE) and American Diabetes Association (ADA) recommend that a foot examination (visual inspection, sensory exam, and pulse exam) be performed during an initial assessment. AACE/ACE (2002) recommends that a foot examination be a part of every follow-up assessment visit, which should occur quarterly. ADA (2004) recommends that all individuals with diabetes should receive an annual foot examination to identify high-risk foot conditions. This examination should include assessment of protective sensation, foot structure and biomechanics, vascular status, and skin integrity. The ADA (2004) recommends that people with one or more high-risk foot conditions should be evaluated more frequently for the development of additional risk factors. People with neuropathy should have a visual inspection of their feet at every contact with a health care professional. Page 21

22 (NQF 0027) Smoking and Tobacco Use Cessation, Medical assistance EMeasure Name Smoking and Tobacco Use Cessation, Medical assistance: a. Advising Smokers and Tobacco Users to Quit, b. Discussing Smoking and Tobacco Use Cessation Medications, c. Discussing Smoking and Tobacco Use Cessation Strategies EMeasure Id Pending Version Number 1 Set Id Pending Available Date No information Measurement Period Measure Steward National Committee for Quality Assurance Endorsed by National Quality Forum Description Measure scoring Measure type Rationale Clinical Recommendation Statement January 1, 20xx through December 31, 20xx The percentage of patients 18 years of age and older who were current smokers or tobacco users, who were seen by a practitioner during the measurement year and who received advice to quit smoking or tobacco use or whose practitioner recommended or discussed smoking or tobacco use cessation medications, methods or strategies. Proportion Process This measure assesses different facets of providing medical assistance with smoking cessation or tobacco use. Smoking is the leading preventable cause of premature death in the United States and is identified as a causal factor in more than 25 diseases and health problems (USDHHS 2004). In 2003, based on evidence that cessation strategies are effective in improving health outcomes, the USPSTF recommended that clinicians screen adults for tobacco use and provide tobacco cessation interventions. Interventions to control smoking are also strategically important because of the financial burden: approximately $167 billion in annual health-related economic losses, when considered with other tobacco use causes. This measure facilitates efforts to implement recommended clinical practices and guidelines and subsequently reduce mortality rates and health problems related to smoking and tobacco use. United States Preventative Services Task Force (USPSTF): The USPSTF guideline strongly recommends that clinicians screen all adult for tobacco use and provide tobacco cessation interventions for those who use tobacco products. The USPSTF found good evidence that brief smoking cessation interventions, including screening, brief behavioral counseling (less than 3 minutes), and pharmacotherapy delivered in primary care settings, are effective in increasing Page 22

23 References the proportion of smokers who successfully quit smoking and remain abstinent after 1 year. Veterans Affairs/Department of Defense: The VA/DoD s Clinical Practice Guideline for the Management of Tobacco Use recommends that any person (age greater than 12 years) who is eligible for care in the Veterans Health Administration (VHA) or the Department of Defense (DoD) health care delivery system should be screened for tobacco use and should be asked about tobacco use at most visits. Tobacco users should be advised to quit and assessed for willingness to quit at every visit. All tobacco users who are willing to quit should be offered an effective tobacco cessation intervention, including: pharmacotherapy, counseling, and follow-up. Tobacco users attempting to quit should be prescribed one or more effective first-line pharmacotherapies for tobacco use cessation. The guideline also cites strong evidence that minimal counseling (lasting less than three minutes) increases overall tobacco abstinence rates. Public Health Service: The Public Health Service Clinical Practice Guideline recommends that clinicians engage in a number of activities to aid tobacco users in quitting, which include: Implement an officewide system that ensures that, for EVERY patient at EVERY clinic visit, tobacco-use status is queried and documented (repeated assessment is not necessary in the case of the adult who has never used tobacco or has not used tobacco for many years, and for whom this information is clearly documented in the medical record). In a clear, strong, and personalized manner, urge every tobacco user to quit. As every tobacco user if he or she is willing to make a quit attempt at this time (e.g., within the next 30 days). Provide practical counseling (problem solving/training). Recommend the use of approved pharmacotherapy, except in special circumstances. Provide supplementary materials. U.S. Preventive Services Task Force (USPSTF). Counseling to prevent tobacco use and tobacco-caused disease: recommendation statement. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2003 Nov. 13. U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Denominator = o AND: Patient characteristic: birth date (age) >= 17 years to capture all patients who will reach the age of 18 years and older during the measurement period ; o OR: "Encounter: encounter outpatient" <= 2 years before or simultaneously to measurement end date ; Patient encounter (CPT or HCPCS): (99201,99202,99203,99204,99205,99211,99212,99213,99214,99215, 99217,99218,99219,99220,99241,99242,99243,99244,99245,99341, 99342,99343,99344,99345,99347,99350,99384,99385,99386,99387, 99394,99395,99396,99397,99401,99402,99403,99404,99411, ,99429,99455,99456) Page 23

24 Numerator = Simply Podiatry PQRS Measures Summary o OR: "Patient characteristic: tobacco user" <=1 year before or simultaneously to measurement period ; o OR: "Encounter: tobacco use cessation counseling" <=1 year before or simultaneously to measurement period ; OR: Communication to patient: tobacco use cessation counseling <=1 year before or simultaneously to measurement end date ; Tobacco Cessation Counseling (CPT or HCPCS): (99406,99407) Page 24

25 (NQF 0061) Diabetes: Blood Pressure Management EMeasure Name Diabetes: Blood Pressu EMeasure Id Pending re Management Version Number 1 Set Id Pending Available Date No information Measurement Period January 1, 20xx throug h December 31, 20xx Measure Steward National Committee for Quality Assurance Endorsed by National Quality Forum Description The percentage of patients years of age with diabetes (type 1 or type 2) who had BP <140/90 mmhg. Measure scoring Proportion Measure type Process Rationale This measure evaluates the percentage of patients in a specific age demogr aphic who were diagnosed with type 1 or type 2 diabetes and who sustain a dequate blood pressure control. Diabetes mellitus (diabetes) is a group of di seases characterized by high blood glucose levels caused by the body s inabi lity to correctly produce or utilize the hormone insulin It is recognized as a l eading cause of death and disability in the U.S. and is highly underreported as a cause of death. Diabetes of either type may cause life-threatening, lifeending or lifealtering complications, including poor blood pressure control and subseque nt cardiovascular disease of varying severity. Maintaining a healthy blood pr essure has been shown to reduce complications due to diabetes, with a 10 mm Hg reduction in systolic blood pressure lowering the risk of complicatio ns by 12% It also reduces the chance of cardiovascular disease among patie nt with diabetes by up to 50% and reduces the chance of other related com plications (eye, kidney, nerve) by more than 25% This measure facilitates lo ngterm management of blood pressure levels for patients diagnosed with diab etes. Page 25

26 Clinical Recommendation Statement American Association of Clinical Endocrinologists and American College of E ndocrinology (AACE/ACE): Recommends that a blood pressure determinati on during the initial evaluation, including orthostatic evaluation, be include d in the initial and every interim physical examination. American College of Physicians (ACP): Blood pressure control must be a pri ority in the management of persons with hypertension and type 2 diabetes. American Diabetes Association (ADA): Blood pressure should be measured at every routine diabetes visit. Patients found to have systolic blood pressur e >130 mmhg or diastolic >80 mmhg should have blood pressure confirmed on a separate day. Orthostatic measurement of blood pressure should be p erformed to assess for the presence of autonomic neuropathy. (Level of Evi dence: E) American Geriatrics Society (AGS): Older persons with diabetes are likely to benefit greatly from cardiovascular risk reduction, therefore monitor and tr eat hypertension and dyslipidemias. JNC VII: Recommends that measurement of blood pressure in the standing position is indicated periodically, especially in those at risk for postural hypo tension. At least two measurements should be made and the average recor ded. After BP is at goal and stable, follow-up visits can usually be at 3- to 6- month intervals. Comorbidities such as heart failure, associated diseases such as diabetes, and t he need for laboratory tests influence the frequency of visits. National Kidney Foundation (NKF): Recommends that all individuals should be evaluated during health encounters to determine whether they are at in creased risk of having or of developing chronic kidney disease. This evaluati on of risk factors should include blood pressure measurement. References American Association of Clinical Endocrinologists and American College of E ndocrinology. The American Association of Clinical Endocrinologists Medical Guidelines for the Management of Diabetes Mellitus: The AACE System of I ntensive Diabetes Self-Management 2002 California Healthcare Foundation/American Geriatrics Society (AGS) Improvi ng Care of Elders with Diabetes. Guidelines for Improving the Care of the Ol der Person with Diabetes Mellitus. J Am Geriatr Soc 2003;51:S265- S280. Available at ecutive_summary.shtml Accessed September Definitions Measure set The Seventh Report of the Joint National Committee on Prevention, Detecti on, Evaluation, and Treatment of High Blood Pressure (JNC VII). NIH Publicat ion No , August CLINICAL QUALITY MEASUR E SET Page 26

27 Denominator = OAND: Patient characteristic: birth date (age) >= 17 years and <=74 years to capture all patients who will reach the ages bet ween 18 and 75 years during the measurement period ; o AND: OR: Medication dispensed: medications indicative of diabetes <=2 years before or simultaneously to measurement end date ; OR: Medication order: medications indicative of diabetes <=2 years before or simultaneously to measurement end date ; OR: Medication active: medications indicative of diabetes <=2 years before or simultaneously to measurement end date ; Diabetes Medication (CPT or HCPCS): (199149, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,861806,861816, , ) OR: AND: Diagnosis active: diabetes <=2 years before or simultaneously to measurement end date ; Indicated on a Patient History record as diabetic, OR: Diagnosis Active: Diabetes (CPT or HCPCS): (648.02, , ,250, 250.0, , , , , , ,250.12, , , , , , , , , , 250.4,250.40, , , , , , , , , , ,250.63, 250.7, , , , , 250.8, , , , ,250.9, , , , , 357.2, 362.0, , , , ,362.05, , , , 648.0, , ) AND: OR: >=1 count(s) of Encounter: encounter acute inpatient or ED ; Plan (CPT or HCPCS): (99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99251, 99252, 99253, 99254, 99255, 99291, 99281, 99282, 99283, 99284, 99285) OR: >=2 count(s) of Encounter: encounter non-acute inpt, outpatient, or ophthalmology occurring on 2 different dates; Plan (CPT or HCPCS): (99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99241, 99242, 99243, Page 27

28 99244, 99245, 99341, 99342, 99343, 99344, 99345, 99347, 99350, 99384, 99385, 99386, 99387, 99394, 99395, 99396, 99397, 99401, 99402, 99403, 99404, 99411, 99412, 99420, 99429, 99455, 99456, 92002, 92003, 92004, 92005, 92006, 92007, 92008, 92009, 92010, 92011, 92012, 92013, 92014) Numerator = o AND: OR: Physical exam finding: diastolic blood pressure, MINIMUM value < 90 mmhg during MOST RECENT Encounter: encounter non-acute inpt, outpatient, or ophthalmology ; (entered on Extra Tests/Notes page of Exam) OR: Physical exam finding: diastolic blood pressure, MINIMUM value < 90 mmhg during MOST RECENT Encounter: Encounter acute inpatient or ED ; (entered on Extra Tests/Notes page of Exam) o AND: OR: Physical exam finding: systolic blood pressure, MINIMUM value < 140 mmhg during MOST RECENT Encounter: encounter non-acute inpt, outpatient, or ophthalmology ; (entered on Extra Tests/Notes page of Exam) OR: Physical exam finding: systolic blood pressure, MINIMUM value < 140 mmhg during MOST RECENT Encounter: Encounter acute inpatient or ED ; (entered on Extra Tests/Notes page of Exam) Exclusions = o OR: AND: Diagnosis active: polycystic ovaries ; Diagnosis (CPT or HCPCS): (256.4) AND NOT: AND: Diagnosis active: diabetes <= 2 years before or simultaneously to measurement end date ; AND: OR: Encounter: encounter acute inpatient or ED <=2 years before or simultaneously to measurement end date ; OR: Encounter: encounter non-acute inpt, outpatient, or ophthalmology <=2 years before or simultaneously to measurement end date ; o OR: AND: OR: Diagnosis active: gestational diabetes <=2 years before or simultaneously to measurement end date ; OR: Diagnosis active: steroid induced diabetes <=2 years before or simultaneously to measurement end date ; Diagnosis (CPT or HCPCS): (249.6, , , 249.7, , , 249.8, , , 249.9, , , 251.8, 962.0, 648.8, , , , , , 249, 249.0, , , 249.1, , , 249.2, , , 249.3, , , 249.4, , , 249.5, , ) AND: Page 28

29 OR: Medication order: medications indicative of diabetes <=2 years before or simultaneously to measurement end date ; OR: Medication dispensed: medications indicative of diabetes <=2 years before or simultaneously to measurement end date ; OR: Medication active: medications indicative of diabetes <=2 years before or simultaneously to measurement end date ; Plan (CPT or HCPCS): (861736, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ) AND NOT: AND: Diagnosis active: diabetes <=2 years before or simultaneously to measurement end date ; AND: OR: Encounter: Encounter acute inpatient or ED <=2 years before or simultaneously to measurement end date ; OR: Encounter: encounter non-acute inpt, outpatient, or ophthalmology <=2 years before or simultaneously to measurement end date ; Summary calculation Calculation is generic to all measures: Calculate the final denominator by adding all that meet denominator criteria. Subtract from the final denominator all that do not meet numerator criteria yet also meet exclusion criteria. Note some measures do not have exclusion criteria. The performance calculation is the number meeting numerator criteria divided by the final denominator. For measures with multiple patient populations, repeat this process for each patient population and report each result separately. Page 29

30 For measures with multiple numerators, calculate each numerator separately within each population using the paired exclusion. Page 30

31 (NQF 0041) Preventive Care and Screening: Influenza Immunization for Patients >= 50 Years Old EMeasure Name Preventive Care and Screening: EMeasure Id Pending Influenza Immunization for Patients > 50 Years Old Version Number 1 Set Id Pending Available Date No information Measurement Period January 1, 20xx through December 31, 20xx Measure Steward American Medical Association Physician Consortium for Performance Improvement Endorser Description Measure scoring Measure type Rationale Clinical Recommendation Statement Reference Definitions National Quality Forum Percentage of patients aged 50 years and older who received an influenza immunization during the flu season (September through February). Proportion Process Influenza vaccination has shown to decrease hospitalizations for influenza, especially for those with risk factors, however annual influenza vaccination rates remain low. Annual influenza immunization is recommended for all groups who are at increased risk for complications from influenza including persons aged 50 years. (CDC, USPSTF) Population criteria Denominator = o AND: Patient s within date range of PQRS report Start and End dates, and birth date (age) >= 50 years; Numerator = o AND: Medication administered: influenza vaccine ; (Immunization vaccine name with Influenza in the name.) o AND: Immunization date between September - February; Exclusions = o OR: Medication not done: influenza immunization contraindication ; o OR: Medication not done: influenza immunization declined ; o OR: Medication not done: influenza vaccine for patient reason ; o OR: Medication not done: influenza vaccine for medical reason ; o OR: Medication not done: influenza vaccine for system reason ; Summary Calculation Calculation is generic to all measures: Calculate the final denominator by adding all that meet denominator criteria. Page 31

32 Subtract from the final denominator all that do not meet numerator criteria yet also meet exclusion criteria. Note some measures do not have exclusion criteria. The performance calculation is the number meeting numerator criteria divided by the final denominator. For measures with multiple patient populations, repeat this process for each patient population and report each result separately. For measures with multiple numerators, calculate each numerator separately within each population using the paired exclusion. Page 32

33 (NQF 0024) Weight Assessment and Counseling for Children and Adolescents EMeasure Name Weight Assessment and EMeasure Id Pending Counseling for Children and Adolescents Version Number 1 Set Id Pending Available Date No information Measurement Period January 1, 20xx through December 31, 20xx Measure Steward National Committee for Quality Assurance Endorsed by National Quality Forum Description The percentage of patients 2-17 years of age who had an outpatient visit with a PCP or OB/GYN and who had evidence of BMI percentile documentation, counseling for nutrition and counseling for physical activity during the measurement year. Measure scoring Proportion Measure type Process Rationale This measure assesses the percentage of age-appropriate patients who had an outpatient visit with a PCP or OB/GYN and who had evidence of a BMI percentile assessment, counseling for nutrition or counseling for physical activity. The prevalence of overweight and obesity has increased sharply for children over the last 30 years: from 5.0% to 13.9% for those aged 2 5 years; from 6.5% to 18.8% for those aged 6 11 years; and from 5.0% to 17.4% for those aged years. This increasing prevalence has had significant economic ramifications, with economic costs correlated to obesity and related comorbidities estimated at over $70 billion, or 7% of the national health care budget. To address this problem and its long-term implications effectively, promotion of routine physical activity and healthy eating and lifestyle changes are essential (CDC 2007). This measure is important in efforts to improve long-term health outcomes and quality of life. Clinical Recommendation Statement U.S. Preventive Services Task Force (USPSTF): I Recommendation. Insufficient evidence to recommend for or against screening for overweight in children and adolescents reflects the paucity of strong evidence of the effectiveness of interventions for this problem in the clinical setting. The American Academy of Pediatrics (AAP): The child s height, weight and percentiles for age should be determined at the start of the physical examination. Because obesity is strongly linked to hypertension, BMI should be calculated from the height and weight, and the BMI percentile should be calculated. Poor growth may indicate an underlying chronic illness. The American Medical Association (AMA), Health Resources and Services Administration (HRSA), and Centers for Disease Control and Prevention (CDC): The Expert Committee recommends that physicians and allied healthcare providers perform, at a minimum, a yearly assessment of weight status in all children, and that this assessment include calculation of height, weight (measured appropriately), and body mass index (BMI) for age and plotting of those measures on standard growth charts. The American Academy of Pediatrics and the American College of Clinical Endocrinology (ACCE): The AAP and the ACCE recommend and encourage pediatric providers to screen children for obesity using BMI; examine overweight children for obesity-related diseases; initiate weight management practices to improve diet and physical activity habits; and increase frequency of visits to reinforce behavior changes. The Centers for Disease Control and Prevention (CDC): The CDC recommends using the percentile BMI for age and gender as the most appropriate and easily available method to screen for childhood overweight or at risk for overweight. BMI is calculated by dividing the weight in kilograms by the height in meters squared. Age and gender norms for BMI are readily accessible. BMI correlates with adiposity and with complications of childhood overweight such as hypercholesterolemia, hypertension and later development of cardiovascular disease. Although more precise measures of lean body mass and body fat such as dual x- ray absorptiometry (DEXA) may be appropriate for clinical studies, BMI norms are Page 33

34 particularly helpful for screening in busy office practices and for population assessment. Reference Definitions U.S. Preventive Services Task Force (USPSTF). Screening and interventions for overweight in children and adolescents: recommendation statement. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); p. 11. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics Aug; 114(2 Suppl): AMA/HRSA/ CDC Expert Committee on the Assessment, Prevention and Treatment of Child and Adolescent Overweight and Obesity. Recommendations on the assessment, prevention and treatment of child and adolescent overweight and obesity. Chicago (IL): AMA Jun. 1. Dorsey, K.B., C. Wells, H.M. Krumholz, J.C. Concato. Diagnosis, evaluation, and treatment of childhood obesity in pediatric practice. Arch Pediatr Adolesc Med July; 159: Baker, S., S. Barlow, W. Cochran, G. Fuchs, W. Klish, N. Krebs, R. Strauss, A. Tershakovec, J. Udall. Overweight children and adolescents: a clinical report of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr May; 40(5): Denominator = o AND: Patient characteristic: birth date (age) >=2 and <=16 years to expect screening for patients within one year after reaching 2 years until 17 years; o AND: Encounter: encounter outpatient w/pcp or obgyn ; o AND NOT: Encounter: encounter pregnancy ; (as defined by the patient s most recent patient history record with the Are you pregnant or nursing? answer. Numerator 1 = o AND: Physical exam finding: BMI percentile ; Numerator 2 = o AND: Communication to patient: counseling for nutrition ; Numerator 3 = o AND: Communication to patient: counseling for physical activity ; Plan for all Numerators(CPT or HCPCS): (G0270, G0271, S9449, S9452, S9470, 97802, 97803, 97804) Exclusions = o AND: None; Page 34

35 Summary calculation Calculation is generic to all measures: Calculate the final denominator by adding all that meet denominator criteria. Subtract from the final denominator all that do not meet numerator criteria yet also meet exclusion criteria. Note some measures do not have exclusion criteria. The performance calculation is the number meeting numerator criteria divided by the final denominator. For measures with multiple patient populations, repeat this process for each patient population and report each result separately. For measures with multiple numerators, calculate each numerator separately within each population using the paired exclusion. Page 35

36 (NQF 0038) Childhood Immunization Status - Four DTaP EMeasure Name Childhood Immunization EMeasure Id Pending Status Version Number 1 Set Id Pending Available Date No information Measurement Period January 1, 20xx through December 31, 20xx Measure Steward National Committee for Quality Assurance Endorsed by National Quality Forum Description The percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV); one measles, mumps and rubella (MMR); two H influenza type B (HiB); three hepatitis B (Hep B), one chicken pox (VZV); four pneumococcal conjugate (PCV); two hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday. The measure calculates a rate for each vaccine and two separate combination rates. Measure scoring Proportion Measure type Process Rationale This measure monitors the appropriate and timely use of vaccines for children prior to their second birthday. Pediatric vaccines are responsible for preventing 10.5 million diseases per birth cohort in the U.S. and are a costeffective preventive measure. For every dollar spent on immunizations, as many as $29 can be saved in direct and indirect costs. With the development and use of vaccines, the prevalence of some infectious diseases has dramatically reduced; since the beginning of the 20th century, there has been a 99% decline in vaccine-preventable disease morbidity. Despite the established guidelines and well-known benefits of vaccination, however, in 2007, 22.5% of children months of age had not received the recommended immunizations. General clinical consensus notes that if immunization practices ceased, most infectious diseases currently prevented by vaccinations would reemerge as serious health threats. This measure facilitates efforts toward infectious disease prevention among a vulnerable subgroup of the population. Clinical Recommendation Current CDC/ACIP Guidelines recommend infants and toddlers receive the Statement Hepatitis B series, four DTaP vaccinations, four HiB vaccinations, three IPV vaccinations, one MMR vaccination, four pneumococcal conjugate vaccinations, and one varicella vaccination. Some combination products on the market include both the DTaP and HiB vaccines and should only be administered three times. In these cases, children receive three HiB vaccinations instead of the four mentioned above. The recommendation is to receive these vaccinations between birth and 18 months of age. The current HEDIS specifications allow a grace period by measuring compliance with these recommendations between birth and age two. CDC. General Recommendations on Immunization: Recommendations of the Reference Advisory Committee on Immunization Practices (ACIP). MMWR 2006; 55(RR15); Definitions Page 36

37 Denominator = o AND: Patient characteristic: birth date (age) >=1 year and <2 years to capture all patients who will reach 2 years during the measurement period ; o AND: Encounter: encounter outpatient w/pcp & obgyn ; Numerator 1= o AND: >= 4 count(s) of Medication administered: DTaP vaccine, different dates, occurring >=42 days and <2 years after Patient characteristic: birth date ; (Vaccine name = 'Diptheria, Tetanus, acellular Pertussis (DTaP)') AND NOT: OR: Medication allergy: DTaP vaccine ; (Alergy name = 'Diptheria, Tetanus, acellular Pertussis (DTaP)') OR: Diagnosis active: encephalopathy ; Diagnosis (CPT or HCPCS): (348.3) OR: Diagnosis active: progressive neurological disorder ; Numerator 2 = o AND: >=3 count(s) of Medication administered: IPV, different dates, occurring >=42 days and <2 years after Patient characteristic: birth date ; (Vaccine name with polio in name) AND NOT: OR: Medication allergy: IPV ; (Alergy name = IPV ) OR: Medication allergy: neomycin ; (Alergy name = neomycin ) OR:: Medication allergy: streptomycin ; (Alergy name = streptomycin ) OR: Medication allergy: polymyxin ; (Alergy name = polymyxin ) Numerator 3 = o AND: Medication administered: MMR >=1, occurring <2 years after the Patient characteristic: birth date ; (Vaccine Name with Measles Mumps Rubella in the name) OR: AND: >1 count(s) of Medication administered: mumps vaccine, occurring <2 years after Patient characteristic: birth date ; (Vaccine Name with mumps in the name) AND: > 1 count(s) of Medication administered: measles vaccine, occurring <2 years after Patient characteristic: birth date ; (Vaccine Name with measles in the name) AND: >1 count(s) of Medication administered: rubella vaccine, occurring <2 years after Patient characteristic: birth date ; (Vaccine Name with rubella in the name) OR: Diagnosis resolved: measles ; AND: >1 count(s) of Medication administered: mumps vaccine, occurring <2 years after Patient characteristic: birth date ; (Vaccine Name with mumps in the name) AND: >1 count(s) of Medication administered: rubella vaccine, occurring <2 years after Patient characteristic: birth date ; (Vaccine Name with rubella in the name) OR: Diagnosis resolved: mumps ; AND: >1 count(s) of Medication administered: measles vaccine, occurring <2 years after Patient characteristic: birth date ; (Vaccine Name with measles in the name) AND: >1 count(s) of Medication administered: rubella vaccine, occurring <2 years after Patient characteristic: birth date ; (Vaccine Name with rubella in the name) Page 37

38 Numerator 4 = Simply Podiatry PQRS Measures Summary OR: Diagnosis resolved: rubella ; AND: >1 count(s) of Medication administered: mumps vaccine, occurring <2 years after Patient characteristic: birth date ; (Vaccine Name with mumps in the name) AND: >1 count(s) of Medication administered: measles vaccine, occurring <2 years after Patient characteristic: birth date ; (Vaccine Name with measles in the name) AND NOT: OR: Diagnosis active: cancer of lymphoreticular or histiocytic tissue ; OR: Diagnosis inactive: cancer of lymphoreticular or histiocytic tissue ; OR: Diagnosis active: asymptomatic HIV ; OR: Diagnosis active: multiple myeloma ; OR: Diagnosis active: leukemia ; OR: Medication allergy: MMR ; OR: Diagnosis active: immunodeficiency ; o AND: >=2 count(s) of Medication administered: HiB, occurring >=42 days and <2 years after Patient characteristic: birth date ; AND NOT: Medication allergy: HiB ; Numerator 5 = o AND: OR: >=3 count(s) of Medication administered: hepatitis B vaccine, occurring < 2 years after Patient characteristic: birth date ; OR: Diagnosis resolved: hepatitis B diagnosis ; AND NOT: OR: Substance allergy: Baker s yeast ; OR: Medication allergy: hepatitis B vaccine ; Numerator 6 = o AND: >=1 count(s) of Medication administered: VZV, occurring < 2 years after Patient characteristic: birth date ; o OR: Diagnosis resolved: VZV ; AND NOT OR: Diagnosis active: cancer of lymphoreticular or histiocytic tissue ; OR: Diagnosis inactive: cancer of lymphoreticular or histiocytic tissue ; OR: Diagnosis active: asymptomatic HIV ; OR: Diagnosis active: multiple myeloma ; OR: Diagnosis active: leukemia ; OR: Medication allergy: VZV ; Page 38

39 OR: Diagnosis active: immunodeficiency ; Numerator 7 = o AND: >=4 count(s) of Medication administered: pneumococcal vaccine, occurring >=42 days and <2 years after Patient characteristic: birth date ; AND NOT: Medication allergy: pneumococcal vaccination ; Numerator 8 = o AND: >=2 count(s) of Medication administered: hepatitis A vaccine, occurring <2 years after Patient characteristic: birth date ; o OR: Diagnosis resolved: hepatitis A diagnosis ; o AND NOT: Medication allergy: hepatitis A vaccine ; Numerator 9 = o AND: >=2 count(s) of Medication administered: rotavirus vaccine, occurring >=42 days and <2 years after Patient characteristic: birth date ; AND NOT: Medication allergy: rotavirus vaccine ; Numerator 10 = o AND: >=2 count(s) of Medication administered: influenza vaccine, occurring >=180 days and <2 years after Patient characteristic: birth date ; AND NOT: OR: Diagnosis active: cancer of lymphoreticular or histiocytic tissue ; OR: Diagnosis inactive: cancer of lymphoreticular or histiocytic tissue ; OR: Diagnosis active: asymptomatic HIV ; OR: Diagnosis active: multiple myeloma ; OR: Diagnosis active: leukemia ; OR: Medication allergy: influenza vaccine ; OR: Diagnosis active: immunodeficiency ; Numerator 11 = o AND: >= 4 count(s) of Medication administered: DTaP vaccine, different dates, occurring >=42 days and <2 years after Patient characteristic: birth date ; AND NOT: OR: Medication allergy: DTaP vaccine ; OR: Diagnosis active: encephalopathy ; OR: Diagnosis active: progressive neurological disorder ; o AND: >=3 count(s) of Medication administered: IPV, different dates, occurring >=42 days and <2 years after Patient characteristic: birth date ; AND NOT: Page 39

40 OR: Medication allergy: IPV ; OR: Medication allergy: neomycin ; OR:: Medication allergy: streptomycin ; o AND: Medication administered: MMR >=1, occurring <2 years after the Patient characteristic: birth date ; OR: AND: >1 count(s) of Medication administered: mumps vaccine, occurring <2 years after Patient characteristic: birth date ; AND NOT: Medication allergy: mumps vaccine ; AND: > 1 count(s) of Medication administered: measles vaccine, occurring <2 years after Patient characteristic: birth date ; AND NOT: Medication allergy: measles vaccine ; AND: >1 count(s) of Medication administered: rubella vaccine, occurring <2 years after Patient characteristic: birth date ; AND NOT: Medication allergy: rubella vaccine ; OR: Diagnosis resolved: measles ; AND: >1 count(s) of Medication administered: mumps vaccine, occurring <2 years after Patient characteristic: birth date ; AND NOT: Medication allergy: mumps vaccine ; AND: >1 count(s) of Medication administered: rubella vaccine, occurring <2 years after Patient characteristic: birth date ; AND NOT: Medication allergy: rubella vaccine ; OR: Diagnosis resolved: mumps ; AND: >1 count(s) of Medication administered: measles vaccine, occurring <2 years after Patient characteristic: birth date ; AND NOT: Medication allergy: measles vaccine ; AND: >1 count(s) of Medication administered: rubella vaccine, occurring <2 years after Patient characteristic: birth date ; AND NOT: Medication allergy: rubella vaccine ; OR: Diagnosis resolved: rubella ; AND: >1 count(s) of Medication administered: mumps vaccine, occurring <2 years after Patient characteristic: birth date ; AND NOT: Medication allergy: mumps vaccine ; AND: >1 count(s) of Medication administered: measles vaccine, occurring <2 years after Patient characteristic: birth date ; AND NOT: Medication allergy: measles vaccine ; AND NOT: OR: Diagnosis active: cancer of lymphoreticular or histiocytic tissue ; OR: Diagnosis inactive: cancer of lymphoreticular or histiocytic tissue ; OR: Diagnosis active: asymptomatic HIV ; OR: Diagnosis active: multiple myeloma ; OR: Diagnosis active: leukemia ; OR: Medication allergy: MMR ; OR: Diagnosis active: immunodeficiency ; Page 40

41 OR: Medication allergy: polymyxin ; date ; o AND: >=1 count(s) of Medication administered: VZV, occurring < 2 years after Patient characteristic: birth o OR: Diagnosis resolved: VZV ; AND NOT OR: Diagnosis active: cancer of lymphoreticular or histiocytic tissue ; OR: Diagnosis inactive: cancer of lymphoreticular or histiocytic tissue ; OR: Diagnosis active: asymptomatic HIV ; OR: Diagnosis active: multiple myeloma ; OR: Diagnosis active: leukemia ; OR: Medication allergy: VZV ; OR: Diagnosis active: immunodeficiency ; o AND: OR: >=3 count(s) of Medication administered: hepatitis B vaccine, occurring < 2 years after Patient characteristic: birth date ; OR: Diagnosis active: hepatitis B diagnosis ; OR: Diagnosis resolved: hepatitis B diagnosis ; AND NOT: OR: Substance allergy: Baker s yeast ; OR: Medication allergy: hepatitis B vaccine ; Numerator 12 = o AND: >= 4 count(s) of Medication administered: DTaP vaccine, different dates, occurring >=42 days and <2 years after Patient characteristic: birth date ; AND NOT: OR: Medication allergy: DTaP vaccine ; OR: Diagnosis active: encephalopathy ; OR: Diagnosis active: progressive neurological disorder ; o AND: >=3 count(s) of Medication administered: IPV, different dates, occurring >=42 days and <2 years after Patient characteristic: birth date ; AND NOT: OR: Medication allergy: IPV ; OR: Medication allergy: neomycin ; OR:: Medication allergy: streptomycin ; o AND: Medication administered: MMR >=1, occurring <2 years after the Patient characteristic: birth date ; OR: AND: >1 count(s) of Medication administered: mumps vaccine, occurring <2 years after Patient characteristic: birth date ; AND NOT: Medication allergy: mumps vaccine ; Page 41

42 AND: > 1 count(s) of Medication administered: measles vaccine, occurring <2 years after Patient characteristic: birth date ; AND NOT: Medication allergy: measles vaccine ; AND: >1 count(s) of Medication administered: rubella vaccine, occurring <2 years after Patient characteristic: birth date ; AND NOT: Medication allergy: rubella vaccine ; OR: Diagnosis resolved: measles ; AND: >1 count(s) of Medication administered: mumps vaccine, occurring <2 years after Patient characteristic: birth date ; AND NOT: Medication allergy: mumps vaccine ; AND: >1 count(s) of Medication administered: rubella vaccine, occurring <2 years after Patient characteristic: birth date ; AND NOT: Medication allergy: rubella vaccine ; OR: Diagnosis resolved: mumps ; AND: >1 count(s) of Medication administered: measles vaccine, occurring <2 years after Patient characteristic: birth date ; AND NOT: Medication allergy: measles vaccine ; AND: >1 count(s) of Medication administered: rubella vaccine, occurring <2 years after Patient characteristic: birth date ; AND NOT: Medication allergy: rubella vaccine ; OR: Diagnosis resolved: rubella ; AND: >1 count(s) of Medication administered: mumps vaccine, occurring <2 years after Patient characteristic: birth date ; AND NOT: Medication allergy: mumps vaccine ; AND: >1 count(s) of Medication administered: measles vaccine, occurring <2 years after Patient characteristic: birth date ; AND NOT: Medication allergy: measles vaccine ; AND NOT: OR: Diagnosis active: cancer of lymphoreticular or histiocytic tissue ; OR: Diagnosis inactive: cancer of lymphoreticular or histiocytic tissue ; OR: Diagnosis active: asymptomatic HIV ; OR: Diagnosis active: multiple myeloma ; OR: Diagnosis active: leukemia ; OR: Medication allergy: MMR ; OR: Diagnosis active: immunodeficiency ; OR: Medication allergy: polymyxin ; date ; o AND: >=1 count(s) of Medication administered: VZV, occurring < 2 years after Patient characteristic: birth o OR: Diagnosis resolved: VZV ; AND NOT OR: Diagnosis active: cancer of lymphoreticular or histiocytic tissue ; OR: Diagnosis inactive: cancer of lymphoreticular or histiocytic tissue ; Page 42

43 OR: Diagnosis active: asymptomatic HIV ; OR: Diagnosis active: multiple myeloma ; OR: Diagnosis active: leukemia ; OR: Medication allergy: VZV ; OR: Diagnosis active: immunodeficiency ; o AND: OR: >=3 count(s) of Medication administered: hepatitis B vaccine, occurring < 2 years after Patient characteristic: birth date ; OR: Diagnosis resolved: hepatitis B diagnosis ; AND NOT: OR: Substance allergy: Baker s yeast ; OR: Medication allergy: hepatitis B vaccine ; o AND: >=4 count(s) of Medication administered: pneumococcal vaccine, occurring >=42 days and <2 years after Patient characteristic: birth date ; AND NOT: Medication allergy: pneumococcal vaccination ; Page 43