Occupational Therapy Reporting Individual Measures

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Solomon Simpson
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1 Cheat Sheet Occupational Therapy Reporting Individual Measures This cheat sheet is designed to help you report the most possible G-code and CPT code by the PQRS measure.

2 Measure #126 - Diabetes - Neurological Evaluation CPT Codes: 97001, 97002, 97597, 97598; Frequency: minimum once per reporting period Did you perform a lower extremity neurological exam? G8404 Exam performed G8405 Exam not performed G8406

per reporting period Did you perform a lower extremity

3 Measure #127 - Diabetes - Footwear Evaluation CPT Codes: 97001, 97002, 97597, 97598; Frequency: minimum once per reporting period Did you perform a footwear evaluation? G8410 Exam performed and documented G8415 Exam not performed G8416

reporting period Did you perform a footwear evaluation?

4 Measure #128 - Body Mass Index (BMI) and Follow Up CPT Codes: 97001, 97003; Frequency: minimum once per reporting period Did you perform a BMI assessment? G8422 G8421 BMI was not calculated at visit Was the patient s BMI normal* (between )? Was a follow-up plan created for the patient? Was the BMI higher than 25? G8420 BMI calculated as normal and documented in EMR *rmal BMI for age 65+ is 23 and <30; Age is 18.5 and <25 G8419 BMI calculated outside of normal parameter, no follow-up G8938 BMI calculated, but patient is not eligible for follow-up G8417 Calculated a higher BMI, a follow-up plan was documented in EMR G8418 Calculated a lower BMI, a follow-up plan was documented in EMR

G8420 BMI calculated as normal and documented in EMR *rmal BMI for age 65+ is 23 and <30; Age 18-64 is 18.

5 Measure #130 - Medications CPT Codes: 97001, 97002, 97003, 97004; Frequency: each visit Did you document the patient s current medications? G8430 G8427 Documented patient s medications, including drug name, dosage, frequency and route. G8428 Reason not given

6 Measure #131 - Pain Assessment and Follow Up CPT Codes: 97001, 97003; Frequency: each visit Did you complete a pain assessment? G8442 G8732 Reason not given Does the patient have pain? G8731 Pain is negative, no follow up required Was a follow-up documented? G8509 Pain is positive, no documentation of follow-up, reason not G8939 Pain assessment documented, follow-up plan not documented, patient is not eligible G8730 Pain is positive, a follow-up plan was documented in EMR

G8731 Pain is negative, no follow up required Was a follow-up documented?

7 Measure #154 - Falls - Risk Assessment CPT Codes: 97001, 97002, 97003, 97004; Frequency: minimum once per reporting period Does the patient have more than 2 falls or any falls within the injury period in the last year? 1100F Patient screened for future falls, documented RECD & CONTINUE 1101F but screened for future falls 1101F - 8P, no documented falls with modifier 8P (not performed, reason not specified) Was a fall assessment completed? 3288F - 8P Fall documented with modifier 8P (not performed, reason not specifie); MAY CONTINUE WITH FALLS - PLAN OF CARE 3288F - 1P Fall documented with modiefier 1P (not performed due to medical reason) 3288F Fall documented; MAY CONTINUE WITH FALLS - PLAN OF CARE

1100F Patient screened for future falls, documented RECD & CONTINUE 1101F but screened for future falls 1101F - 8P, no documented falls with modifier 8P (not performed, reason

8 Measure #155 - Falls - Plan of Care CPT Codes: 97001, 97002, 97003, 97004; Frequency: minimum once per reporting period Did you complete a plan of care for the patient? 0518F Plan of care is documented in EMR 0518F - 8P Plan of care is not documented with modifier 8P (not performed, reason not specified 0518F - 1P Plan of care is not documented with modifier 1P (not performed due to medical reason)

0518F Plan of care is documented in EMR 0518F - 8P Plan of care is not documented with modifier 8P

9 Measure #173 - Unhealthy Alcohol Use - Screening CPT Codes: 97003, 97004; Frequency: minimum once per reporting period Did you screen the patient for unhealthy alcohol use? 3016F Patient was screened for unhealthy alcohol use 3016F - 8P Screening was not performed with modifier 8P (not performed, reason not 3016F - 1P Screening was not performed with modifier 1P (not performed due to medical reason)

3016F Patient was screened for unhealthy alcohol use 3016F - 8P Screening was not performed with

10 Measure #181 - Elder Maltreatment Screen and Follow Up Plan CPT Codes: 97003; Frequency: minimum once per reporting period For patient s aged 65 and older: Was the patient screened for elderly maltreatment? G8535 Patient not eligible G8536 Reason not given Was it positive for elder maltreatment? G8734F Screen documented as negative, no follow-up required Was a follow-up plan documented? G8735 Screen documented as positive, follow-up plan not documented, G8941 Screen documented, patient not eligible for follow-up G8733 Screen documented as positive and documented follow-up plan

G8535 Patient not eligible G8536 Reason not given Was it positive for elder maltreatment?

11 Measure #226 - Tobacco Use - Screening and Cessation Intervention CPT Codes: 97003, 97004; Frequency: minimum once per reporting period Was the patient screened for tobacco use? 4004F- 8P Tobacco screening not performed with modifier 8P (not performed, reason no specified) 4004F- 1P Tobacco screening not performed with modifier1p (not performed due to medical reason) as a tobacco user? 1036F Patient screen for tobacco use and identified as a non-user 4004F Patient screened for tobacco use and received tobacco cessation intervention (counseling, pharmacotherpay, or both), if identified as a tobacco user

4004F- 8P Tobacco screening not performed with modifier 8P (not performed, reason no specified) 4004F- 1P Tobacco screening not performed with

12 Cheat Sheet Physical Therapy Reporting Individual Measures This cheat sheet is designed to help you report the most possible G-code and CPT code by the PQRS measure.

13 Measure #126 - Diabetes - Neurological Evaluation CPT Codes: 97001, 97002, 97597, 97598; Frequency: minimum once per reporting period Did you perform a lower extremity neurological exam? G8404 Exam performed G8405 Exam not performed G8406

14 Measure #127 - Diabetes - Footwear Evaluation CPT Codes: 97001, 97002, 97597, 97598; Frequency: minimum once per reporting period Did you perform a footwear evaluation? G8415 Exam not performed G8416 G8410 Exam performed and documented

15 Measure #128 - Body Mass Index (BMI) and Follow Up CPT Codes: 97001, 97003; Frequency: minimum once per reporting period Did you perform a BMI assessment? G8422 G8421 BMI was not calculated at visit Was the patient s BMI normal* (between )? Was a follow-up plan created for the patient? Was the BMI higher than 25? G8420 BMI calculated as normal and documented in EMR *rmal BMI for age 65+ is 23 and <30; Age is 18.5 and <25 G8419 BMI calculated outside of normal parameter, no follow-up G8938 BMI calculated, but patient is not eligible for follow-up G8417 Calculated a higher BMI, a follow-up plan was documented in EMR G8418 Calculated a lower BMI, a follow-up plan was documented in EMR

16 Measure #130 - Medications CPT Codes: 97001, 97002, 97003, 97004; Frequency: each visit Did you document the patient s current medications? G8430 G8427 Documented patient s medications, including drug name, dosage, frequency and route. G8428 Reason not given

17 Measure #131 - Pain Assessment and Follow Up CPT Codes: 97001, 97003; Frequency: each visit Did you complete a pain assessment? G8442 G8732 Reason not given Does the patient have pain? G8731 Pain is negative, no follow up required Was a follow-up documented? G8509 Pain is positive, no documentation of follow-up, reason not G8939 Pain assessment documented, follow-up plan not documented, patient is not eligible G8730 Pain is positive, a follow-up plan was documented in EMR

18 Measure #154 - Falls - Risk Assessment CPT Codes: 97001, 97002, 97003, 97004; Frequency: minimum once per reporting period Does the patient have more than 2 falls or any falls within the injury period in the last year? 1100F Patient screened for future falls, documented RECD & CONTINUE 1101F but screened for future falls 1101F - 8P, no documented falls with modifier 8P (not performed, reason not specified) Was a fall assessment completed? 3288F - 8P Fall documented with modifier 8P (not performed, reason not specifie); MAY CONTINUE WITH FALLS - PLAN OF CARE 3288F - 1P Fall documented with modiefier 1P (not performed due to medical reason) 3288F Fall documented; MAY CONTINUE WITH FALLS - PLAN OF CARE

19 Measure #155 - Falls - Plan of Care CPT Codes: 97001, 97002, 97003, 97004; Frequency: minimum once per reporting period Did you complete a plan of care for the patient? 0518F Plan of care is documented in EMR 0518F - 8P Plan of care is not documented with modifier 8P (not performed, reason not specified 0518F - 1P Plan of care is not documented with modifier 1P (not performed due to medical reason)

20 Measure #182 - Functional Outcome Assessment CPT Codes: 97001, 97002; Frequency: each visit Did you complete a functional outcome asssessment? G8540 G8541 Reason not given Were there any G8542 DOCUMENT DEFICIENCIES Was a plan of care created? G8543 Documented assessment, but no documentation of plan of G8539 Documented assessment and the plan of care based on the G8942 Documented assessment and the plan of care within previous 30 days

G8540 G8541 Reason not given Were there any G8542 DOCUMENT DEFICIENCIES Was a plan of care created?

PQRS Cheat Sheet. Occupational Therapy Reporting- Individual Measures

PQRS Cheat Sheet. Occupational Therapy Reporting- Individual Measures PQRS Cheat Sheet Occupational Therapy Reporting- Individual Measures Medicare requires that practitioners meet certain quality reporting thresholds and collect enough data to assess trends and performance.