Part 3 of 4 - Local Health Department Specifications
DRAFT DSRIP Category C
Measure Specifications: DY7-8
Part 3 of 4 - Local Health Department Specifications
Contents
Measure Page #
L1-103: Controlling High Blood Pressure
L1-105: Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention
L1-107: Colorectal Cancer Screening
L1-108: Childhood Immunization Status (CIS)
L1-115: Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%)
L1-147: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up
L1-160: Follow-Up After Hospitalization for Mental Illness
L1-186: Breast Cancer Screening
L1-205: Third next available appointment
L1-207: Diabetes care: BP control (<140/90mm Hg)
L1-210: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
L1-211: Weight Assessment and Counseling for Nutrition and Physical Activity for Children/ Adolescents
L1-224: Dental Sealant: Children
L1-225: Dental Caries: Children
L1-227: Dental Caries: Adults
L1-231: Preventive Services for Children at Elevated Caries Risk of Carries
L1-235: Post-Partum Follow-Up and Care Coordination
L1-237: Well-Child Visits in the First 15 Months of Life (6 or more visits)
L1-241: Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons
L1-242: Reduce Emergency Department visits for Chronic Ambulatory Care Sensitive Conditions (ACSC)
L1-268: Pneumonia vaccination status for older adults
L1-269: Preventive Care and Screening: Influenza Immunization
L1-271: Immunization for Adolescents
L1-272: Adults (18+ years) Immunization status
L1-280: Chlamydia Screening in Women (CHL)
L1-343: Syphilis positive screening rates
L1-344: Follow-up after Treatment for Primary or Secondary Syphilis
L1-345: Gonorrhea Positive Screening Rates
L1-346: Follow-up testing for N. gonorrhoeae among recently infected men and women
L1-347: Latent Tuberculosis Infection (LTBI) treatment rate
L1-387: Reduce Emergency Department visits for Behavioral Health and Substance Abuse (Reported as two rates)
L1-400: Tobacco Use and Help with Quitting Among Adolescents
L1-103: Controlling High Blood Pressure
Updated
Measure Description:
The percentage of patients 18 to 85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90) during the measurement year.
L1-103: Controlling High Blood PressureDY7/DY8 Program ID / 103
NQF Number / 0018
Measure Steward / NCQA
Measure Source / CMS MIPS #236 (Claims/Registry)
eMeasure: https://ecqi.healthit.gov/ecqm/measures/CMS165v6
DSRIP Specified Setting / Primary Care, Outpatient Specialty Care (to be specified by provider)
Measure Classification / Clinical Outcome
Measure Parts / 1
Unit of Measurement / Individuals
Payer Type Instructions / None
Benchmark Description / National Quality Compass 2016 - All LOBs: Average (90th and 25th percentiles)
HPL: 0.7041
MPL: 0.4687
Notes / Measure is not eligible for a shortened baseline measurement period.
Denominator Description
Patients 18-85 years of age who had a diagnosis of essential hypertension within the first six months of the measurement period or any time prior to the measurement period
Denominator Inclusions
CLAIMS/REGISTRY:
Patients18 to 85 years of age on date of encounter
AND
Diagnosis for hypertension (ICD-10-CM): I10
AND
Patient encounter during performance period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205,
99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0402, G0438, G0439
E.H.R.:
AND: Age>= 18 year(s) at: "Measurement Period"
AND: Age< 85 year(s) at: "Measurement Period"
AND: "Occurrence A of Diagnosis: Essential Hypertension" satisfies any:
< 6 month(s) starts after or concurrent with start of "Measurement Period"
satisfies all:
starts before start of "Measurement Period"
overlaps "Measurement Period"
AND: Union of:
"Encounter, Performed: Office Visit"
"Encounter, Performed: Face-to-Face Interaction"
"Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up"
"Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up"
"Encounter, Performed: Home Healthcare Services"
"Encounter, Performed: Annual Wellness Visit"
during "Measurement Period"
Denominator Exclusions
CLAIMS/REGISTRY:
Hospice services given to patient any time during the measurement period: G9740
OR
Documentation of end stage renal disease (ESRD), dialysis, renal transplant before or during the measurement period or pregnancy during the measurement period: G9231
E.H.R.:
OR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Home for Hospice Care)" ends during "Measurement Period"
OR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Health Care Facility for Hospice Care)" ends during "Measurement Period"
OR: Union of:
"Intervention, Order: Hospice care ambulatory"
"Intervention, Performed: Hospice care ambulatory"
overlaps "Measurement Period"
OR: Union of:
"Diagnosis: Pregnancy"
"Diagnosis: End Stage Renal Disease"
"Diagnosis: Chronic Kidney Disease, Stage 5"
overlaps "Measurement Period"
OR: Union of:
"Procedure, Performed: Vascular Access for Dialysis"
"Encounter, Performed: ESRD Monthly Outpatient Services"
"Procedure, Performed: Kidney Transplant"
"Procedure, Performed: Dialysis Services"
starts before end of "Measurement Period"
Numerator Description
Patients whose blood pressure at the most recent visit is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement period
Numerator Instructions: To describe both systolic and diastolic blood pressure values, each must be reported separately. If there are multiple blood pressures on the same date of service, use the lowest systolic and lowest diastolic blood pressure on that date as the representative blood pressure.
NUMERATOR NOTE: In reference to the numerator element, only blood pressure readings performed by an eligible clinician in the provider office are acceptable for numerator compliance with this measure. Blood pressure readings from the patient's home (including readings directly from monitoring devices) are not acceptable.
If no blood pressure is recorded during the measurement period, the patient's blood pressure is assumed "not controlled."
If there are multiple blood pressure readings on the same day, use the lowest systolic and the lowest diastolic reading as the most recent blood pressure reading.
Numerator Inclusions (Performance Met)
CLAIMS/REGISTRY:
Most recent systolic blood pressure < 140 mmHg (G8752)
AND
Most recent diastolic blood pressure < 90 mmHg (G8754)
E.H.R.:
AND: Most Recent:
"Occurrence A of Encounter, Performed: Adult Outpatient Visit" satisfies all:
during "Measurement Period"
overlaps "Physical Exam, Performed: Diastolic Blood Pressure (result)"
overlaps "Physical Exam, Performed: Systolic Blood Pressure (result)"
overlaps "Occurrence A of Diagnosis: Essential Hypertension"
AND: "Occurrence A of Diagnosis: Essential Hypertension" satisfies all:
starts before start of "Occurrence A of Encounter, Performed: Adult Outpatient Visit"
overlaps "Occurrence A of Encounter, Performed: Adult Outpatient Visit"
AND: "Physical Exam, Performed: Diastolic Blood Pressure" satisfies all:
Most Recent: during "Occurrence A of Encounter, Performed: Adult Outpatient Visit"
(result < 90 mmHg)
AND: "Physical Exam, Performed: Systolic Blood Pressure" satisfies all:
Most Recent: during "Occurrence A of Encounter, Performed: Adult Outpatient Visit"
(result < 140 mmHg)
Numerator Exclusions (Performance Not Met)
CLAIMS/REGISTRY:
Most recent systolic blood pressure ≥ 140 mmHg (G8753)
OR
Most recent diastolic blood pressure ≥ 90 mmHg (G8755)
OR
No documentation of blood pressure measurement, reason not given (G8756)
E.H.R.:
None
DSRIP Specific Modifications
Additional Information
Data Criteria (QDM Data Elements):
• "Diagnosis: Chronic Kidney Disease, Stage 5" using "Chronic Kidney Disease, Stage 5 Grouping Value Set (2.16.840.1.113883.3.526.3.1002)"
• "Diagnosis: End Stage Renal Disease" using "End Stage Renal Disease Grouping Value Set (2.16.840.1.113883.3.526.3.353)"
• "Diagnosis: Essential Hypertension" using "Essential Hypertension Grouping Value Set (2.16.840.1.113883.3.464.1003.104.12.1011)"
• "Diagnosis: Pregnancy" using "Pregnancy Grouping Value Set (2.16.840.1.113883.3.526.3.378)"
• "Encounter, Performed: Adult Outpatient Visit" using "Adult Outpatient Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1065)"
• "Encounter, Performed: Annual Wellness Visit" using "Annual Wellness Visit Grouping Value Set (2.16.840.1.113883.3.526.3.1240)"
• "Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient SNOMEDCT Value Set (2.16.840.1.113883.3.666.5.307)"
• "Encounter, Performed: ESRD Monthly Outpatient Services" using "ESRD Monthly Outpatient Services Grouping Value Set (2.16.840.1.113883.3.464.1003.109.12.1014)"
• "Encounter, Performed: Face-to-Face Interaction" using "Face-to-Face Interaction Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1048)"
• "Encounter, Performed: Home Healthcare Services" using "Home Healthcare Services Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1016)"
• "Encounter, Performed: Office Visit" using "Office Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1001)"
• "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" using "Preventive Care Services - Established Office Visit, 18 and Up Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1025)"
• "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" using "Preventive Care Services-Initial Office Visit, 18 and Up Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1023)"
• "Intervention, Order: Hospice care ambulatory" using "Hospice care ambulatory SNOMEDCT Value Set (2.16.840.1.113762.1.4.1108.15)"
• "Intervention, Performed: Hospice care ambulatory" using "Hospice care ambulatory SNOMEDCT Value Set (2.16.840.1.113762.1.4.1108.15)"
• "Physical Exam, Performed: Diastolic Blood Pressure" using "Diastolic Blood Pressure Grouping Value Set (2.16.840.1.113883.3.526.3.1033)"
• "Physical Exam, Performed: Systolic Blood Pressure" using "Systolic Blood Pressure Grouping Value Set (2.16.840.1.113883.3.526.3.1032)"
• "Procedure, Performed: Dialysis Services" using "Dialysis Services Grouping Value Set (2.16.840.1.113883.3.464.1003.109.12.1013)"
• "Procedure, Performed: Kidney Transplant" using "Kidney Transplant Grouping Value Set (2.16.840.1.113883.3.464.1003.109.12.1012)"
• "Procedure, Performed: Vascular Access for Dialysis" using "Vascular Access for Dialysis Grouping Value Set (2.16.840.1.113883.3.464.1003.109.12.1011)"
• Attribute: "Discharge status: Discharged to Health Care Facility for Hospice Care" using "Discharged to Health Care Facility for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.207)"
• Attribute: "Discharge status: Discharged to Home for Hospice Care" using "Discharged to Home for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.209)"
Measure Alignment: CMS Alignment: Adult Core Set; CMS Consensus Core Set: ACO and PCMH / Primary Care Measures; CMS Consensus Core Set: Cardiovascular Measures; MACRA MIPS Measure; Proposed 2018 MCO P4Q Measure.
DRAFT Category C Measure Specifications 09/296/2017 v2
Part 3 of 4 - Local Health Department Specifications 1
L1-105: Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention
Updated
Measure Description:
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user
L1-105: Preventive Care & Screening: Tobacco Use: Screening & Cessation InterventionDY7/DY8 Program ID / 105
NQF Number / 0028
Measure Steward / NCQA
Measure Source / CMS MIPS #226 (Claims/Registry)
eMeasure: https://ecqi.healthit.gov/ecqm/measures/CMS138v6
DSRIP Specified Setting / Behavioral Health: Outpatient, Primary Care, Outpatient Specialty Care (to be specified by provider), other
Measure Classification / Process
Measure Parts / 1
Unit of Measurement / Individuals
Payer Type Instructions / None
Benchmark Description / NA
HPL: NA
MPL: NA
Notes
Denominator Description
All patients aged 18 years and older
DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the PFS (Physician Fee Schedule). These non-covered services will not be counted in the denominator population for claims-based measures.
Denominator Inclusions
CLAIMS/REGISTRY:
Patients aged ≥ 18 years on date of encounter
AND
Patient encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90845, 92002, 92004, 92012, 92014, 92521, 92522, 92523, 92524, 92540, 92557, 92625, 96150, 96151, 96152, 96160, 96161 97165, 97166, 97167, 97168, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99406, 99407, 99411*, 99412*, 99429*, G0438, G0439
WITHOUT
Telehealth Modifier: GQ, GT
E.H.R.:
Initial Population =
AND: Age>= 18 year(s) at: "Measurement Period"
AND:
OR: Count>= 2 : Union of:
"Encounter, Performed: Face-to-Face Interaction"
"Encounter, Performed: Health & Behavioral Assessment - Individual"
"Encounter, Performed: Health and Behavioral Assessment - Initial"
"Encounter, Performed: Health and Behavioral Assessment, Reassessment"
"Encounter, Performed: Home Healthcare Services"
"Encounter, Performed: Occupational Therapy Evaluation"
"Encounter, Performed: Office Visit"
"Encounter, Performed: Ophthalmological Services"
"Encounter, Performed: Psych Visit - Diagnostic Evaluation"
"Encounter, Performed: Psych Visit - Psychotherapy"
"Encounter, Performed: Psychoanalysis"
"Encounter, Performed: Speech and Hearing Evaluation"
during "Measurement Period"
OR: Count>= 1 : Union of:
"Encounter, Performed: Annual Wellness Visit"
"Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up"
"Encounter, Performed: Preventive Care Services - Group Counseling"
"Encounter, Performed: Preventive Care Services - Other"
"Encounter, Performed: Preventive Care Services-Individual Counseling"
"Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up"
during "Measurement Period"
Population Criteria 1:
Denominator =
AND: Initial Population
Population Criteria 2:
Denominator =
AND: Initial Population
AND: $TobaccoUseScreeningUser
Population Criteria 3:
Denominator =
AND: Initial Population
Denominator Exclusions
CLAIMS/REGISTRY:
Documentation of medical reason(s) for notscreening for tobacco use (eg, limited life expectancy, other medical reason) (4004F with 1P)
E.H.R.:
None
Numerator Description
Patients who were screened for tobacco use at least once within 24 months AND who received tobacco cessation intervention if identified as a tobacco user
Definitions: Tobacco Use – Includes any type of tobacco
Tobacco Cessation Intervention – Includes brief counseling (3 minutes or less), and/or pharmacotherapy
NUMERATOR NOTE: In the event that a patient is screened for tobacco use and identified as a user but did not receive tobacco cessation intervention or tobacco status is unknown report 4004F with8P.
This measure defines tobacco cessation counseling as lasting 3 minutes or less. Services typically provided under CPT codes 99406 and 99407 satisfy the requirement of tobacco cessation intervention, as these services provide tobacco cessation counseling for 3-10 minutes. If a patient received these types of services, report CPT II 4004F.
Numerator Inclusions (Performance Met)
CLAIMS/REGISTRY:
Patient screened for tobacco use AND received tobacco cessation intervention (counseling, pharmacotherapy, or both), if identified as a tobacco user (4004F)
OR
Current tobacco non-user (1036F)
E.H.R.:
Population Criteria 1:
AND:
OR: $TobaccoUseScreeningNonUser
OR: $TobaccoUseScreeningUser
Population Criteria 2:
AND: Occurrence A of $TobaccoCessationIntervention starts after or concurrent with start of $TobaccoUseScreeningUser
AND: Occurrence A of $TobaccoCessationIntervention starts before end of "Measurement Period"
Population Criteria 3:
AND:
OR: $TobaccoUseScreeningNonUser
OR:
AND: Occurrence A of $TobaccoCessationIntervention starts after or concurrent with start of $TobaccoUseScreeningUser
AND: Occurrence A of $TobaccoCessationIntervention starts before end of "Measurement Period"
Numerator Exclusions (Performance Not Met)
CLAIMS/REGISTRY:
Tobacco screening OR tobacco cessation intervention not performed, reason not otherwise specified (4004F with 8P)
E.H.R.:
None
DSRIP Specific Modifications
Additional Information
Data Criteria (QDM Variables):
• $TobaccoCessationIntervention =
o Union of:
"Intervention, Performed: Tobacco Use Cessation Counseling"
"Medication, Active: Tobacco Use Cessation Pharmacotherapy"
"Medication, Order: Tobacco Use Cessation Pharmacotherapy"
• $TobaccoUseScreeningNonUser =
o "Assessment, Performed: Tobacco Use Screening" satisfies all:
Most Recent: <= 24 month(s) starts before end of "Measurement Period"
(result: Tobacco Non-User)
• $CounselingNotPerformed =
o "Intervention, Performed not done: Medical Reason" for "Tobacco Use Cessation Counseling" starts before end of "Measurement Period"
• $TobaccoUseScreeningUser =
o "Assessment, Performed: Tobacco Use Screening" satisfies all:
Most Recent: <= 24 month(s) starts before end of "Measurement Period"
(result: Tobacco User)
• $MedicationNotOrdered =
o "Medication, Order not done: Medical Reason" for "Tobacco Use Cessation Pharmacotherapy" starts before end of "Measurement Period"
Data Criteria (QDM Data Elements):
• "Assessment, Performed: Tobacco Use Screening" using "Tobacco Use Screening Grouping Value Set (2.16.840.1.113883.3.526.3.1278)"
• "Assessment, Performed not done: Medical Reason" using "Medical Reason Grouping Value Set (2.16.840.1.113883.3.526.3.1007)"
• "Diagnosis: Limited Life Expectancy" using "Limited Life Expectancy Grouping Value Set (2.16.840.1.113883.3.526.3.1259)"
• "Encounter, Performed: Annual Wellness Visit" using "Annual Wellness Visit Grouping Value Set (2.16.840.1.113883.3.526.3.1240)"
• "Encounter, Performed: Face-to-Face Interaction" using "Face-to-Face Interaction Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1048)"
• "Encounter, Performed: Health & Behavioral Assessment - Individual" using "Health & Behavioral Assessment - Individual Grouping Value Set (2.16.840.1.113883.3.526.3.1020)"
• "Encounter, Performed: Health and Behavioral Assessment - Initial" using "Health and Behavioral Assessment - Initial Grouping Value Set (2.16.840.1.113883.3.526.3.1245)"
• "Encounter, Performed: Health and Behavioral Assessment, Reassessment" using "Health and Behavioral Assessment, Reassessment Grouping Value Set (2.16.840.1.113883.3.526.3.1529)"
• "Encounter, Performed: Home Healthcare Services" using "Home Healthcare Services Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1016)"
• "Encounter, Performed: Occupational Therapy Evaluation" using "Occupational Therapy Evaluation Grouping Value Set (2.16.840.1.113883.3.526.3.1011)"
• "Encounter, Performed: Office Visit" using "Office Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1001)"
• "Encounter, Performed: Ophthalmological Services" using "Ophthalmological Services Grouping Value Set (2.16.840.1.113883.3.526.3.1285)"
• "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" using "Preventive Care Services - Established Office Visit, 18 and Up Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1025)"
• "Encounter, Performed: Preventive Care Services - Group Counseling" using "Preventive Care Services - Group Counseling Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1027)"
• "Encounter, Performed: Preventive Care Services - Other" using "Preventive Care Services - Other Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1030)"
• "Encounter, Performed: Preventive Care Services-Individual Counseling" using "Preventive Care Services-Individual Counseling Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1026)"
• "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" using "Preventive Care Services-Initial Office Visit, 18 and Up Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1023)"
• "Encounter, Performed: Psych Visit - Diagnostic Evaluation" using "Psych Visit - Diagnostic Evaluation Grouping Value Set (2.16.840.1.113883.3.526.3.1492)"
• "Encounter, Performed: Psych Visit - Psychotherapy" using "Psych Visit - Psychotherapy Grouping Value Set (2.16.840.1.113883.3.526.3.1496)"
• "Encounter, Performed: Psychoanalysis" using "Psychoanalysis Grouping Value Set (2.16.840.1.113883.3.526.3.1141)"
• "Encounter, Performed: Speech and Hearing Evaluation" using "Speech and Hearing Evaluation Grouping Value Set (2.16.840.1.113883.3.526.3.1530)"
• "Intervention, Performed: Tobacco Use Cessation Counseling" using "Tobacco Use Cessation Counseling Grouping Value Set (2.16.840.1.113883.3.526.3.509)"
• "Intervention, Performed not done: Medical Reason" using "Medical Reason Grouping Value Set (2.16.840.1.113883.3.526.3.1007)"
• "Medication, Active: Tobacco Use Cessation Pharmacotherapy" using "Tobacco Use Cessation Pharmacotherapy Grouping Value Set (2.16.840.1.113883.3.526.3.1190)"
• "Medication, Order: Tobacco Use Cessation Pharmacotherapy" using "Tobacco Use Cessation Pharmacotherapy Grouping Value Set (2.16.840.1.113883.3.526.3.1190)"
• "Medication, Order not done: Medical Reason" using "Medical Reason Grouping Value Set (2.16.840.1.113883.3.526.3.1007)"
• Attribute: "Result: Tobacco Non-User" using "Tobacco Non-User Grouping Value Set (2.16.840.1.113883.3.526.3.1189)"
• Attribute: "Result: Tobacco User" using "Tobacco User Grouping Value Set (2.16.840.1.113883.3.526.3.1170)"
Measure Alignment: CMS Alignment: CMS Consensus Core Set: ACO and PCMH / Primary Care Measures; CMS Consensus Core Set: Cardiovascular Measures; MACRA MIPS Measure; CCBHC Measure.
DRAFT Category C Measure Specifications 09/296/2017 v2
Part 3 of 4 - Local Health Department Specifications 1
L1-107: Colorectal Cancer Screening
Updated
Measure Description:
The percentage of patients 50–75 years of age who had appropriate screening for colorectal cancer.
L1-107: Colorectal Cancer ScreeningDY7/DY8 Program ID / 107
NQF Number / 0034
Measure Steward / NCQA
Measure Source / CMS MIPS #113 (Claims/Registry)
eMeasure: https://ecqi.healthit.gov/ecqm/measures/CMS130v6
DSRIP Specified Setting / Primary Care
Measure Classification / Cancer Screening
Measure Parts / 1
Unit of Measurement / Individuals
Payer Type Instructions / None
Benchmark Description / NA
HPL: NA
MPL: NA
Notes
Denominator Description
Patients 50-75 years of age with a visit during the measurement period
Denominator Inclusions
CLAIMS/REGISTRY:
Patients 50 to 75 years of age on date of encounter
AND
Patient encounter during the performance period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0402, G0438, G0439
E.H.R.:
AND: Age>= 50 year(s) at: "Measurement Period"
AND: Age< 75 year(s) at: "Measurement Period"
AND: Union of:
"Encounter, Performed: Office Visit"
"Encounter, Performed: Face-to-Face Interaction"
"Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up"
"Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up"
"Encounter, Performed: Home Healthcare Services"
"Encounter, Performed: Annual Wellness Visit"
during "Measurement Period"
Denominator Exclusions
CLAIMS/REGISTRY:
G9710: Patient was provided hospice services any time during the measurement period
OR
G9711: Patients with a diagnosis or past history of total colectomy or colorectal cancer
E.H.R.:
OR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Home for Hospice Care)" ends during "Measurement Period"
OR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Health Care Facility for Hospice Care)" ends during "Measurement Period"
OR: Union of:
"Intervention, Order: Hospice care ambulatory"
"Intervention, Performed: Hospice care ambulatory"
overlaps "Measurement Period"
OR: Union of:
"Diagnosis: Malignant Neoplasm of Colon"
"Procedure, Performed: Total Colectomy"
starts before end of "Measurement Period"
Numerator Description
Patients with one or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria:
• Fecal occult blood test (FOBT) during the measurement period
• Flexible sigmoidoscopy during the measurement period or the four years prior to the measurement period
• Colonoscopy during the measurement period or the nine years prior to the measurement period
• Computed tomography (CT) colonography during the measurement period or the four years prior to the measurement period
• Fecal immunochemical DNA test (FIT-DNA) during the measurement period or the two years prior to the measurement period
Numerator Inclusions (Performance Met)
CLAIMS/REGISTRY:
CPT II 3017F: Colorectal cancer screening results documented and reviewed
E.H.R.:
AND: Union of:
"Procedure, Performed: Colonoscopy" <= 9 year(s) ends before or concurrent with end of "Measurement Period"
"Laboratory Test, Performed: Fecal Occult Blood Test (FOBT) (result)" during "Measurement Period"
"Procedure, Performed: Flexible Sigmoidoscopy" <= 4 year(s) ends before or concurrent with end of "Measurement Period"
"Laboratory Test, Performed: FIT DNA (result)" <= 2 year(s) ends before or concurrent with end of "Measurement Period"
"Procedure, Performed: CT Colonography" <= 4 year(s) ends before or concurrent with end of "Measurement Period"
Numerator Exclusions (Performance Not Met)
CLAIMS/REGISTRY:
3017F with 8P: Colorectal cancer screening results were not documented and reviewed, reason not otherwise specified (Append a reporting modifier (8P) to CPT Category II code 3017F to report circumstances when the action described in the
DSRIP Specific Modifications
Additional Information
Data Criteria (QDM Data Elements):
• "Diagnosis: Malignant Neoplasm of Colon" using "Malignant Neoplasm of Colon Grouping Value Set (2.16.840.1.113883.3.464.1003.108.12.1001)"
• "Encounter, Performed: Annual Wellness Visit" using "Annual Wellness Visit Grouping Value Set (2.16.840.1.113883.3.526.3.1240)"
• "Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient SNOMEDCT Value Set (2.16.840.1.113883.3.666.5.307)"
• "Encounter, Performed: Face-to-Face Interaction" using "Face-to-Face Interaction Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1048)"
• "Encounter, Performed: Home Healthcare Services" using "Home Healthcare Services Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1016)"
• "Encounter, Performed: Office Visit" using "Office Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1001)"
• "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" using "Preventive Care Services - Established Office Visit, 18 and Up Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1025)"
• "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" using "Preventive Care Services-Initial Office Visit, 18 and Up Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1023)"
• "Intervention, Order: Hospice care ambulatory" using "Hospice care ambulatory SNOMEDCT Value Set (2.16.840.1.113762.1.4.1108.15)"
• "Intervention, Performed: Hospice care ambulatory" using "Hospice care ambulatory SNOMEDCT Value Set (2.16.840.1.113762.1.4.1108.15)"
• "Laboratory Test, Performed: Fecal Occult Blood Test (FOBT)" using "Fecal Occult Blood Test (FOBT) Grouping Value Set (2.16.840.1.113883.3.464.1003.198.12.1011)"
• "Laboratory Test, Performed: FIT DNA" using "FIT DNA Grouping Value Set (2.16.840.1.113883.3.464.1003.108.12.1039)"
• "Procedure, Performed: Colonoscopy" using "Colonoscopy Grouping Value Set (2.16.840.1.113883.3.464.1003.108.12.1020)"
• "Procedure, Performed: CT Colonography" using "CT Colonography Grouping Value Set (2.16.840.1.113883.3.464.1003.108.12.1038)"
• "Procedure, Performed: Flexible Sigmoidoscopy" using "Flexible Sigmoidoscopy Grouping Value Set (2.16.840.1.113883.3.464.1003.198.12.1010)"
• "Procedure, Performed: Total Colectomy" using "Total Colectomy Grouping Value Set (2.16.840.1.113883.3.464.1003.198.12.1019)"
• Attribute: "Discharge status: Discharged to Health Care Facility for Hospice Care" using "Discharged to Health Care Facility for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.207)"
• Attribute: "Discharge status: Discharged to Home for Hospice Care" using "Discharged to Home for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.209)"
Measure Alignment: CMS Alignment: CMS Consensus Core Set: ACO and PCMH / Primary Care Measures; MACRA MIPS Measure.