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Seizure Frequency for Patients with Epilepsy Measure Title Seizure Frequency for Patients with Epilepsy Description Percentage of all visits for patients with a diagnosis of epilepsy where seizure frequency of each seizure type was documented. Measurement January 1, 20xx to December 31, 20xx Period Eligible Eligible Providers Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant Population (PA), Advanced Practice Registered Nurse (APRN) Care Setting(s) Outpatient Ages All Event Office Visit Diagnosis Epilepsy Denominator All visits for patients with a diagnosis of epilepsy. Numerator Patient visits with current seizure frequency* documented for each seizure type.

*Current seizure frequency: A record of the exact number of seizures gathered from patient records, journal, or calendar OR the average or typical recent seizure frequency, often expressed as the average daily, weekly, or monthly seizure frequency since the last visit. Required None Exclusions Allowable  Caregiver is unavailable for a patient who is non-communicative or has an intellectual Exclusions disability.  Patient or caregiver declines to report seizure frequency. Exclusion For accuracy in reporting a patient or caregiver must be willing to provide data. Rationale Measure Percentage Scoring Interpretation Higher Score Indicates Better Quality of Score Measure Type Process Measure Quality improvement. This measure will not be submitted to accountability programs for their Purpose consideration. Level of Provider Measurement Risk Not Applicable Adjustment For Process The following clinical recommendation statements are quoted verbatim from the referenced Measures clinical guidelines and represent the evidence base for the measure: Relationship to  The seizure type(s) and epilepsy syndrome, aetiology, and co-morbidity should be Desired determined, because failure to classify the epilepsy syndrome correctly can lead to Outcome inappropriate treatment and persistence of seizures.(1)  When a patient with epilepsy receives follow-up care, then an estimate of the number of seizures since the last visit and assessment of drug side-effects should be documented. (Level D 1+/ Primary)2  If a patient is thought to have a diagnosis of epilepsy then the diagnosis should include a best estimation of seizure types. (Level C 2+/Secondary)(2) The main objective in treating epilepsy is to reduce the frequency of seizures and achieve seizure freedom without side effects. In order to determine whether a patient is seizure-free the seizure frequency must be known. Seizure freedom is associated with improvement in health-related quality of life.

Opportunity to Provider performance may improve as seizure frequency is not gathered effectively.(3-5) This Improve Gap in measure will help assess the gap and inform quality improvement efforts. For example, after Care implementation of an epilepsy quality measure checklist in an epilepsy clinic without any other intervention, documentation of compliance with this measure increased from 65% to 75%, illustrating that the measure has the intended consequence of increasing compliance.(6) Harmonization There are no known similar measures. with Existing Measures References 1. National Institute of Clinical Health and Excellence. The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care (update). 2012. Clinical guideline 137. Available at: http://www.nice.org.uk/nicemedia/live/13635/57779/57779.pdf Accessed on February 18, 2014. 2. Pugh MJ, Berlowitz DR, Montouris G, et al. What constitutes high quality of care for adults with epilepsy? Neurology 2007;69:2020-2027. 3. Fountain NB, Van Ness PC, Swain-Eng R, et al. Quality improvement in neurology: AAN epilepsy quality measures. Neurology 2011;76:94-99. 4. Wasade VS, Spanaki M, Iyengar R, et al. AAN Epilepsy Quality Measures in clinical practice: a survey of neurologists. Epilepsy Behav. 2012;24(4):468-473. 5. Wicks P, Fountain NB. Patient assessment of physician performance of epilepsy quality- of-care measures. NeurolClinPract 2012;2(4):335-342. 6. Cisneros-Franco JM, Díaz-Torres MA, Rodríguez-Castañeda JB, et al. Impact of the implementation of the AAN epilepsy quality measures on the medical records in a university hospital. BMC Neurology 2013;13:112. Available at: http://www.biomedcentral.com/1471-2377/13/112. Accessed on February 18, 2014.

Flow Chart Diagram: Seizure Frequency for Patients with Epilepsy

Did the patient have at least one new or established patient visit with an eligible provider during the measurement period? No

Yes

Did patient have a diagnosis of epilepsy on any contact during the current or prior No measurement period OR on their active Patient NOT problem list during the measurement Included in Data period? Submission

Yes

Patient INCLUDED in Eligible Population

Did the patient or caregiver decline to report seizure frequency? Yes No Patient NOT Included in Was a caregiver unavailable for a patient Denominator who is non‐communicative or who has an intellectual disability? Yes

Patient At every office visit, was patient’s current seizure INCLUDED in frequency documented for each seizure type? Denominator Yes No

Patient met Patient did numerator NOT meet criteria numerator criteria

40 ©2017. American Academy of Neurology Institute. All Rights Reserved. CPT Copyright 2004-2016 American Medical Association. Quality ID #290: Parkinson’s Disease: Psychiatric Symptoms Assessment for Patients with Parkinson’s Disease – National Quality Strategy Domain: Effective Clinical Care – Meaningful Measure Area: Prevention, Treatment, and Management of Mental Health

2021 COLLECTION TYPE: MIPS CLINICAL QUALITY MEASURES (CQMS)

MEASURE TYPE: Process

DESCRIPTION: Percentage of all patients with a diagnosis of Parkinson’s Disease [PD] who were assessed for psychiatric symptoms once in the past 12 months

INSTRUCTIONS: This measure is to be submitted a minimum of once per performance period for patients with a diagnosis of Parkinson’s Disease seen during the performance period. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

NOTE: Patient encounters for this measure conducted via telehealth (e.g., encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable.

Measure Submission Type: Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality-data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

DENOMINATOR: All patients with a diagnosis of Parkinson’s Disease

DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.

Denominator Criteria (Eligible Cases): All patients regardless of age AND Diagnosis for Parkinson’s disease (ICD-10-CM): G20 AND Patient encounter during the performance period (CPT): 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99241*, 99242*, 99243*, 99244*, 99245*, 99251*, 99252*, 99253*, 99254*, 99255*, 99304, 99305, 99306, 99307, 99308, 99309, 99310

NUMERATOR: Patients with a diagnosis of PD who were assessed for psychiatric symptoms once in the past 12 months

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 1 of 6 Definitions: Assessed – Is a verbal discussion. Please see “Opportunity for Improvement” section below for suggestions on possible screening tools.

Psychiatric Symptoms – Defined as: psychosis (i.e., hallucinations and delusions), depression, anxiety disorder, apathy, AND Impulse Control Disorder (i.e., gambling, hypersexual activity, binge eating, increased spending).

Numerator Instructions: Opportunity for Improvement

The following screening tools may be helpful for use in practice: For depression (8): Geriatric Depression scale Beck Depression Hamilton Depression scale For Anxiety (5): Beck Anxiety Inventory Hospital Anxiety and Depression Scale Self-rating Anxiety Scale Anxiety Status Inventory Strait Trait Anxiety Inventory Hamilton Anxiety Rating Scale For Psychosis (4): Parkinson psychosis rating scale Rush hallucination inventory Baylor hallucination questionnaire Neuropsychiatric inventory (NPI or NPI-Q) Brief psychiatric rating scale Positive and negative syndrome scale Schedule for assessment of positive symptoms Unified Parkinson disease rating scale Part I For Impulse Control Disorder (9): Questionnaire for Impulsive-Compulsive Disorders in Parkinson’s Disease-Rating Scale (QUIP-RS) Minnesota Impulsive Disorders Interview

NUMERATOR NOTE: The 12 month look back period is defined as 12 months from the date of the denominator eligible encounter. Numerator Options: Performance Met: Psychosis, depression, anxiety, apathy, AND impulse control disorder assessed (G2121) OR Performance Not Met: Psychosis, depression, anxiety, apathy, AND impulse control disorder not assessed (G2122)

RATIONALE: Psychiatric symptoms are often under diagnosed and under treated. Using appropriate measures will assure that psychiatric symptoms are properly diagnosed and treated so as to not interfere with functioning levels.

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 2 of 6 CLINICAL RECOMMENDATION STATEMENTS: • Clinicians should be aware of dopamine dysregulation syndrome, an uncommon disorder in which dopaminergic medication misuse is associated with abnormal behaviors, including hypersexuality, pathological gambling and stereotypic motor acts. This syndrome may be difficult to manage. (Level D) (1) • Clinicians should have a low threshold for diagnosing depression in PD. (Level D) (1) • All people with PD and psychosis should receive a general medical evaluation and treatment for any precipitating condition. (Level D) (1) • Patients should be warned about the potential for dopamine agonists to cause impulse control disorders and excessive daytime somnolence and be informed of the implications for driving/operating machinery. (Level A) (2) • Self-rating or clinician-rated scales may be used to screen for depression in patients with Parkinson’s Disease. (Level C) (2)

Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary coding sets should obtain all necessary licenses from the owners of these code sets. The AAN and its members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT®) or other coding contained in the specifications.

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 3 of 6 2021 Clinical Quality Measure Flow for Quality ID #290: Parkinson’s Disease: Psychiatric Symptoms Assessment for Patients with Parkinson's Disease

Disclaimer: Refer to the measure specification for specific coding and instructions to submit this measure.

Denominator Numerator Start

Data Completeness Met + Psychosis, depression, Performance Met anxiety, apathy, AND impulse Yes G2121 or equivalent control disorder (60 patients) assessed a All patients regardless of age

Data Completeness Met + Psychosis, depression, Performance Not Met anxiety, apathy, AND impulse Yes Diagnosis for G2122 or equivalent control disorder not No Parkinson’s disease as (10 patients) assessed c listed in Denominator*

No Yes

Data Completeness Not Met the Quality Data Code or equivalent was not submitted (10 patients) Patient encounter Not Included in Eligible No during the performance Population/Denominator period as listed in Denominator*

Yes

Include in Eligible Population/Denominator (80 patients) d

SAMPLE CALCULATIONS

Data Completeness= Performance Met (a=60 patients) + Performance Not Met (c=10 patients) = 70 patients = 87.50% Eligible Population / Denominator (d=80 patients) = 80 patients

Performance Rate= Performance Met (a=60 patients) = 60 patients = 85.71% Data Completeness Numerator (70 patients) = 70 patients

* See the posted measure specification for specific coding and instructions to submit this measure.

NOTE: Submission Frequency: Patient-Process CPT only copyright 2020 American Medical Association. All rights reserved. The measure diagrams were developed by CMS as a supplemental resource to be used in conjunction with the measure specifications. They should not be used alone or as a substitution for the measure specification. v5

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 4 of 6 2021 Clinical Quality Measure Flow Narrative for Quality ID #290: Parkinson’s Disease: Psychiatric Symptoms Assessment for Patients with Parkinson’s Disease Disclaimer: Refer to the measure specification for specific coding and instructions to submit this measure.

1. Start with Denominator

2. All patients regardless of age.

3. Check Diagnosis for Parkinson’s disease as listed in the Denominator*:

a. If Diagnosis for Parkinson’s disease as listed in the Denominator* equals No, do not include in Eligible Population/Denominator. Stop processing.

b. If Diagnosis for Parkinson’s disease as listed in the Denominator* equals Yes, proceed to check Patient encounter during the performance period as listed in Denominator*.

4. Check Patient encounter during the performance period as listed in Denominator*:

a. If Patient encounter during the performance period as listed in Denominator* equals No, do not include in Eligible Population/Denominator. Stop processing.

b. If Patient encounter during the performance period as listed in Denominator* equals Yes, include in Eligible Population.

5. Denominator Population:

• Denominator Population is all Eligible Patients in the Denominator. Denominator is represented as Denominator in the Sample Calculation listed at the end of this document. Letter d equals 80 patients in the Sample Calculation.

6. Start Numerator

7. Check Psychosis, depression, anxiety, apathy, AND impulse control disorder assessed:

a. If Psychosis, depression, anxiety, apathy, AND impulse control disorder assessed equals Yes, include in Data Completeness Met and Performance Met.

• Data Completeness Met and Performance Met letter is represented in the Data Completeness and Performance Rate in the Sample Calculation listed at the end of this document. Letter a equals 60 patients in the Sample Calculation.

b. If Psychosis, depression, anxiety, apathy, AND impulse control disorder assessed equals No, proceed to check Psychosis, depression, anxiety, apathy, AND impulse control disorder not assessed.

8. Check Psychosis, depression, anxiety, apathy, AND impulse control disorder not assessed:

a. If Psychosis, depression, anxiety, apathy, AND impulse control disorder not assessed equals Yes, include in Data Completeness Met and Performance Not Met.

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 5 of 6 • Data Completeness Met and Performance Not Met letter is represented in the Data Completeness in the Sample Calculation listed at the end of this document. Letter c equals 10 patients in the Sample Calculation.

b. If Psychosis, depression, anxiety, apathy, AND impulse control disorder not assessed equals No, proceed to check Data Completeness Not Met.

9. Check Data Completeness Not Met:

a. If Data Completeness Not Met, the Quality Data Code or equivalent was not submitted. 10 patients have been subtracted from the Data Completeness Numerator in the Sample Calculation.

Sample Calculations

Data Completeness equals Performance Met (a equals 60 patients) plus Performance Not Met (c equals 10 patients) divided by Eligible Population/Denominator (d equals 80 patients). All equals 70 patients divided by 80 patients. All equals 87.50 percent.

Performance Rate equals Performance Met (a equals 60 patients) divided by Data Completeness Numerator (70 patients). All equals 60 patients divided by 70 patients. All equals 85.71 percent.

* See the posted measure specification for specific coding and instructions to submit this measure.

NOTE: Submission Frequency: Patient-Process

The measure diagrams were developed by CMS as a supplemental resource to be used in conjunction with the measure specifications. They should not be used alone or as a substitution for the measure specification.

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$PHULFDQ$FDGHP\RI1HXURORJ\$OO5LJKWV5HVHUYHG &37&RS\ULJKW$PHULFDQ0HGLFDO$VVRFLDWLRQ The Parkinson’s disease (PD) measurement set was updated in 2015. The specification for the querying about symptoms of autonomic dysfunction for patients with PD measure was modified in January 2018 for implementation in the Axon Registry®. The modification was made to reflect the CMS’ requirement a follow‐up action occur after a score was recorded. Changes were made solely for registry implementation. Measure Title Querying and Follow-up About Symptoms of Autonomic Dysfunction for Patients with Parkinson’s Disease Description Percentage of all patients with a diagnosis of PD (or caregivers, as appropriate) who were queried about symptoms of autonomic dysfunction* in the past 12 months and if autonomic dysfunction identified, patient had appropriate follow-up. Measurement Period January 1, 20xx to December 31, 20xx Eligible Population Eligible Providers Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant (PA), Advanced Practice Registered Nurse (APRN) Care Setting(s) Outpatient, Inpatient, ED or Urgent Care, Residential (SNF, home care) Ages All ages Event Patient had an office visit, E/M services performed or supervised by an eligible provider, admitted to an inpatient or residential facility, seen for consultation in the ED or urgent care. Diagnosis Parkinson’s Disease Denominator All patients with a diagnosis of Parkinson’s Disease Numerator Patients with a diagnosis of PD (or caregivers, as appropriate) who were queried about symptoms of autonomic dysfunction* in the past 12 months and if autonomic dysfunction identified, patient had appropriate follow-up**.

*Autonomic dysfunction is defined as: orthostatic hypotension or intolerance, constipation, urinary urgency, incontinence, and nocturia, fecal incontinence, urinary retention requiring catheterization, delayed gastric emptying, dysphagia, drooling, hyperhidrosis, or sexual dysfunction.

**Follow-up actions will be identified in the Axon Registry via use of the following key search phrases: “treatment plan modified” or “appropriate treatment plan”. Additional key phrases for symptom specific needs are below:  orthostatic hypertension – “stop antihypertensives”, “add midodrine or droxidopa”, or “home monitoring”;  constipation – “recommended/use PEG 3350, senokot, or Dulcolax”;  urinary urgency or incontinence – “recommended/use oxybutynin”, “refer to incontinence clinic”, “have urodynamics”, or “add mirabegron”;  urinary retention – “catheterization inserted/placed”;  dysphagia – “may require speech language pathologist”;  drooling – “botulinum toxin injection” or “atropine drops”;  sexual dysfunction – “referral to PCP” Required Exclusions None Allowable Exclusions None Exclusion Rationale Not Applicable Measure Scoring Percentage/Proportion Interpretation of Higher Score Indicates Better Quality Score Measure Type Process Level of Measurement Individual provider, Practice, System Risk Adjustment Not Applicable For Process Measures Autonomic dysfunction is directly related to the quality of life of patients with PD. Relationship to The desired outcome is to address and eliminate autonomic dysfunction in patients Desired Outcome with PD. This measure will provide an incentive for providers to identify autonomic dysfunction and offer available treatments to improve quality of life. Opportunity to Autonomic dysfunction was found to be the most prevalent non-motor symptom of Improve Gap in Care PD, affecting more than 70% of patients in all stages of PD (3). Non-motor challenges may become the chief therapeutic challenge in advanced stages of PD, and many may not have effective treatment options (4). In a two-year study development of symptoms in the cardiovascular, apathy, urinary, psychiatric, and fatigue domains was associated with significant life-quality worsening (5).

In a 2013 study by Baek et al. reviewing compliance with quality measure recommendations, it was noted provider compliance rate for annual review of autonomic dysfunction was 22.8% (6). Harmonization with The work group recommended continued use of this measure given the specific Existing Measures assessment needs of the population. A general functional outcomes measure exists, but does not address disease staging. PQRS Measure #182 assess Functional Outcomes. Individuals aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter and documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies. References 1. Suchowersky O, Reich S, Perlmutter J, et al. Quality Standards Subcommittee of the American Academy of Neurology. Practice Parameter: diagnosis and prognosis of new onset Parkinson disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2006; 66(7):968-975. 2. NICE National Collaborating Centre for Primary Care. National Collaborating Centre for Chronic Conditions. Parkinson’s Disease: National Clinical Guideline for Management in Primary and Secondary Care (2006) London: Royal College of Physicans. 3. Sung VW, Nicholas AP. Nonmotor Symptoms in Parkinson’s Disease: Expanding the View of Parkinson’s Disease Beyond a Pure Motor, Pure Dopaminergic Problem. Neurol Clin 2013; 31:S1-S16. 4. Seppi K, Weintraub D, Coelho M, et al. The Movement Disorder Society Evidence-Based Medicine Review Update: Treatments for the Non-Motor Symptoms of Parkinson’s Disease. Mov Disord 2011; 26(3):S42-S80. 5. Antonini A, Barone P, Marconi R, et al. The progression of non-motor symptoms in Parkinson’s disease and their contribution to moto disability and quality of life. J Neurol 2012; 259:2621-2631. 6. Baek WS, Swenseid SS, Poon KT. Quality Care Assessment of Parkinson’s Disease at a Tertiary Medical Center. International Journal of Neuroscience 2013; 123(4):221-225.

Code System Code Code Description ICD-9 332.0 Paralysis Agitans Quality ID #282: Dementia: Functional Status Assessment – National Quality Strategy Domain: Effective Clinical Care – Meaningful Measure Area: Prevention, Treatment, and Management of Mental Health

2021 COLLECTION TYPE: MIPS CLINICAL QUALITY MEASURES (CQMS)

MEASURE TYPE: Process

DESCRIPTION: Percentage of patients with dementia for whom an assessment of functional status was performed at least once in the last 12 months

INSTRUCTIONS: This measure is to be submitted a minimum of once per performance period for patients with a diagnosis of dementia seen during the performance period. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

NOTE: Patient encounters for this measure conducted via telehealth (e.g., encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable.

DENOMINATOR: All patients with a diagnosis of dementia DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.

Denominator Criteria (Eligible Cases): All patients regardless of age AND Diagnosis for dementia (ICD-10-CM): A52.17, A81.00, A81.01, A81.89, F01.50, F01.51, F02.80, F02.81, F03.90, F03.91, F05, F10.27, G30.0, G30.1, G30.8, G30.9, G31.01, G31.09, G31.83, G31.85, G31.89, G94 AND Patient encounter during the performance period (CPT): 90791, 90792, 90832, 90834, 90837, 96116, 96130, 96132, 96136, 96138, 96146, 96156, 96158, 96164, 96167, 96170, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99251*, 99252*, 99253*, 99254*, 99255*, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99339, 99340, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99487, 99490, 99497

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 1 of 7 NUMERATOR: Patients for whom an assessment of functional status was performed at least once in the last 12 months Definition: Assessment of functional status - Functional status is assessed by use of a validated tool, direct assessment of the patient, or by querying a knowledgeable informant. A direct assessment of functional status includes an evaluation of the patient’s ability to perform instrumental activities of daily living (IADL) and basic activities of daily living (ADL).

Numerator Instructions: To meet this measure providers must assess BOTH IADL and ADL performance. 1. IADL Assessment (users must meet one of the two below bullets to meet IADL assessment component) • To meet the measure’s IADL component using a validated tool, providers must use one of the following tools: o Lawton Instrumental Activities of Daily Living Scale o Bristol Activities of Daily Living Scale o Katz Index of Independence in Activities of Daily Living o Functional Activities Questionnaire o Functional Independence Measure Instrument • To meet the measure’s IADL component using a direct assessment, providers must document 3 out of the following 5 domains. o Cleaning or hobbies, o Money management, o Medication management, o Transportation, and o Cooking or communication 2. ADL Assessment (users must meet one of the two below bullets to meet ADL assessment component) • To meet the measure’s ADL component using a validated tool, providers must use either: o Barthel ADL Index o Bristol Activities of Daily Living Scale • To meet the measure’s ADL component using a direct assessment, providers must document 3 out of the following 7 domains. o Grooming, o Bathing, o Dressing, o Eating, o Toileting, o Gait, and o Transferring. NUMERATOR NOTE: The 12 month look back period is defined as 12 months from the date of the denominator eligible encounter. Denominator Exception(s) are determined on the date of the denominator eligible encounter. Documentation of advanced stage dementia and caregiver knowledge is limited would meet the measure exception criteria.

Numerator Options: Performance Met: Functional status performed once in the last 12 months (G9916) OR Denominator Exception: Documentation of advanced stage dementia and caregiver knowledge is limited (G9917) OR Performance Not Met: Functional status not performed, reason not otherwise Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 2 of 7 specified (G9918)

RATIONALE: Maintaining or increasing physical functioning levels is a desired outcome. This is key to maintaining quality of life and reducing caregiver burden. This requires regular assessment of function in multiple domains.

In routine practice, persons with dementia may not be assessed regularly for changes in their ability to perform both basic and instrumental activities of daily living. (Black BS, Johnston D, Rabins PV, et al. Unmet Needs of Community-Residing Persons with Dementia and Their Informal Caregivers: Findings from the MIND at Home Study. J Am Geriatr Soc 2013;61(12):2087-2095.) Frequent and comprehensive assessments will allow health care providers to track these changes and to make timely interventions aimed at preserving function or mitigating disability.

When planning interventions to improve or maintain function, it is important to consider a broad range of causes of functional impairment, including impaired cognition.

CLINICAL RECOMMENDATION STATEMENTS: Perform regular, comprehensive person-centered assessments and timely interim assessments. Assessments, conducted at least every 6 months, should prioritize issues that help the person with dementia to live fully. These include assessments of the individual and care partner’s relationships and subjective experience and assessment of cognition, behavior, and function, using reliable and valid tools. Assessment is ongoing and dynamic, combining nomothetic (norm-based) and idiographic (individualized) approaches. (Molony SL, Kolanowski A, Van Haitsma K, et al. Person-Centered Assessment and Care Planning. The Gerontologist. 2018; 58(1):S32-S47.)

COPYRIGHT: Quality Measures published by the American Academy of Neurology Institute (AANI) and its affiliates are assessments of current scientific and clinical information provided as an educational service. The information: 1) should not be considered inclusive of all proper treatments, methods of care, or as a statement off the standard of care; 2) is not continually updated and may not reflect the most recent evidence (new evidence may emerge between the time information is developed and when it is published or read); 3) addresses only the question(s) or topic(s) specifically identified; 4) does not mandate any particular course of medical care; and 5) is not intended to substitute for the independent professional judgment of the treating provider, as the information does not account for individual variation among patients. In all cases, the selected course of action should be considered by the treating provider in the context of treating the individual patient. Use of the information is voluntary. AANI provides this information on an “as is” basis, and makes no warranty, expressed or implied, regarding the information. AANI specifically disclaims any warranties of merchantability or fitness for a particular use or purpose. AANI assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this information or for any errors or omissions.

The American Psychiatric Association’s (APA), PCPI’s, and AMA’s significant past efforts and contributions to the development and updating of the Measure are acknowledged.

Limited proprietary coding may be contained in the Measure specifications for convenience. A license agreement must be entered prior to a third party’s use of Current Procedural Terminology (CPT®) or other proprietary code set contained in the Measure. Any other use of CPT or other coding by the third party is strictly prohibited. AANI, APA, AMA, and the former members of the PCPI disclaim all liability for use or accuracy of any CPT or other coding contained in the specifications.

CPT® contained in the Measures specifications is copyright 2004-2020 American Medical Association. LOINC® copyright 2004-2020 Regenstrief Institute, Inc. SNOMED CLINICAL TERMS (SNOMED CT®) copyright 2004-2020. The Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 3 of 7 International Health Terminology Standards Development Organisation (IHTSDO). ICD-10 is copyright 2020 World Health Organization. All Rights Reserved.

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 4 of 7 2021 Clinical Quality Measure Flow for Quality ID #282: Dementia: Functional Status Assessment

Disclaimer: Refer to the measure specification for specific coding and instructions to submit this measure.

Denominator Numerator

Data Completeness Met + Performance Met Functional status performed once Yes All patients G9916 or equivalent Start in the last 12 months regardless of age (50 patients) a

Diagnosis for No dementia as listed in Denominator*

Documentation of Data Completeness Met + Denominator Exception advanced stage dementia and Yes caregiver knowledge is limited G9917 or equivalent Yes (10 patients) b

Patient encounter No during the performance Not Included in Eligible No Population/Denominator period as listed in Denominator*

Data Completeness Met + Functional status not performed, Performance Not Met Yes reason not otherwise specified G9918 or equivalent Yes (10 patients) c

Include in Eligible Population/Denominator (80 patients) d No

Data Completeness Not Met the Quality Data Code or equivalent was not submitted (10 patients)

SAMPLE CALCULATIONS

Data Completeness= Performance Met (a=50 patients) + Denominator Exception (b=10 patients) + Performance Not Met (c=10 patients) = 70 patients = 87.50% Eligible Population / Denominator (d=80 patients) = 80 patients

Performance Rate= Performance Met (a=50 patients) = 50 patients = 83.33% Data Completeness Numerator (70 patients) – Denominator Exception (b=10 patients) = 60 patients

* See the posted measure specification for specific coding and instructions to submit this measure.

NOTE: Submission Frequency: Patient-Process CPT only copyright 2020 American Medical Association. All right s reserved. The measure diagrams were developed by CMS as a supplement al resource t o be used in conjunction with the measure specifications. They should not be used alone or as a substitution for the measure specification. V5

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 5 of 7 2021 Clinical Quality Measure Flow Narrative for Quality ID #282: Dementia: Functional Status Assessment Disclaimer: Refer to the measure specification for specific coding and instructions to submit this measure.

1. Start with Denominator

2. All patients regardless of age

3. Check Diagnosis for dementia as listed in Denominator*:

a. If Diagnosis for dementia as listed in Denominator* equals No, do not include in Eligible Population/Denominator. Stop Processing.

b. If Diagnosis for dementia as listed in Denominator* equals Yes, proceed to check Patient encounter during the performance period as listed in Denominator*.

4. Check Patient encounter during the performance period as listed in Denominator*:

a. If Patient encounter during the performance period as listed in Denominator* equals No, do not include in Eligible Population/Denominator. Stop Processing.

b. If Patient encounter during the performance period as listed in Denominator* equals Yes, include in Eligible Population/Denominator.

5. Denominator Population:

6. Start Numerator

7. Check Functional status performed once in the last 12 months:

a. If Functional status performed once in the last 12 months equals Yes, include in Data Completeness Met and Performance Met.

b. If Functional status performed once in the last 12 months equals No, proceed to check Documentation of advanced stage dementia and caregiver knowledge is limited.

8. Check Documentation of advanced stage dementia and caregiver knowledge is limited:

a. If Documentation of advanced stage dementia and caregiver knowledge is limited equals Yes, include in Data Completeness Met and Denominator Exception.

• Data Completeness Met and Denominator Exception letter is represented in the Data Completeness and Performance Rate in the Sample Calculation listed at the end of this document. Letter b equals 10 patients in the Sample Calculation.

b. If Documentation of advanced stage dementia and caregiver knowledge is limited equals No, proceed to check Functional status not performed, reason not otherwise specified. Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 6 of 7 9. Check Functional status not performed, reason not otherwise specified:

a. If Functional status not performed, reason not otherwise specified equals Yes, include in Data Completeness Met and Performance Not Met.

• Data Completeness Met and Performance Not Met letter is represented in the Data Completeness in the Sample Calculation listed at the end of this document. Letter c equals 10 patients in the Sample Calculation.

b. If Functional status not performed, reason not otherwise specified equals No, proceed to check Data Completeness Not Met.

10. Check Data Completeness Not Met:

• If Data Completeness Not Met, the Quality Data Code or equivalent was not submitted. 10 patients have been subtracted from the Data Completeness Numerator in the Sample Calculation.

Sample Calculations Data Completeness equals Performance Met (a equals 50 patients) plus Denominator Exception (b equals 10 patients) plus Performance Not Met (c equals 10 patients) divided by Eligible Population/Denominator (d equals 80 patients). All equals 70 patients divided by 80 patients. All equals 87.5 percent.

Performance Rate equals Performance Met (a equals 50 patients) divided by Data Completeness Numerator (70 patients) minus Denominator Exception (b equals 10 patients). All equals 50 patients divided by 60 patients. All equals 83.33 percent.

*See the posted measure specification for specific coding and instructions to submit this measure. NOTE: Submission Frequency: Patient-Process The measure diagrams were developed by CMS as a supplemental resource to be used in conjunction with the measure specifications. They should not be used alone or as a substitution for the measure specification.

Axon Registry® #11: Diabetes/Pre-Diabetes Screening for Patients with DSP

These specifications have been modified at the Center for Medicare & Medicaid Services’ request for implementation in Axon Registry

Measure Description Percentage of patients age 18 years and older with a diagnosis of distal symmetric polyneuropathy who had screening tests for diabetes reviewed, requested or ordered when seen for an initial evaluation for distal symmetric polyneuropathy and if screen positive referred to endocrinology or primary care physician. Measure Components Numerator Patients who had screening tests for diabetes (i.e., fasting blood sugar test, Statement hemoglobin A1C, or a 2 hour Glucose Tolerance Test) reviewed, requested, or ordered when seen for an initial evaluation for distal symmetric polyneuropathy, and if screen positive, referred to endocrinology or primary care physician.

Suggested key phrases for use in Axon Registry include: Screening:  Fasting blood sugar test  Hemoglobin A1c  2-hour glucose tolerance test Follow-up:  Referral to endocrinology  Referral to PCP Denominator All patients age 18 years and older with a diagnosis of distal symmetric Statement polyneuropathy. Denominator  Documentation of a medical reason for not reviewing, requesting or Exceptions ordering diabetes screening tests (e.g., patient had previous diabetes screening in the measurement period)  Documentation of a patient reason for not reviewing, requesting or ordering diabetes screening tests (e.g., patient declines to undergo testing)  Documentation of a system reason for not reviewing, requesting or ordering diabetes screening tests (e.g., patient does not have insurance to pay for testing)

Denominator  Patient has a diagnosis of diabetes Exclusions  Patient has a known medical condition to cause neuropathy Supporting The following evidence statements are quoted verbatim from the referenced Guideline & clinical guidelines: Other  Screening laboratory tests may be considered for all patients with References polyneuropathy. (Level C) 27  Those tests that provide the highest yield of abnormality are blood glucose, serum B12 with metabolites (methylmalonic acid with or without homocysteine), and serum protein immunofixation electrophoresis. (Level C)27

 If there is no definite evidence of diabetes mellitus by routine testing of blood glucose, testing for impaired glucose tolerance may be considered in distal symmetric sensory polyneuropathy. (Level C) 27  All patients should be screened for distal symmetric polyneuropathy(DSP) at diagnosis and at least annually thereafter, using simple clinical tests. (Level B)24

Measure Importance Relationship to Early intervention and control of diabetes in DSP patients can improve care. DSP desired patients screened for pre-diabetes or diabetes may reduce complications over time. outcome Patients with painful diabetic neuropathy sensory polyneuropathy are more likely to have impaired glucose tolerance tests (GTT) than those with painless sensory polyneuropathy.44

DSP is the most common variety of neuropathy and type of diabetic neuropathy.1.4 Approximately 30% of neuropathies are caused by diabetes.3 Neuropathies affect up to 50% of patients with diabetes.7 Since DSP is the major contributory factor for diabetic foot ulcers and the lower-limb amputation rates in diabetic subjects are 15 times higher than in the non-diabetic population, an early detection of DSP by screening and appropriate diagnosis is of utmost importance.15

Opportunity Approximately 1.9 million people 20 years and older were newly diagnosed with for diabetes in 2010. In 2005–2008, based on fasting glucose or hemoglobin A1c Improvement levels, 35% of U.S. adults aged 20 years or older had pre-diabetes (50% of adults aged 65 years or older). Applying this percentage to the entire U.S. population in 2010 yields an estimated 79 million American adults aged 20 years or older with prediabetes.44

DSP affects at least one in four diabetic patients.1 Diabetes is one of the five major chronic conditions that affect 25% of the US community population14 and amounted to more than $62.3 billion health care costs in 1996.9

Data collected between 1988 and 1995 (derived from the Center for Disease Control's population-based Behavioral Risk Factor Surveillance System [BRFSS], as well as the National Health and Nutrition Examination [NHANES] surveys) reveal significant quality gaps in the treatment of diabetes and in screening for diabetes-related complications.7 Diabetics also do not receive appropriate screening measures: only 55% obtain annual foot examinations.16

The UK Prospective Diabetes Study showed the effects of different treatment therapies and the associated outcomes over time. The group studied the effects of diet alone and deterioration of glycemic control; this shows the importance of early intervention and control of diabetes.45

Quality  Efficient Addressed Exception If patients already have an underlying diagnosis of diabetes, the testing would Justification include evaluation of degree of glycemic control, rather than tests for initial diagnosis of diabetes. If patients have already been diagnosed with diabetes, has a diagnosed cause of their neuropathy or has previously completed testing they do not need to undergo additional testing as this would be unnecessary. Patients have a right to refuse testing for personal (patient exception) or financial reasons (system exception).

Harmonization There are no other measures currently available that are similar to this measure or with Existing need to be harmonized with this measure. Measures

Measure Title Treatment prescribed for acute migraine attacks Description Percentage of patients age 6 years and older with a diagnosis of migraine who were prescribed a guideline recommended or FDA approved/cleared treatment for acute migraine attacks during the measurement period. Measurement January 1, 20xx to December 31, 20xx Period Eligible Eligible Providers Medical Doctor (MD), Doctor of Osteopathy (DO), Advanced Population Practice Provider (APP), Advanced Practice Registered Nurse (APRN) Care Setting(s) Outpatient Care Ages > 6 years of age Event Patient had an office visit or E/M services performed or supervised by an eligible provider Diagnosis Migraine Denominator Patients > 6 years of age diagnosed with migraine. Numerator Patients who were prescribed a guideline recommended or FDA approved/cleared treatment* for acute migraine attacks once during the measurement period.

*Guideline recommended or FDA approved/cleared acute medications for acute migraine attack include the following but are not limited to: triptans, dihydroergotamine (DHE), NSAIDs, D2 antagonists. Guideline recommended or FDA approved/cleared acute migraine attack treatment may include neuromodulation. Clinicians should use their best judgment to prescribe a treatment for acute migraine attacks to meet the specific needs of the individual patient.

For data collection via a clinical registry, we suggest using the following key phrases for capturing exclusions. These key phrases should be recorded on the encounter date: • “Patient and/or caregiver declines therapies” • “Patient declines therapies” • “Caregiver declines therapies” • “All guideline recommended treatments and FDA approved/cleared treatments are contraindicated” • “All guideline recommended treatments and FDA approved/cleared treatments are ineffective” • “Patient is currently taking effective medication” 20 ©2020. American Academy of Neurology Institute and American Headache Society. All Rights Reserved. CPT® Copyright 2004-2020 American Medical Association. • “Patient has history of acute migraine medication overuse” • “Patient has minimal pain with migraine” • “Patient has no pain with migraine” Exclusion Patients and their caregivers have the right to refuse a service. Patients who have Rationale contraindications or are already on an effective treatment should be excluded from the measure. Additionally, it may be inappropriate to prescribe a medication to a patient who has medication overuse or one that does not experience pain with migraine. Measure Scoring Percentage/proportion Interpretation of Higher score indicates better quality Score Measure Type Process Level of Provider Measurement Risk Adjustment Not applicable For Process By providing appropriate guideline recommended treatments, it is anticipated that headache Measures severity and duration of headache would be reduced for patients that have acute attacks. Relationship to Desired Outcome

Process Intermediate Outcomes Outcomes •Acute treatment prescribed •Treatment adherence •Reduction in headache severity •Reduction in duration of headache •Improvement of most bothersome symptom

Opportunity to Only 29% of patients are satisfied with their acute migraine treatment.1 Among persons with Improve Gap in episodic migraine, 18.31% reported current use of triptans for acute headache treatment.2 Care Triptan use increased with headache frequency, headache-related disability and allodynia, but decreased among persons with depression.2 Less than 1 in 5 persons with migraine in the US who were respondents to this survey used triptans for acute headache treatment over the course of a year.2

In a population sample of individuals with episodic migraine (EM), more than 40% have at least one unmet need in the area of acute treatment. The leading reasons for unmet needs, which include headache-related disability and dissatisfaction with current acute treatment, suggest opportunities for improving outcomes for persons with EM.3

In an analysis of data from the 2005 American Migraine Prevalence and Prevention (AMPP) study, authors reported that 91.7% of respondents meeting criteria for EM used acute treatment for their headaches. Of these respondents, only 36.1% used migraine-specific medications. Triptans were used by 18.3% of the sample, opioids were used by 11.7% of the sample, and barbiturate medications were used by 6.1% of the sample.4 According to another study, 21.87% of patients use triptans for acute treatment of migraine, 20% use ergots, 20.87% use opioids, and 13.52% use barbiturates.5

21 ©2020. American Academy of Neurology Institute and American Headache Society. All Rights Reserved. CPT® Copyright 2004-2020 American Medical Association. Using the guideline recommended first-line acute treatments would provide superior pain relief for migraine. Triptans and ergots are considered first-line acute treatments for migraine according to the latest American Headache Society guideline.6 The leading reasons for unmet needs, which include headache related disability and dissatisfaction with current acute treatment, suggest opportunities for improving outcomes for persons with EM.3 Harmonization ICSI: Diagnosis and treatment of headache: percentage of patients with migraine headache with Existing prescribed appropriate acute treatment. Measures References 1. Lipton RB, Stewart WF. Acute migraine therapy: do doctors understand what patients with migraine want from therapy? Headache 1999; 39:S20-26. 2. Bigal ME, Buse DC, Hen YT, et al. Rates and predictors of starting a triptan: results from the American Migraine Prevalence and Prevention Study. Headache 2010; 50:1440-8. 3. Lipton RB, Buse DC, SerranoD, et al. Examination of unmet treatment needs among persons with episodic migraine: results of the American Migraine Prevalence and Prevention (AMPP) Study. Headache 2013; 53:1300-11. 4. Lipton RB, Buse DC, Serrano, D, et al. Acute medication use patterns in episodic migraine: results of the American Migraine prevalence and prevention (AMPP) study. Cephalgia 2009; 29:17 (Presented at the 14th Congress of the International Headache Society, September 10-13, 2009). 5. Bigal ME, Borouchu S, Serrano D. The acute treatment of episodic and chronic migraine in the United States. Cephalgia 2009; 29:891-897. 6. Marmura MJ, Silberstein SD, Schwedt TJ. The acute treatment of migraine in adults: the American Headache Society evidence assessment of migraine pharmacotherapies. Headache 2015; 55:3-20. Supporting evidence • Evers S, Afra J, Frese A, et al. EFNS guideline on the drug treatment of migraine – revised report of an EFNS task force. European J of Neurology 2009, 16: 968–981 (EFNS: 2009; Drug treatment of migraine). • Scottish Intercollegiate Guidelines Network (SIGN) Diagnosis and management of headache in adults Guideline 107. 2008. • US Headache Consortium. Matchar D, Young W, Rosenberg J et al. Evidence-Based Guidelines for Migraine Headache in the Primary Care Setting: Pharmacological Management of Acute Attacks. • Cameron C, Kelly S, Hsieh SC, et al. Triptans in Acute Treatment of Migraine: Systematic review and Network Meta-Analysis. Headache 2015; 55:221-35. • Marmura MJ, Silberstein SJ, Schwedt TJ. Acute treatment of migraine in adults: The American Headache Society Evidence Assessment of Migraine Pharmacotherapies. Headache 2015; 55:3-20. • Richer L, Billinghurst L, Linsdell MA, et al. Drugs for acute treatment of migraine in children and adolescents. Cochrane 2016. • Cameron C, Kelly S, Hsieh S, et al. Triptans in the Acute Treatment of Migraine: A Systematic Review and Network Meta-Analysis. Headache 2015; 55:221-235. • Derry CJ, Derry S, Moore RA. Sumatriptan (all route of administration) for acute migraine attacks in adults – overview of Cochrane review (review). Cochrane Database of Systematic Reviews 2014; Issue 5. • Oskoui M, Pringsheim T, Holler-Managan Y, et al. Practice guideline update summary: Acute treatment of migraine in children and adolescents: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 2019; Epub ahead of print.

22 ©2020. American Academy of Neurology Institute and American Headache Society. All Rights Reserved. CPT® Copyright 2004-2020 American Medical Association. • Oskoui M, Pringsheim T, Billinghurst L, et al. Practice guideline update summary: Pharmacologic treatment for pediatric migraine prevention. Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 2019; Epub ahead of print. • Turner S, Rende E, Pezzuto T, et al. Pediatric Migraine Action Plan (PedMAP). Headache 2019; 59:1871-1873.

23 ©2020. American Academy of Neurology Institute and American Headache Society. All Rights Reserved. CPT® Copyright 2004-2020 American Medical Association. Flow Chart Diagram: Recommended treatment for acute migraine attack

Was patient 6 years or older during the measurement period? Patient NOT No Included in Yes Eligible Population No Did the patient have at least one new or established patient visit with an eligible No provider during the measurement period?

Yes

Did patient have a diagnosis of migraine No during the measurement period?

Yes

Patient INCLUDED in Eligible Population

No or N/A

Did the patient present to the emergency department or urgent care on date of presentation? Yes No or N/A

On the date of the encounter, were all guideline recommended or FDA approved/cleared treatment contraindicated or ineffective? Yes No or N/A Remove from On the date of the encounter, was the denominator* patient already on an effective over the counter medication or an acute medication *Do not remove/exclude Yes if patient meets the prescribed by another clinician? numerator No or N/A

On the date of the encounter, did patient Yes have acute migraine medication overuse, and additional medications were contraindicated?

Remove from On the date of the encounter, did patient have minimal or no pain with migraine? denominator*

Yes *Do not remove/exclude if patient meets the No or N/A numerator

On the date of the encounter, did patient and/or caregiver decline treatment? Yes

No or N/A

Patient During the measurement period, was the patient prescribed a guideline recommended or FDA INCLUDED in approved/cleared treatment for acute migraine Denominator attacks* during the measurement period?

Yes No

Patient did Patient met NOT meet numerator numerator criteria criteria

25 ©2020. American Academy of Neurology Institute and American Headache Society. All Rights Reserved. CPT® Copyright 2004-2020 American Medical Association. eCQM Title Documentation of Current Medications in the Medical Record eCQM Identifier 68 10.3.000 (Measure eCQM Version Number Authoring Tool)

NQF Number 0419e GUID 9a032d9c-3d9b-11e1-8634-00237d5bf174

Measurement January 1, 20XX through December 31, 20XX Period

Measure Steward Centers for Medicare & Medicaid Services (CMS)

Measure PCPI(R) Foundation (PCPI[R]) Developer

Endorsed By National Quality Forum

Percentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests Description to documenting a list of current medications using all immediate resources available on the date of the encounter

Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. PCPI disclaims all liability for use or accuracy of any Current Procedural Terminology (CPT[R]) or other coding contained in the specifications. Copyright CPT(R) contained in the Measure specifications is copyright 2004-2019 American Medical Association. LOINC(R) copyright 2004-2019 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2019 International Health Terminology Standards Development Organisation. ICD-10 is copyright 2019 World Health Organization. All Rights Reserved.

These performance measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications. Disclaimer THE MEASURES AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.

Due to technical limitations, registered trademarks are indicated by (R) or [R].

Measure Scoring Proportion

Measure Type Process

Stratification None

Risk Adjustment None

Rate None Aggregation

According to the National Center for Health Statistics, during the years of 2011-2014, 46.9 percent of patients (both male and female) were prescribed at least one prescription medication with 10.9 percent taking 5 or more medications. Additionally, 90.6 percent of patients (both male and female) aged 65 years and older were prescribed at least one medication with 40.7 percent taking 5 or more medications (2017). In this context, maintaining an accurate and complete medication list has proven to be a challenging documentation endeavor for various health care provider settings. While most of outpatient encounters (2/3) result in providers prescribing at least one medication, hospitals have been the focus of medication safety efforts (Stock, Scott, & Gurtel, 2009). Nassaralla, Naessens, Chaudhry, Hansen, and Scheitel (2007) caution that this is at odds with the current trend, where patients with chronic illnesses are increasingly being treated in the outpatient setting and require careful monitoring of multiple medications. Additionally, Nassaralla et al. (2007) reveal that it is in fact in outpatient settings where more fatal adverse drug events (ADE) occur when these are compared to those occurring in hospitals (1 of 131 outpatient deaths compared to 1 in 854 inpatient deaths). In the outpatient setting, ADEs occur 25% of the time and over one-third of these are considered preventable (Tache, Sonnichsen, & Ashcroft, 2011). Particularly vulnerable are patients over 65 years, with evidence suggesting that the rate of ADEs per 10,000 person per year increases with age; 25-44 years old at 1.3; 45- 64 at 2.2, and 65 + at 3.8 (Sarkar, López, & Maselli, 2011). Another vulnerable group is chronically ill individuals. These population groups are more likely to experience ADEs and subsequent hospitalization.

A multiplicity of providers and inadequate care coordination among them has been identified as barriers to collecting complete and reliable medication records. Data indicate that reconciliation and documentation continue to be poorly executed with discrepancies occurring in 92% (74 of 80 patients) of medication lists among admittance to the emergency room. Of 80 patients included in the study, the home medications were reordered for 65% of patients on Rationale their admission and of the 65% the majority (29%) had a change in their dosing interval, while 23% had a change in their route of administration, and 13% had a change in dose. A total of 361 medication discrepancies, or the difference between the medications patients were taking before admission and those listed in their admission orders, were identified in at least 74 patients (Poornima et al., 2015). The study found that "Through an appropriate reconciliation programme, around 80% of errors relating to medication and the potential harm caused by these errors could be reduced" (Penumarthi et al., 2015, p. 243).

Documentation of current medications in the medical record facilitates the process of medication review and reconciliation by the provider, which is necessary for reducing ADEs and promoting medication safety. The need for provider to provider coordination regarding medication records, and the existing gap in implementation, is highlighted in the American Medical Association's Physician's Role in Medication Reconciliation, which states that "critical patient information, including medical and medication histories, current medications the patient is receiving and taking, and sources of medications, is essential to the delivery of safe medical care. However, interruptions in the continuity of care and information gaps in patient health records are common and significantly affect patient outcomes" (2007, p. 7). This is because clinical decisions based on information that is incomplete and/or inaccurate are likely to lead to medication error and ADEs. Weeks, Corbette, and Stream (2010) noted similar barriers and identified the utilization of health information technology as an opportunity for facilitating the creation of universal medication lists. One 2015 meta-analysis showed an association between EHR documentation with an overall RR of 0.46 (95% CI = 0.38 to 0.55; P < 0.001) and ADEs with an overall RR of 0.66 (95% CI = 0.44 to 0.99; P = 0.045). This meta-analysis provides evidence that the use of the EHR can improve the quality of healthcare delivered to patients by reducing medication errors and ADEs (Campanella et al., 2016).

The Joint Commission's 2019 Ambulatory Health Care National Patient Safety Goals guide providers to maintain and communicate accurate patient medication information. Specifically, the section "Use Medicines Safely NPSG.03.06.01" states the following: "Record and pass along correct information about a patient’s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows Clinical which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of Recommendation medicines every time they visit a doctor." Statement The National Quality Forum's Safe Practices for Better Healthcare - 2010 Update, states the following: "the healthcare organization must develop, reconcile, and communicate an accurate patient medication list throughout the continuum of care" (p. 40).

Improvement Higher score indicates better quality Notation

American Medical Association. (2007). The physician’s role in medication reconciliation: Issues, strategies, and safety Reference principles. Retrieved from https://pogoe.org/sites/default/files/Medication%20Reconciliation.pdf

Reference Campanella, P., Lovato, E., Marone, C., Fallacara, L., Mancuso, A., Ricciardi, W., & Specchia, M. L. (2016). The impact of electronic health records on health care quality: A systematic review and meta-analysis. European Journal of Public Health, 26(1), 60-64. doi:10.1093/eurpub/ckv122 Nassaralla, C. L., Naessens, J. M., Chaudhry, R., Hansen, M. A., & Scheitel, S. M. (2007). Implementation of a Reference medication reconciliation process in an ambulatory internal medicine clinic. Quality and Safety in Health Care, 16(2), 90-94. doi:10.1136/qshc.2006.021113

National Center for Health Statistics. (2017). Health, United States, 2017: Supplementary Table 79: Prescription drug Reference use in the United States by sex, race, age, and origin. Retrieved from https://www.cdc.gov/nchs/data/hus/2017/079.pdf

National Quality Forum. (2010). Safe practices for better healthcare - 2010 update. Retrieved from Reference http://www.qualityforum.org/Projects/Safe_Practices_2010.aspx

Penumarthi, P., Pasala, R., T V, R., Nagasubramanian, VR., Devi, G S., Seshadri, P. (2015). Medication reconciliation Reference and medication error prevention in an emergency department of a tertiary care hospital. Journal of Young Pharmacists, 7(3), 241-249. doi:10.5530/jyp.2015.3.15

Sarkar, U., López, A., Maselli, J.H., Gonzales, R. (2011). Adverse drug events in U.S. adult ambulatory medical care. Reference Health Services Research, 46(5), 1517-1533. doi:10.1111/j.1475-6773.2011.01269.x

Stock, R., Scott, J., & Gurtel, S. (2009). Using an electronic prescribing system to ensure accurate medication lists in Reference a large multidisciplinary medical group. The Joint Commission Journal on Quality and Patient Safety, 35(5), 271-277.

Tache, S. V., Sonnichsen, A., & Ashcroft, D. M. (2011). Prevalence of adverse drug events in ambulatory care: A Reference systematic review. The Annals of Pharmacotherapy, 45(7-8), 977-989. doi: 10.1345/aph.1P627

The Joint Commission. (2019). Ambulatory Health Care National Patient Safety Goals. Retrieved from Reference https://www.jointcommission.org/assets/1/6/2019_AHC_NPSGs_final.pdf

Weeks, D. L., Corbette, C. F., & Stream, G. (2010). Beliefs of ambulatory care physicians about accuracy of patient Reference medication records and technology-enhanced solutions to improve accuracy. Journal for Healthcare Quality, 32(5), 12- 21. doi:10.1111/j.1945-1474.2010.00097.x

Current Medications: Medications the patient is presently taking including all prescriptions, over-the-counters, herbals and vitamin/mineral/dietary (nutritional) supplements with each medication's name, dosage, frequency and administered route. Definition Route: Documentation of the way the medication enters the body (some examples include but are not limited to: oral, sublingual, subcutaneous injections, and/or topical).

This eCQM is an episode-based measure. This measure is to be reported for every encounter during the measurement period.

Eligible professionals or eligible clinicians reporting this measure may document medication information received from the patient, authorized representative(s), caregiver(s) or other available healthcare resources.

This list must include all known prescriptions, over-the-counter (OTC) products, herbals, vitamins, minerals, dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration. Guidance This measure should also be reported if the eligible professional or eligible clinician documented the patient is not currently taking any medications.

By reporting the action described in this measure, the provider attests to having documented a list of current medications utilizing all immediate resources available at the time of the encounter.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

Transmission TBD Format

Initial All visits occurring during the 12 month measurement period for patients aged 18 years and older Population

Denominator Equals Initial Population

Denominator None Exclusions

Eligible professional or eligible clinician attests to documenting, updating or reviewing the patient's current Numerator medications using all immediate resources available on the date of the encounter

Numerator Not Applicable Exclusions

Documentation of a medical reason(s) for not documenting, updating, or reviewing the patient’s current medications Denominator list (e.g., patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment Exceptions would jeopardize the patient's health status)

Supplemental For every patient evaluated by this measure also identify payer, race, ethnicity and sex Data Elements

Table of Contents

• Population Criteria • Definitions • Functions • Terminology • Data Criteria (QDM Data Elements) • Supplemental Data Elements • Risk Adjustment Variables

Population Criteria

Initial Population

"Qualifying Encounter During Measurement Period" QualifyingEncounter with ["Patient Characteristic Birthdate": "Birth date"] BirthDate such that Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) >= 18

Denominator

"Initial Population"

Denominator Exclusions None

Numerator

"Qualifying Encounter During Measurement Period" QualifyingEncounter with ( ["Procedure, Performed": "Documentation of current medications (procedure)"] union ["Intervention, Performed": "Documentation of current medications (procedure)"] ) MedicationsDocumented such that MedicationsDocumented.relevantDatetime during QualifyingEncounter.relevantPeriod

Numerator Exclusions

None

Denominator Exceptions

"Qualifying Encounter During Measurement Period" QualifyingEncounter with ( ["Procedure, Not Performed": "Documentation of current medications (procedure)"] union ["Intervention, Not Performed": "Documentation of current medications (procedure)"] ) MedicationsNotDocumented such that MedicationsNotDocumented.authorDatetime during QualifyingEncounter.relevantPeriod and MedicationsNotDocumented.negationRationale in "Medical Reason"

Stratification

None

Definitions

Denominator

"Initial Population"

Denominator Exceptions

Initial Population

Numerator

Qualifying Encounter During Measurement Period

["Encounter, Performed": "Encounter to Document Medications"] ValidEncounter where ValidEncounter.relevantPeriod during "Measurement Period"

SDE Ethnicity

["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

["Patient Characteristic Payer": "Payer"]

SDE Race

["Patient Characteristic Race": "Race"]

SDE Sex

["Patient Characteristic Sex": "ONC Administrative Sex"]

Functions

Global.CalendarAgeInYearsAt(BirthDateTime DateTime, AsOf DateTime)

years between ToDate(BirthDateTime)and ToDate(AsOf)

Global.ToDate(Value DateTime)

DateTime(year from Value, month from Value, day from Value, 0, 0, 0, 0, timezoneoffset from Value)

Terminology

• code "Birth date" ("LOINC Code (21112-8)") • code "Documentation of current medications (procedure)" ("SNOMEDCT Code (428191000124101)") • valueset "Encounter to Document Medications" (2.16.840.1.113883.3.600.1.1834) • valueset "Ethnicity" (2.16.840.1.114222.4.11.837) • valueset "Medical Reason" (2.16.840.1.113883.3.526.3.1007) • valueset "ONC Administrative Sex" (2.16.840.1.113762.1.4.1) • valueset "Payer" (2.16.840.1.114222.4.11.3591) • valueset "Race" (2.16.840.1.114222.4.11.836) Data Criteria (QDM Data Elements)

• "Encounter, Performed: Encounter to Document Medications" using "Encounter to Document Medications (2.16.840.1.113883.3.600.1.1834)" • "Intervention, Not Performed: Documentation of current medications (procedure)" using "Documentation of current medications (procedure) (SNOMEDCT Code 428191000124101)" • "Intervention, Performed: Documentation of current medications (procedure)" using "Documentation of current medications (procedure) (SNOMEDCT Code 428191000124101)" • "Patient Characteristic Birthdate: Birth date" using "Birth date (LOINC Code 21112-8)" • "Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity (2.16.840.1.114222.4.11.837)" • "Patient Characteristic Payer: Payer" using "Payer (2.16.840.1.114222.4.11.3591)" • "Patient Characteristic Race: Race" using "Race (2.16.840.1.114222.4.11.836)" • "Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex (2.16.840.1.113762.1.4.1)" • "Procedure, Not Performed: Documentation of current medications (procedure)" using "Documentation of current medications (procedure) (SNOMEDCT Code 428191000124101)" • "Procedure, Performed: Documentation of current medications (procedure)" using "Documentation of current medications (procedure) (SNOMEDCT Code 428191000124101)"

Supplemental Data Elements

SDE Ethnicity

["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

["Patient Characteristic Payer": "Payer"]

SDE Race

["Patient Characteristic Race": "Race"]

SDE Sex

["Patient Characteristic Sex": "ONC Administrative Sex"]

Risk Adjustment Variables

None

Measure Set CLINICAL QUALITY MEASURE SET Quality ID #47 (NQF 0326): Advance Care Plan – National Quality Strategy Domain: Communication and Care Coordination – Meaningful Measure Area: Care is Personalized and Aligned with Patient’s Goals 2021 COLLECTION TYPE: MIPS CLINICAL QUALITY MEASURES (CQMS)

MEASURE TYPE: Process – High Priority

DESCRIPTION: Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan

INSTRUCTIONS: This measure is to be submitted a minimum of once per performance period for patients seen during the performance period. There is no diagnosis associated with this measure. This measure may be submitted by Merit- based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

NOTE: This measure is appropriate for use in all healthcare settings (e.g., inpatient, nursing home, ambulatory) except the emergency department. For each of these settings, there should be documentation in the medical record(s) that advance care planning was discussed or documented.

NOTE: Patient encounters for this measure conducted via telehealth (e.g., encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable.

DENOMINATOR: All patients aged 65 years and older

DENOMINATOR NOTE: MIPS eligible clinicians indicating the Place of Service as the emergency department will not be included in this measure.

Denominator Criteria (Eligible Cases): Patients aged ≥ 65 years on date of encounter AND Patient encounter during the performance period (CPT or HCPCS): 90791, 90832, 90834, 90837, 90845, 90846, 90847, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99291, 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, G0402, G0438, G0439 WITHOUT Place of Service (POS): 23 Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 1 of 7

AND NOT DENOMINATOR EXCLUSION: Hospice services received by patient any time during the measurement period: G9692 NUMERATOR: Patients who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan

Definition: Documentation that Patient did not Wish or was not able to Name a Surrogate Decision Maker or Provide an Advance Care Plan – May also include, as appropriate, the following: • That the patient’s cultural and/or spiritual beliefs preclude a discussion of advance care planning, as it would be viewed as harmful to the patient's beliefs and thus harmful to the physician-patient relationship.

Numerator Instruction: If patient’s cultural and/or spiritual beliefs preclude a discussion of advance care planning, submit 1124F.

NUMERATOR NOTE: The CPT Category II codes used for this measure indicate: Advance Care Planning was discussed and documented. The act of using the Category II codes on a claim indicates the provider confirmed that the Advance Care Plan was in the medical record (that is, at the point in time the code was assigned, the Advance Care Plan in the medical record was valid) or that advance care planning was discussed. The codes are required annually to ensure that the provider either confirms annually that the plan in the medical record is still appropriate or starts a new discussion.

The provider does not need to review the Advance Care Plan annually with the patient to meet the numerator criteria; documentation of a previously developed advanced care plan that is still valid in the medical record meets numerator criteria.

Services typically provided under CPT codes 99497 and 99498 satisfy the requirement of Advance Care Planning discussed and documented, minutes. If a patient received these types of services, submit CPT II 1123F or 1124F.

Numerator Options: Performance Met: Advance Care Planning discussed and documented; advance care plan or surrogate decision maker documented in the medical record (1123F) OR Performance Met: Advance Care Planning discussed and documented in the medical record; patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan (1124F) OR Performance Not Met: Advance Care Planning not documented, reason not otherwise specified (1123F with 8P) RATIONALE: It is essential that the patient’s wishes regarding medical treatment be established as much as possible prior to incapacity. The Work Group has determined that the measure should remain as specified with no required timeframe based on a review of the literature. Studies have shown that people do change their preferences often with regard to advanced care planning, but it primarily occurs after a major medical event or other health status change. In the

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 2 of 7 stable patient, it would be very difficult to define the correct interval. It was felt by the Work Group that the error rate in simply not having addressed the issue at all is so much more substantial (Teno, 1997) than the risk that an established plan has become outdated that we should not define a specific timeframe at this time. As this measure is tested and reviewed, we will continue to evaluate if and when a specific timeframe should be included.

CLINICAL RECOMMENDATION STATEMENTS: Advance directives are designed to respect patient’s autonomy and determine his/her wishes about future life- sustaining medical treatment if unable to indicate wishes. Key interventions and treatment decisions to include in advance directives are: resuscitation procedures, mechanical respiration, chemotherapy, radiation therapy, dialysis, simple diagnostic tests, pain control, blood products, transfusions, and intentional deep sedation.

Oral statements:

• Conversations with relatives, friends, and clinicians are most common form; should be thoroughly documented in medical record for later reference. • Properly verified oral statements carry same ethical and legal weight as those recorded in writing. Instructional advance directives (DNR orders, living wills):

• Written instructions regarding the initiation, continuation, withholding, or withdrawal of particular forms of life- sustaining medical treatment. • May be revoked or altered at any time by the patient. • Clinicians who comply with such directives are provided legal immunity for such actions. Durable power of attorney for health care or health care proxy:

• A written document that enables a capable person to appoint someone else to make future medical treatment choices for him or her in the event of decisional incapacity. (AGS)

The National Hospice and Palliative Care Organization provides the Caring Connection web site, which provides resources and information on end-of-life care, including a national repository of state-by-state advance directives.

COPYRIGHT: This Physician Performance Measure (Measure) and related data specifications were developed by the former PCPI® Foundation (PCPI®) and the National Committee for Quality Assurance (NCQA). Neither the American Medical Association (AMA) or NCQA shall be responsible for any use of the Measure. The Measure is not a clinical guideline and does not establish a standard of medical care and has not been tested for all potential applications.

THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.

The AMA and NCQA make no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications.

The Measure can be reproduced and distributed, without modification, for noncommercial purposes (e.g., use by healthcare providers in connection with their practices) without obtaining approval from NCQA. Commercial use is defined as the sale, licensing, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain. All commercial uses or requests for modification must be approved by NCQA and are subject to a license at the discretion of NCQA.

Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. The AMA and NCQA disclaim all liability Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 3 of 7 for use or accuracy of any third party codes contained in the specifications.

CPT® contained in the Measure specifications is copyright 2004-2020 American Medical Association. LOINC® copyright 2004-2020 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms® (SNOMED CT®) copyright 2004-2020 International Health Terminology Standards Development Organisation. ICD-10 copyright 2020 World Health Organization. All Rights Reserved.

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 4 of 7 2021 Clinical Quality Measure Flow for Quality ID #47 (NQF 0326): Advance Care Plan Disclaimer: Refer to the measure specification for specific coding and instructions to submit this measure.

Start Denominator Numerator

Advance Care Planning discussed and Data Completeness Met + documented; advance care plan Performance Met or surrogate decision maker Yes 1123F or equivalent Patients aged documented in the (30 patients) ≥ 65 years on date of 1 No medical record a encounter

No Yes

Advance Patient Care Planning encounter during discussed and documented Data Completeness Met + Not included in Eligible No the performance period in the medical record; patient Performance Met Population/Denominator Yes as listed in did not wish or was not able to 1124F or equivalent name a surrogate decision (10 patients) Denominator* 2 maker or provide an a advance care plan

Yes No

Denominator Exclusion Hospice services received by patient any time during Data Completeness Met + Yes the measurement period: Advance Care Planning Performance Not Met G9692 or not documented, reason not Yes 1123F with 8P or equivalent equivalent otherwise specified (30 patients) c

No Include in Eligible Population/ Data Completeness Not Met Denominator Quality Data Code or equivalent (80 patients) d not submitted (10 patients)

SAMPLE CALCULATIONS Data Completeness= Performance Met (a1+a2=40 patients) + Performance Not Met (c=30 patients) = 70 patients = 87.50% Eligible Population / Denominator (d=80 patients) = 80 patients

Performance Rate= Performance Met (a1+a2=40 patients) = 40 patients = 57.14% Data Completeness Numerator (70 patients) = 70 patients

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 5 of 7 2021 Clinical Quality Measure Flow Narrative for Quality ID #047 (NQF 0326): Advance Care Plan Disclaimer: Refer to the measure specification for specific coding and instructions to submit this measure.

1. Start with Denominator

2. Check Patients aged greater than or equal to 65 years on date of encounter:

a. If Patients aged greater than or equal to 65 years on date of encounter equals No, do not include in Eligible Population/Denominator. Stop processing.

b. If Patients aged greater than or equal to 65 years on date of encounter equals Yes, proceed to Patient encounter during the performance period as listed in Denominator*.

3. Check Patient encounter during the performance period as listed in Denominator*:

a. If Patient encounter during the performance period as listed in Denominator* equals No, do not include in Eligible Population/Denominator. Stop processing.

b. If Patient encounter during the performance period as listed in Denominator* equals Yes, proceed to Hospice services received by patient any time during the measurement period.

4. Check Hospice services received by patient any time during the measurement period:

a. If Hospice services received by patient any time during the measurement period equals No, include in Eligible Population/Denominator.

b. If Hospice services received by patient any time during the measurement period equals Yes, do not include in Eligible Population/Denominator. Stop processing.

5. Denominator Population:

a. Denominator Population is all Eligible Patients in the Denominator. Denominator is represented as Denominator in the Sample Calculation listed at the end of this document. Letter d equals 80 patients in the Sample Calculation.

6. Start Numerator

7. Check Advance Care Planning discussed and documented; advance care plan or surrogate decision make documented in the medical record:

a. If Advance Care Planning discussed and documented; advance care plan or surrogate decision make documented in the medical record equals Yes, include in Data Completeness Met and Performance Met.

• Data Completeness Met and Performance Met letter is represented as Data Completeness and Performance Rate in the Sample Calculation listed at the end of this document. Letter a equals 30 patients in the Sample Calculation.

b. If Advance Care Planning discussed and documented; advance care plan or surrogate decision make documented in the medical record equals No, proceed to Advance Care Planning Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 6 of 7 discussed and documented in the medical record; patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.

8. Check Advance Care Planning discussed and documented in the medical record; patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan:

a. Advance Care Planning discussed and documented in the medical record; patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan equals Yes, include in Data Completeness Met and Performance Met.

b. If Advance Care Planning discussed and documented in the medical record; patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan equals No, proceed to Advance Care Planning not documented, reason not otherwise specified.

9. Check Advance Care Planning not documented, reason not otherwise specified:

a. If Advance Care Planning not documented, reason not otherwise specified equals Yes, include in Data Completeness Met and Performance Not Met.

• Data Completeness Met and Performance Not Met letter is represented as Data Completeness in the Sample Calculation listed at the end of this document. Letter c equals 30 patients in the Sample Calculation.

b. If Advance Care Planning not documented, reason not otherwise specified equals No, proceed to Data Completeness Not Met.

10. Check Data Completeness Not Met:

a. If Data Completeness Not Met, the Quality Data Code or equivalent was not submitted. 10 patients have been subtracted from the Data Completeness Numerator in Sample Calculation.

Sample Calculations:

Data Completeness equals Performance Met ( a plus a equals 40 patients) plus Performance Not Met (c equals 30 patients) divided by Eligible Population/Denominator (d equals 80 patients). All equals 70 patients divided by 80 patients. All equals 87.5 percent.

Performance Rate equals Performance Met ( a plus a equals 40) divided by Data Completeness Numerator (70 patients). All equals 40 patients divided by 70 patients. All equals 57.14 percent.

*See the posted measure specification for specific coding and instructions to submit this measure. NOTE: Submission Frequency: Patient-process The measure diagrams were developed by CMS as a supplemental resource to be used in conjunction with the measure specifications. They should not be used alone or as a substitution for the measure specification.

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 7 of 7 Quality ID #268: Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy – National Quality Strategy Domain: Effective Clinical Care – Meaningful Measure Area: Management of Chronic Conditions

2021 COLLECTION TYPE: MIPS CLINICAL QUALITY MEASURES (CQMS)

MEASURE TYPE: Process

DESCRIPTION: Percentage of all patients of childbearing potential (12 years and older) diagnosed with epilepsy who were counseled at least once a year about how epilepsy and its treatment may affect contraception and pregnancy

INSTRUCTIONS: This measure is to be submitted a minimum of once per performance period for patients with a diagnosis of epilepsy during the performance period. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

NOTE: Patient encounters for this measure conducted via telehealth (e.g., encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable.

Measure Submission Type: Measure data may be submitted by individual MIPS eligible clinicians, groups, or third-party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality-data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third-party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third-party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

DENOMINATOR: All females, including all individuals of childbearing potential (12 years and older) with a diagnosis of epilepsy.

Definition: Female Unable to Bear Children – For the purposes of this measure, this includes patients who are pre- menstrual, post-menopausal, surgically sterile, or have reproductive organs absent, and is represented by code M1016.

Denominator Criteria (Eligible Cases): All females age 12 years and older AND Diagnosis for Epilepsy (ICD-10-CM):G40.001, G40.009, G40.011, G40.019, G40.101, G40.109, G40.111, G40.119, G40.201, G40.209, G40.211, G40.219, G40.301, G40.309, G40.311, G40.319, G40.401, G40.409, G40.411, G40.419, G40.501, G40.509, G40.801, G40.802, G40.803, G40.804, G40.811, G40.812, G40.813, G40.814, G40.821, G40.822, G40.823, G40.824, G40.901, G40.909, G40.911, G40.919, G40.A01, G40.A09, G40.A11, G40.A19, G40.B01, G40.B09, G40.B11, G40.B19 AND Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 1 of 7 Patient encounter during the performance period (CPT): 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241*, 99242*, 99243*, 99244*, 99245* AND NOT DENOMINATOR EXCLUSION: Female Patients Unable to Bear Children: M1016

NUMERATOR: Female patients or caregivers counseled at least once a year about how epilepsy and its treatment may affect contraception and pregnancy

Definition: Counseling – Counseling must include a discussion of at least two of the following three counseling topics: • Need for folic acid supplementation, • Drug to drug interactions with contraception medication, • Potential anti-seizure medications effect(s) on fetal/child development and/or pregnancy. Numerator Options: Performance Met: Counseling for women of childbearing potential with epilepsy (4340F) OR Performance Not Met: Counseling about epilepsy specific safety issues provided to patient or caregiver was not performed, reason not otherwise specified (4340F with 8P) RATIONALE: Epilepsy is associated with reduced fertility, increased pregnancy risks, and risks for malformations in the infant. Treatment of seizures with anti-seizure medications may alter hormone levels, render oral contraceptives less effective and may interfere with embryonic and fetal development. Certain anti-seizure medications may have specific malformation risks. Folic acid supplementation, monotherapy for epilepsy, using lower doses of medication when possible, and proper obstetrical, prenatal and pre-pregnancy care all should be discussed with the patient so they understand the risks involved and how to mitigate these risks.

CLINICAL RECOMMENDATION STATEMENTS: [AED=Antiepileptic Drugs; WWE= Women with Epilepsy; MCMs=major congenital malformations; VPA=valproate; PHT=phenytoin; LTG=lamotrigine; CBZ=carbamazepine; PHT=phenytoin; PB=phenobarbital] • There is probably no substantially increased risk (greater than two times expected) of late pregnancy bleeding for WWE taking AEDs (Level B). Neurology 2009; 73(2): 126-132 • There is probably no moderately increased risk (greater than 1.5 times expected) of premature contractions or premature labor and delivery for WWE taking AEDs (Level B). Neurology 2009; 73(2): 126-132 • Seizure freedom for at least 9 months prior to pregnancy is probably associated with a high likelihood (84%–92%) of remaining seizure-free during pregnancy (Level B). Neurology 2009; 73(2): 126-132 • Counseling of WWE who are contemplating pregnancy should reflect that there is probably no increased risk of reduced cognition in the offspring of WWE not taking AEDs (Level B). Neurology; 73(2): 133–141. • If possible, avoidance of the use of VPA as part of polytherapy during the first trimester of pregnancy should be considered to decrease the risk of MCMs (Level B). Neurology; 73(2): 133–141. • To reduce the risk of MCMs, the use of VPA during the first trimester of pregnancy should be avoided, if possible, compared to the use of CBZ (Level A). Neurology; 73(2): 133–141. • To reduce the risk of MCMs, avoidance of the use of polytherapy with VPA during the first trimester of pregnancy, if possible, should be considered, compared to polytherapy without VPA (Level B). Neurology; 73(2): 133–141. • Avoidance of the use of VPA, if possible, should be considered to reduce the risk of neural tube defects and facial clefts (Level B) and may be considered to reduce the risk of hypospadias (Level C). Neurology; 73(2): 133–141. • CBZ exposure probably does not produce cognitive impairment in offspring of WWE (Level B). Neurology; 73(2): Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 2 of 7 133–141. • Avoiding VPA in WWE during pregnancy, if possible, should be considered to reduce the risk of poor cognitive outcomes (Level B). Neurology; 73(2): 133–141. • For WWE who are pregnant, avoidance of VPA, if possible, should be considered compared to CBZ to reduce the risk of poor cognitive outcomes (Level B). Neurology; 73(2): 133–141. • The fact that PB, PRM, PHT, CBZ, LVT, VPA, GBP, LTG, OXC, and TPM cross the placenta may be factored into the clinical decision regarding the necessity of AED treatment for a woman with epilepsy (Level B for PB, PRM, PHT, CBZ, LVT, and VPA, and Level C for GBP, LTG, OXC, and TPM). Neurology 2009; 73(2): 142-149

CPT® contained in the Measures specifications is copyright 2004 – 2020 American Medical Association. G codes and associated descriptions included in these Measure specifications are in the public domain.

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 3 of 7 2021 Clinical Quality Measure Flow for Quality ID #268: Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy Disclaimer: Refer to the measure specification for specific coding and instructions to submit this measure.

Denominator Numerator Start

Counseling for women Data Completeness Met + of childbearing potential Yes Performance Met with epilepsy 4340F or equivalent (40 patients) a All females age No 12 years and older No

Yes

Counseling about epilepsy Data Completeness Met + specific safety issues provided to Performance Not Met Yes patient or caregiver was not 4340F with 8P or equivalent Diagnosis for Epilepsy performed, reason not (30 patients) No as listed in otherwise specified b Denominator*

Not Included in Eligible No Population/Denominator Yes

Data Completeness Not Met the Quality Data Code or equivalent was not submitted Patient encounter (10 patients) No during the performance period as listed in Denominator*

Yes

Female patients Yes unable to bear children: M1016 or equivalent Denominator Exclusion

Include in Eligible Population/ Denominator (80 patients) d

Data Completeness= Performance Met (a=40 patients) + Performance Not Met (b=30 patients) = 70 patients = 87.50% Eligible Population / Denominator (d=80 patients) = 80 patients

Performance Rate= Performance Met (a=40 patients) = 40 patients = 57.14% Data Completeness Numerator (70 patients) = 70 patients

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 5 of 7 2021 Clinical Quality Measure Flow Narrative for Quality ID #268: Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy Disclaimer: Refer to the measure specification for specific coding and instructions to submit this measure.

1. Start with Denominator

2. Check All females age 12 years and older:

a. If All females age 12 years and older equals No, do not include in Eligible Population/Denominator. Stop Processing.

b. If All females age 12 years and older equals Yes, proceed to check Diagnosis for Epilepsy as listed in Denominator*.

3. Check Diagnosis for Epilepsy as listed in Denominator*:

a. If Diagnosis for Epilepsy as listed in Denominator* equals No, do not include in Eligible Population/Denominator. Stop Processing.

b. If Diagnosis for Epilepsy as listed in Denominator* equals Yes, proceed to check Patient encounter during the performance period as listed in Denominator*.

4. Check Patient encounter during the performance period as listed in Denominator*:

a. If Patient encounter during the performance period as listed in Denominator* equals No, do not include in Eligible Population/Denominator. Stop Processing.

b. If Patient encounter during the performance period as listed in Denominator* equals Yes, proceed to check Female patients unable to bear children.

5. Check Female patients unable to bear children:

a. If Female patients unable to bear children equals Yes, do not include in Eligible Population/Denominator. Stop Processing.

b. If Female patients unable to bear children equals No, include in Eligible Population/Denominator.

6. Denominator Population:

7. Start Numerator

8. Check Counseling for women of childbearing potential with epilepsy:

a. If Counseling for women of childbearing potential with epilepsy equals Yes, include in Data Completeness Met and Performance Met.

b. If Counseling for women of childbearing potential with epilepsy equals No, proceed to check Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 6 of 7 Counseling about epilepsy specific safety issues provided to patient or caregiver was not performed, reason not otherwise specified.

9. Check Counseling about epilepsy specific safety issues provided to patient or caregiver was not performed, reason not otherwise specified:

a. If Counseling about epilepsy specific safety issues provided to patient or caregiver was not performed, reason not otherwise specified equals Yes, include in Data Completeness Met and Performance Not Met.

• Data Completeness Met and Performance Not Met letter is represented in the Data Completeness in the Sample Calculation listed at the end of this document. Letter b equals 30 patients in the Sample Calculation.

b. If Counseling about epilepsy specific safety issues provided to patient or caregiver was not performed, reason not otherwise specified equals No, proceed to check Data Completeness Not Met.

10. Check Data Completeness Not Met:

• If Data Completeness Not Met, the Quality Data Code or equivalent not submitted. 10 visits have been subtracted from the Data Completeness Numerator in the Sample Calculation.

Sample Calculations Data Completeness equals Performance Met (a equals 40 patients) plus Performance Not Met (b equals 30 patients) divided by Eligible Population/Denominator (d equals 80 patients). All equals 70 patients divided by 80 patients. All equals 87.50 percent. Performance Rate equals Performance Met (a equals 40 patients) divided by Data Completeness Numerator (70 patients). All equals 40 patients divided by 70 patients. All equals 57.14 percent.

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 7 of 7 Quality ID #419: Overuse of Imaging for the Evaluation of Primary Headache – National Quality Strategy Domain: Efficiency and Cost Reduction – Meaningful Measure Area: Appropriate Use of Healthcare

2021 COLLECTION TYPE: MIPS CLINICAL QUALITY MEASURES (CQMS)

MEASURE TYPE: Process – High Priority

DESCRIPTION: Percentage of patients for whom imaging of the head (CT or MRI) is obtained for the evaluation of primary headache when clinical indications are not present

INSTRUCTIONS: This measure is to be submitted at each denominator eligible visit for patients with a diagnosis of primary headache during the performance period. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

NOTE: Patient encounters for this measure conducted via telehealth (e.g., encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable.

DENOMINATOR: All patients seen for evaluation of primary headache

Definition: Change in headache - A significant change in severity of the headache including changes in location or quality. Other criteria take into account most red flag symptoms and also may reflect change (if a stable primary headache were previously present) but do not reflect a previously tolerated headache that now becomes suddenly disabling in severity. Change also includes any and all new symptoms that may be associated with a headache: arm numbness, speech disturbance, etc.

Denominator Criteria (Eligible Cases): All patients, regardless of age AND Diagnosis for Primary Headache (ICD-10-CM): G43.001, G43.009, G43.011, G43.019, G43.101, G43.109, G43.111, G43.119, G43.401, G43.409, G43.411, G43.501, G43.509, G43.511, G43.519, G43.601, G43.609, G43.611, G43.619, G43.701, G43.709, G43.711, G43.719, G43.801, G43.809,

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 1 of 8 G43.811, G43.819, G43.821, G43.829, G43.831, G43.839, G43.901, G43.909, G43.911, G43.919, G44.019, G44.029, G44.039, G44.1, G44.209, G44.219, G44.221, G44.229, G44.52, G44.59, G44.81, G44.82, G44.89, , R51.0, R51.9, G44.009, G44.049, G44.059, G44.099, G44.51, G44.53, G44.83, G44.84, G44.85 AND Patient encounter during the performance period (CPT): 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241*, 99242*, 99243*, 99244*, 99245* AND NOT DENOMINATOR EXCLUSION: Patients with clinical indications for imaging of the head: • Head trauma: G2187 • New or change in headache above 50 years of age: G2188 • Abnormal neurologic exam: G2189 • Headache radiating to the neck: G2190 • Positional headaches: G2191 • Temporal headaches in patients over 55 years of age: G2192 • New onset headache in pre-school children or younger (<6 years of age): G2193 • New onset headache in pediatric patients with disabilities for which headache is a concern as inferred from behavior: G2194 • Occipital headache in children: G2195 • Thunderclap headache: G44.53 • Trigeminal pain: G50.0 • Persistent headaches: G44.52

NUMERATOR: Patients for whom imaging of the head (Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) is obtained for the evaluation of primary headache when clinical indications are not present

Numerator Instruction: INVERSE MEASURE - A lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Submitting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.

Numerator Options: Performance Met: Imaging of the head (CT or MRI) was obtained (M1027) OR Denominator Exception: Documentation of patients with primary headache diagnosis and imaging other than CT or MRI obtained (M1028) OR Denominator Exception: Imaging needed as part of a clinical trial; or other clinician ordered the study (G9537) OR Performance Not Met: Imaging of the head (CT or MRI) was NOT obtained, Reason not given (M1029)

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 2 of 8 RATIONALE: Imaging headache patients absent specific risk factors for structural disease is not likely to change management or improve outcome. Those patients with a significant likelihood of structural disease requiring immediate attention are detected by clinical screens that have been validated in many settings. Many studies and clinical practice guidelines concur. Also, incidental findings lead to additional medical procedures and expense that do not improve patient well-being.

Overuse of neuroimaging in pediatric patients was reported over a 13-year study period ranging from 41-47% in a study by Graf, et. al. Combining the results of the previous eight studies performed in children with recurrent headaches (7 in clinic-based population, 1 in children referred for neuroimaging), neuroimaging was undertaken in 38.1% of the study populations (1,072/2,815; range 17.5–100%).

You, et al. determined the indications for CT and MRI in Ontario. They studied 11,824 CT and 11,867 MRI scans from a random sample of 40 hospitals in Ontario. Hospital sampling was stratified by region and hospital teaching status. The publication reports that of the 11,824 CT scans completed, 3,930 (33%) were of the head and 1,055 (26.8%) of these were for the indication of headache. Because the CT scans were done for more than one indication the actual proportion of CT scans done solely for the purpose of headache was 16%. Similarly, 4,038 (34%) of all MRI scans were head scans of which 523 (13%) were for the indication of headache. However, similar to CT scans, the MRI scans were requested for multiple indications and the actual proportion of MRI scans done solely for the purpose of headache was estimated to be 4% (Unpublished data, personal communication with author, April 29, 2010).

Information concerning the workup of headache in the ambulatory setting is limited. In actual practice, only about 3% of patients who present with a new headache in the office setting have neuroimaging ordered. When neuroimaging is performed, about 4% of CT scans find a significant and treatable lesion (in one sample of 293 CT scans, there were 12 true-positive scans and 2 false-positive scans). Expert guidelines regarding headaches among ambulatory patients recommend neuroimaging for migraine patients only in the presence of persistent focal abnormal neurological findings.

Opportunity for Improvement: There is a marked need to reduce the unnecessary use of neuroimaging for atraumatic primary headache disorders. This measure is intended to reduce the use of these unnecessary tests, reduce treatment costs, and improve patient safety by reducing the exposure to unnecessary radiation and testing.

CLINICAL RECOMMENDATION STATEMENTS: Neuroimaging recurrent headache: Obtaining a neuroimaging study on a routine basis is not indicated in children with recurrent headaches and a normal neurologic examination. (Level B)

Neuroimaging is not usually warranted for patients with migraine and normal neurological examination. (Level B)

Neuroimaging is not indicated in patients with a clear history of migraine, without red flag features for potential secondary headache, and a normal neurological examination. (Level D)* Only included because it supports neuroimaging overuse in normal exam patients with migraine. But low level evidence. *deemed by guideline group to be one of the most clinically important recommendations.

Do not refer people diagnosed with TTH, migraine, CH or medication overuse headache (MOH) for neuroimaging solely for reassurance.

In adult and pediatric patients with migraine, with no recent change in pattern, no history of seizures, and no other focal neurological signs or symptoms, the routine use of neuroimaging is not warranted. (Grade B)

Don’t do imaging for uncomplicated headache.

The US Headache Consortium identified three consensus-based (not evidence-based) general principles of management for making decisions regarding neuroimaging in patients with headache: 1) testing should be avoided if it will not lead to a change in management; 2) testing is not recommended if the patient is not significantly more likely than anyone else in the general population to have a significant abnormality; and 3) testing that normally may not be recommended as a population policy may make sense at an individual level, resources notwithstanding.

Scottish Intercollegiate Guidelines Network – Diagnosis and management of headache in adults:

• Neuroimaging is not indicated in patients with a clear history of migraine, without red flag features for potential secondary headache, and a normal neurological examination. • Clinicians requesting neuroimaging should be aware that both MRI and CT can identify incidental neurological abnormalities which may result in patient anxiety as well as practical and ethical dilemmas with regard to management. • Brain CT should be performed in patients with headache who have unexplained abnormal neurological signs, unless the clinical history suggests MRI is indicated.

Institute for Clinical Systems Improvement – Diagnosis and Treatment of Headache:

• Clinicians should use a detailed headache history that includes duration of attacks and the exclusion of secondary causes as the principal means to diagnose primary headache. Additional testing in patients without atypical symptoms or an abnormal neurologic examination is unlikely to be helpful. There are, as yet, no tests that confirm the diagnosis of primary headache. The diagnosis of primary headache is dependent on the clinician. The work group recommends careful consideration before proceeding with neuroimaging (CT or MRI).

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 4 of 8 2021 Clinical Quality Measure Flow for Quality ID #419: Overuse of Imaging for the Evaluation of Primary Headache

Disclaimer: Refer to the measure specification for specific coding and instructions to submit this measure.

Numerator

Start Denominator Data Completeness Met + Imaging of the head Performance Met Yes (CT or MRI) was obtained M1027 or equivalent (20 visits) All patients, regardless a of age

Diagnosis for No primary headache as listed in Documentation of Data Completeness Met + Denominator* patients with primary headache Denominator Exception Yes diagnosis and imaging other than M1028 or equivalent CT or MRI obtained (10 visits) b1 Yes

No Patient encounter during the performance No period as listed in Denominator*

Data Completeness Met + Imaging needed Denominator Exception as part of a clinical trial; or other Yes G9537 or equivalent Yes clinician ordered the study Not Included in Eligible (0 visits) Population/Denominator b2 Denominator Exclusion Patients with clinical indications No Yes for imaging of the head as listed in Denominator*

Data Completeness Met + Imaging of the head Performance Not Met Yes No (CT or MRI) was NOT obtained, M1029 or equivalent reason not given (40 visits)

Include in Eligible Population/Denominator (80 visits) d No

Data Completeness Not Met the Quality Data Code or equivalent was not submitted (10 visits)

Data Completeness= Performance Met (a=20 visits) + Denominator Exceptions (b1+b2=10 visits) + Performance Not Met (c=40 visits) = 70 visits = 87.50% Eligible Population / Denominator (d=80 visits) = 80 visits

Performance Rate= Performance Met (a=20 visits) = 20 visits = 33.33% Data Completeness Numerator (70 visits) – Denominator Exceptions (b1+b2=10 visits) = 60 visits

*See the posted measure specification for specific coding and instructions to submit this measure. NOTE: Submission Frequency: Visit CPT only copyright 2020 American Medical Association. All right s reserved. The measure diagrams were developed by CMS as a supplement al resource t o be used in conjunction with the measure specifications. They should not be used alone or as a substitution for the measure specificat ion. v5

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 6 of 8 2021 Clinical Quality Measure Flow Narrative for Quality ID #419: Overuse of Imaging for the Evaluation of Primary Headache Disclaimer: Refer to the measure specification for specific coding and instructions to submit this measure.

1. Start with Denominator

2. All patients regardless of age

3. Check Diagnosis for primary headache as listed in Denominator*:

a. If Diagnosis for primary headache as listed in Denominator* equals No, do not include in Eligible Population/Denominator. Stop Processing.

b. If Diagnosis for primary headache as listed in Denominator* equals Yes, proceed to check Patient encounter during the performance period as listed in Denominator*.

4. Check Patient encounter during the performance period as listed in Denominator*:

a. If Patient encounter during the performance period as listed in Denominator* equals No, do not include in Eligible Population/Denominator. Stop Processing.

b. If Patient encounter during the performance period as listed in Denominator* equals Yes, proceed to check Patients with clinical indications for imaging of the head as listed in Denominator*.

5. Check Patients with clinical indications for imaging of the head as listed in Denominator*:

a. If Patients with clinical indications for imaging of the head as listed in Denominator* equals Yes, do not include in Eligible Population/Denominator. Stop Processing.

b. If Patients with clinical indications for imaging of the head as listed in Denominator* equals No, include in Eligible Population/Denominator.

6. Denominator Population:

• Denominator Population is all Eligible Visits in the Denominator. Denominator is represented as Denominator in the Sample Calculation listed at the end of this document. Letter d equals 80 visits in the Sample Calculation.

7. Start Numerator

8. Check Imaging of the head (CT or MRI) was obtained:

a. If Imaging of the head (CT or MRI) was obtained equals Yes, include in Data Completeness Met and Performance Met.

b. If Imaging of the head (CT or MRI) was obtained equals No, proceed to check Documentation of patients with primary headache diagnosis and imaging other than CT or MRI obtained.

9. Check Documentation of patients with primary headache diagnosis and imaging other than CT or MRI obtained:

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 7 of 8 a. If Documentation of patients with primary headache diagnosis and imaging other than CT or MRI obtained equals Yes, include in Data Completeness Met and Denominator Exception.

b. If Documentation of patients with primary headache diagnosis and imaging other than CT or MRI obtained equals No, proceed to check Imaging needed as part of a clinical trial; or other clinician ordered the study.

10. Check Imaging needed as part of a clinical trial; or other clinician ordered the study:

a. If Imaging needed as part of a clinical trial; or other clinician ordered the study equals Yes, include in Data Completeness Met and Denominator Exception.

• Data Completeness and Denominator Exception is represented in the Data Completeness and Performance Rate in the Sample Calculation listed at the end of this document. Letter b 2 equals 0 visits in the Sample Calculation.

b. If Imaging needed as part of a clinical trial; or other clinician ordered the study equals No, proceed to check Imaging of the head (CT or MRI) was NOT obtained, reason not given.

11. Check Imaging of the head (CT or MRI) was NOT obtained, reason not given:

a. If Imaging of the head (CT or MRI) was NOT obtained, reason not given equals Yes, include in Data Completeness Met and Performance Not Met.

• Data Completeness Met and Performance Not Met letter is represented in the Data Completeness in the Sample Calculation listed at the end of this document. Letter c equals 40 visits in the Sample Calculation.

b. If Imaging of the head (CT or MRI) was NOT obtained, reason not given equals No, proceed to check Data Completeness Not Met.

12. Check Data Completeness Not Met:

• If Data Completeness Not Met, the Quality Data Code or equivalent was not submitted. 10 visits have been subtracted from the Data Completeness Numerator in the Sample Calculation.

Sample Calculations Data Completeness equals Performance Met (a equals 20 visits) plus Denominator Exceptions (b 1 plus b 2 equals 10 visits) plus Performance Not Met (c equals 40 visits) divided by Eligible Population/Denominator (d equals 80 visits). All equals 70 visits divided by 80 visits. All equals 87.50 percent.

Performance Rate equals Performance Met (a equals 20 visits) divided by Data Completeness Numerator (70 visits) minus Denominator Exceptions (b1 plus b2 equals 10 visits). All equals 20 visits divided by 60 visits. All equals 33.33 percent.

*See the posted measure specification for specific coding and instructions to submit this measure. NOTE: Submission Frequency: Visit The measure diagrams were developed by CMS as a supplemental resource to be used in conjunction with the measure specifications. They should not be used alone or as a substitution for the measure specification.

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 8 of 8 Exercise and Appropriate Physical Activity Counseling for Patients with MS Measure Description Percentage of patients with MS who are counseled* on the benefits of exercise and appropriate physical activity for patients with MS in the past 12 months.

Measure Components Numerator Patients with MS counseled* on the benefits of exercise and appropriate physical Statement activity for patients with MS in past 12 months.

*Counseled: to advise seriously and formally after consultation1 Denominator All patients with a diagnosis of MS. Statement Denominator None** Exceptions **All patients including those unable to exercise should be provided information on appropriate range of motion and activity. Supporting The following evidence statements are quoted verbatim from the referenced Guideline & clinical guidelines: Other References x “Evidence-based treatment interventions for mobility optimization include exercise promotion (Level 1).”2 x “Encourage participation in a regular pattern of exercise to improve mood (Level 1).”2 x “Encourage people with MS to exercise. Advise them that regular exercise may have beneficial effects on their MS and does not have any harmful effects on their MS.”3 x “Ensure all people with MS have a comprehensive review of all aspects of their care at least once a year.”3 x “Tailor the comprehensive review to the needs of the person with MS assessing: General health: …exercise…”3 Measure Importance Relationship to Increased rates of physical activity and exercise improve the physical functioning Desired levels and quality of life for patients with MS.4 Outcome Opportunity for Despite known benefits of exercise and physical activity, persons with MS remain Improvement inactive.5,6 The Work Group encourages referral to rehabilitation services, including physical therapy, when clinically appropriate given the evidence supporting improved outcomes for patients.7-9 National Quality ܆ Patient and Family Engagement Strategy ☐ Patient Safety Domains ܆Care Coordination ☐ Population/Public Health ܆ Efficient Use of Healthcare Resources ܈ Clinical Process/Effectiveness Exception Not Applicable Justification Harmonization There are currently not comparable measures in national measurement with Existing programs or endorsed by the National Quality Forum. Measures Measure Designation

Measure Purpose ☒ Quality improvement (Check all that ☒ Accountability apply) Type of Measure ☒Process (Check all that ☐ Outcome apply) ☐ Structure Level of ☒ Individual Provider Measurement ☒ Practice (Check all that ܈ System or Health Plan apply) Care Setting ☒ Outpatient (Check all that ☐ Inpatient apply) ☐ Emergency Departments and Urgent Care Data Source ☒ Electronic health record (EHR) data (Check all that ☒Administrative Data/Claims apply) ☐ Chart Review ☒ Registry References 1 Merriam Webster. Available at: http://www.merriam-webster.com/medical/counsel 2 American Association of Neuroscience Nurses (AANN), Association of Rehabilitation Nurses (ARN), International Organization of Multiple Sclerosis Nurses (IOMSN). Nursing management of the patient with multiple sclerosis. Glenview (IL): American Association of Neuroscience Nurses (AANN); 2011. 49 p. 3 National Institute for Health and Care Excellence. Multiple sclerosis: management of multiple sclerosis in primary and secondary care. NICE Clinical Guideline 186. October 2014. 4 American College of Sports Medicine: ACSM's Resource Manual for Guidelines for Exercise Testing and Prescription, 6th edition edn. Baltimore, MD: Lippincott Williams & Wilkins; 2010. 5 Mayo NE, Bayley M, Duquette P, et. Al. The role of exercise in modifying outcomes for people with multiple sclerosis: a randomized trial. BMC Neurology 2013;13:69. 6 Motl RW, McAuley E, Snook EM. Physical activity and multiple sclerosis: a meta-analysis. Mult Scler 2005; 11(4):459-463. 7 Khan F, Turner-Stokes L, Ng L, et al. Multidisciplinary rehabilitation for adults with multiple sclerosis. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD006036. 8 Rietberg MB, Brooks D, Uitdehaag BMJ, Kwakkel G. Exercise therapy for multiple sclerosis. Cochrane Database of Systematic Reviews 2004, Issue 3. Art. No.: CD003980. 9 Döring A, Caspar FP, Friedemann P, et al. Exercise in multiple sclerosis – an integral component of disease management. The EPMA Journal 2012;3:2-13. Technical Specifications: Electronic Health Record (EHR) Data The AAN is in the process of creating code value sets and the logic required for electronic capture of the quality measures with EHRs. A listing of the quality data model elements, code value sets, and measure logic (through the CMS Measure Authoring Tool) for each of the MS measures will be made available at a later date. Technical Specifications: Administrative Data (Claims) Administrative claims data collection requires users to identify the eligible population (denominator) and numerator using codes recorded on claims or billing forms (electronic or paper). Users report a rate based on all patients in a given practice for whom data are available and who meet the eligible population/ denominator criteria.

Quality ID #291: Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment for Patients with Parkinson’s Disease – National Quality Strategy Domain: Effective Clinical Care – Meaningful Measure Area: Prevention, Treatment and Management of Mental Health

2021 COLLECTION TYPE: MIPS CLINICAL QUALITY MEASURES (CQMS)

MEASURE TYPE: Process

DESCRIPTION: Percentage of all patients with a diagnosis of Parkinson’s Disease [PD] who were assessed for cognitive impairment or dysfunction once in the past 12 months

INSTRUCTIONS: This measure is to be submitted a minimum of once per performance period for patients with a diagnosis of Parkinson’s disease seen during the performance period. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

NOTE: Patient encounters for this measure conducted via telehealth (e.g., encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable.

DENOMINATOR: All patients with a diagnosis of Parkinson’s Disease

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 1 of 6 NUMERATOR: All patients with a diagnosis of Parkinson’s Disease who were assessed for cognitive impairment or dysfunction once in the past 12 months

Definition: Assessed – Is defined as use of a screening tool or referral to neuropsychologist for testing.

Numerator Instructions: Screening tools approved for use in this measure include: (1) • Mini-Mental Status Examination (MMSE)(2,3) • Montreal Cognitive Assessment (MoCA)(2,3) • Dementia Rating Scale (DRS-2) • Parkinson’s Disease Dementia – Short Screen (PDD-SS) • Parkinson Neuropsychiatric Dementia Assessment (PANDA) • Parkinson’s Disease- Cognitive Rating Scale (PD-CRS) • Scales for Outcomes of Parkinson’s Disease – Cognition (SCOPA- Cog)

NUMERATOR NOTE: To meet performance, the cognitive impairment or dysfunction assessment should occur within the previous 12 months from denominator eligible encounter.

Numerator Options: Performance Met: Cognitive impairment or dysfunction assessed (3720F) OR Performance Not Met: Cognitive impairment or dysfunction was not assessed, reason not otherwise specified (3720F with 8P)

RATIONALE: Cognitive functioning impacts life satisfaction and health-related quality of life. It is anticipated that if assessed on an ongoing basis, cognitive deficits may be identified and addressed in a timely manner. Once identified, such deficits could be treated (or patients referred to appropriate resources) and thereby improve individuals quality of life.

CLINICAL RECOMMENDATION STATEMENTS: • The Mini-Mental State Examination (MMSE) and the Cambridge Cognitive Examination (CAM Cog) should be considered as screening tools for dementia in patients with PD (Level B).(4) • An assessment of neuropsychological functioning in a person presenting with parkinsonism suspected of being PD is recommended (Level A) and should include: (I) A collateral history from a reliable carer (II) A brief assessment of cognition (III) Screening for a rapid eye movement (REM) sleep behavior disorder (RBD), psychotic manifestations and severe depression.(5) • Clinical history should be supplemented by an informant (GPP). A neurological and general physical examination should be performed in all patients with dementia (GPP).(6) • Cognitive assessment is central to diagnosis and management of dementias and should be performed in all patients (Level A). Screening tests are available of good accuracy in the general diagnosis of dementia or have been proposed specifically for the differential diagnosis between the different forms of dementia (GPP). Neuropsychological assessment should be performed in all patients in the early stages of the disease (Level B) when the cognitive impairment reflects the disruption of specific brain structures. The neuropsychological assessment should include a global cognitive measure and, in addition, more detailed testing of the main cognitive domains including memory, executive functions and instrumental functions (Level C).(6) • The general practitioner knows the cognitive-behavioral profile of his/her patients and can identify the clinical signs of cognitive decay at their onset, taking also into account the observation of relatives (I/A).(7) • General practitioners should assess all pathological conditions that could cause cognitive disorders (VI/A).(7) Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 2 of 6 • In raising the diagnostic hypothesis of dementia, general practitioners should assess the presence of comorbidities and identify risk factors due to social isolation (VI/A).(7)

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 3 of 6 2021 Clinical Quality Measure Flow for Quality ID #291: Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment for Patients with Parkinson’s Disease

Disclaimer: Refer to the measure specification for specific coding and instructions to submit this measure.

Start

Denominator Numerator

Data Completeness Met + Cognitive impairment or Performance Met Yes All patients regardless dysfunction assessed 3720F or equivalent of age (60 patients) a

Diagnosis for Parkinson’s disease No as listed in Denominator* Cognitive Data Completeness Met + impairment or dysfunction Performance Not Met Yes was not assessed, reason not 3720F with 8P or equivalent Yes otherwise specified (10 patients) c

Patient encounter No Not Included in Eligible during the performance No Population/Denominator period as listed in Denominator* Data Completeness Not Met the Quality Data Code or equivalent was not submitted (10 patients) Yes

Include in Eligible Population/Denominator (80 patients) d

SAMPLE CALCULATIONS

Data Completeness= Performance Met (a=60 patients) + Performance Not Met (c=10 patients) = 70 patients = 87.50% Eligible Population / Denominator (d=80 patients) = 80 patients

Performance Rate= Performance Met (a=60 patients) = 60 patients = 85.71% Data Completeness Numerator (70 patients) = 70 patients

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 4 of 6 2020 Clinical Quality Measure Flow Narrative for Quality ID #291: Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment for Patients with Parkinson’s Disease

Disclaimer: Refer to the measure specification for specific coding and instructions to submit this measure.

1. Start with Denominator

2. All patients regardless of age

3. Check Diagnosis for Parkinson’s disease as listed in Denominator*:

a. If Diagnosis for Parkinson’s disease as listed in Denominator* equals No, do not include in Eligible Population/Denominator. Stop Processing.

b. If Diagnosis for Parkinson’s disease as listed in Denominator* equals Yes, proceed to check Patient encounter during the performance period as listed in Denominator*.

4. Check Patient encounter during the performance period as listed in Denominator*:

a. If Patient encounter during the performance period as listed in Denominator* equals No, do not include in Eligible Population/Denominator. Stop Processing.

b. If Patient encounter during the performance period as listed in Denominator* equals Yes, include in Eligible Population/Denominator.

5. Denominator Population:

6. Start Numerator

7. Check Cognitive impairment or dysfunction assessed:

a. If Cognitive impairment or dysfunction assessed equals Yes, include in Data Completeness Met and Performance Met.

b. If Cognitive impairment or dysfunction assessed equals No, proceed to check Cognitive impairment or dysfunction was not assessed, reason not otherwise specified.

8. Check Cognitive impairment or dysfunction was not assessed, reason not otherwise specified:

a. If Cognitive impairment or dysfunction was not assessed, reason not otherwise specified equals Yes, include in Data Completeness Met and Performance Not Met.

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 5 of 6 b. If Cognitive impairment or dysfunction was not assessed, reason not otherwise specified equals No, proceed to check Data Completeness Not Met.

9. Check Data Completeness Not Met:

• If Data Completeness Not Met, the Quality Data Code or equivalent was not submitted. 10 patients have been subtracted from the Data Completeness Numerator in the Sample Calculation.

Sample Calculations Data Completeness equals Performance Met (a equals 60 patients) plus Performance Not Met (c equals 10 patients) divided by Eligible Population/Denominator (d equals 80 patients). All equals 70 patients divided by 80 patients. All equals 87.50 percent.

Performance Rate equals Performance Met (a equals 60 patients) divided by Data Completeness Numerator (70 patients). All equals 60 patients divided by 70 patients. All equals 85.71 percent.

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 6 of 6 Quality ID #293: Parkinson’s Disease: Rehabilitative Therapy Options – National Quality Strategy Domain: Communication and Care Coordination – Meaningful Measure Area: Management of Chronic Conditions

2021 COLLECTION TYPE: MIPS CLINICAL QUALITY MEASURES (CQMS)

MEASURE TYPE: Process – High Priority

DESCRIPTION: Percentage of all patients with a diagnosis of Parkinson’s Disease (or caregiver(s), as appropriate) who had rehabilitative therapy options (i.e., physical, occupational, and speech therapy) discussed once in the past 12 months

NOTE: Patient encounters for this measure conducted via telehealth (e.g., encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable.

DENOMINATOR: All patients with a diagnosis of Parkinson’s disease

Denominator Criteria (Eligible Cases): All patients regardless of age AND Diagnosis for Parkinson’s disease (ICD-10-CM): G20 AND Patient encounter during the performance period (CPT): 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241*, 99242*, 99243*, 99244*, 99245*, 99304, 99305, 99306, 99307, 99308, 99309, 99310

NUMERATOR: All patients with a diagnosis of Parkinson’s Disease (or caregiver(s), as appropriate) who had rehabilitative therapy options (i.e., physical, occupational, and speech therapy) discussed once in the past 12 months

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 1 of 6 NUMERATOR NOTE: The 12 month look back period is defined as 12 months from the date of the denominator eligible encounter. Denominator Exception(s) are determined on the date of the denominator eligible encounter.

Numerator Options: Performance Met: Rehabilitative therapy options discussed with patient (or caregiver) (4400F)

OR Performance Not Met: Rehabilitative therapy options not discussed with patient (or caregiver), reason not otherwise specified (4400F with 8P)

RATIONALE: For those patients with Parkinson’s disease who have impaired activities of daily living, therapy options such as physical, occupational, and speech therapy should be offered. Rehabilitative therapies play an important role in improving function and quality of life for these patients. Symptomatic therapy can provide benefit for many years. Patients with Parkinson’s disease commonly develop dysarthria.

AAN QSS Neuro Alt (April 2006) Suchowersky O, Gronseth G, Perlmutter J, Reich S, Zesiewicz T, Weiner

WJ, Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter: neuroprotective strategies and alternative therapies for Parkinson disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2006 Apr 11; 66(7):976-82.

Factor, S. Weiner, W. Parkinson’s disease: Diagnosis and Clinical Management. 2002

CLINICAL RECOMMENDATION STATEMENTS: • Physiotherapy should be available for people with PD. Particular consideration should be given to: - gait re-education, improvement of balance and flexibility; enhancement of aerobic capacity; improvement of movement initiation; improvement of functional independence, including mobility and activities of daily living; - provision of advice regarding safety in the home environment. (Level B)(1) • Occupational therapy should be available for people with PD. Particular consideration should be given to: - maintenance of work and family roles, home care and leisure activities; improvement and maintenance of transfers and mobility; improvement of personal self-care activities, such as eating, drinking, washing, and dressing; cognitive assessment and appropriate intervention. (Level D)(1) • Speech and language therapy should be available for people with PD. Particular consideration should be given to: -Improvement of vocal loudness and pitch range, including speech therapy programs such as Lee Silverman Voice Treatment (LSVT) (Level B)(1) • For patients with Parkinson’s disease complicated by dysarthria, speech therapy may be considered to improve speech volume (Level C). Different exercise modalities, including multidisciplinary rehabilitation, active music therapy, treadmill training, balance training, and "cued" exercise training are probably effective in improving functional outcomes for patients with Parkinson’s disease. For patients with Parkinson’s disease, exercise therapy may be considered to improve function (Level C). (2) • The results of this systematic review have suggested that progressive resistance exercise can be effective and worthwhile in people with mild to moderate Parkinson’s disease, but carryover of these benefits may not occur in all measures of physical performance. We recommend that progressive resistance exercise should be implemented into clinical practice as a therapy for Parkinson’s disease, particularly when the aim is improving walking capacity in such people. (3)

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 2 of 6 COPYRIGHT: © 2021 American Academy of Neurology Institute All rights reserved. Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary coding sets should obtain all necessary licenses from the owners of these code sets. The AAN and its members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT®) or other coding contained in the specifications.

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 3 of 6 2021 Clinical Quality Measure Flow for Quality ID #293: Parkinson’s Disease: Rehabilitative Therapy Options

Disclaimer: Refer to the measure specification for specific coding and instructions to submit this measure.

Denominator Numerator

Start Data Completeness Met + Rehabilitative therapy options Performance Met Yes discussed with patient 4400F or equivalent (or caregiver) (50 patients) a

All patients regardless of age

Diagnosis for Data Completeness Met + Rehabilitative therapy options No Parkinson’s disease as Performance Not Met not discussed with patient (or Yes 4400F with 8P or listed in Denominator* caregiver), reason not otherwise equivalent specified (10 patients) c

Yes

Patient encounter Not Included in Eligible No during the performance period Population/Denominator Data Completeness Not Met as listed in Denominator* the Quality Data Code or equivalent was not submitted (10 patients)

Yes

Include in Eligible Population/Denominator (80 patients) d

SAMPLE CALCULATIONS

Data Completeness= Performance Met (a=50 patients) + Performance Not Met (c=10 patients) = 60 patients = 75.00% Eligible Population / Denominator (d=80 patients) = 80 patients

Performance Rate= Performance Met (a=50 patients) = 50 patients = 83.33% Data Completeness Numerator (60 patients) = 60 patients * See the posted measure specification for specific coding and instructions to submit this measure. NOTE: Submission Frequency: Patient-Process CPT only copyright 2020 American Medical Association. All right s reserved. The measure diagrams were developed by CMS as a supplement al resource t o be used in conjunction with the measure specifications. They should not be used alone or as a substitution for the measure specification. v5

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 4 of 6 2021 Clinical Quality Measure Flow Narrative for Quality ID #293: Parkinson’s Disease: Rehabilitative Therapy Options Disclaimer: Refer to the measure specification for specific coding and instructions to submit this measure.

1. Start with Denominator

2. All patients regardless of age

3. Check Diagnosis for Parkinson’s disease as listed in Denominator*:

a. If Diagnosis for Parkinson’s disease as listed in Denominator* equals No, do not include in Eligible Population/Denominator. Stop Processing.

b. If Diagnosis for Parkinson’s disease as listed in Denominator* equals Yes, proceed to check Patient encounter during the performance period as listed in Denominator*.

4. Check Patient encounter during the performance period as listed in Denominator*:

a. If Patient encounter during the performance period as listed in Denominator* equals No, do not include in Eligible Population/Denominator. Stop Processing.

b. If Patient encounter during the performance period as listed in Denominator* equals Yes, include in Eligible Population/Denominator.

5. Denominator Population:

6. Start Numerator

7. Check Rehabilitative therapy options discussed with patient (or caregiver):

a. If Rehabilitative therapy options discussed with patient (or caregiver) equals Yes, include in Data Completeness Met and Performance Met.

b. If Rehabilitative therapy options discussed with patient (or caregiver) equals No, proceed to check Rehabilitative therapy options not discussed with patient (or caregiver), reason not otherwise specified.

8. Check Rehabilitative therapy options not discussed with patient (or caregiver), reason not otherwise specified:

a. If Rehabilitative therapy options not discussed with patient (or caregiver), reason not otherwise specified equals Yes, include in Data Completeness Met and Performance Not Met.

b. If Rehabilitative therapy options not discussed with patient (or caregiver), reason not otherwise Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 5 of 6 specified equals No, proceed to check Data Completeness Not Met.

9. Check Data Completeness Not Met:

• If Data Completeness Not Met, the Quality Data Code or equivalent was not submitted. 10 patients have been subtracted from the Data Completeness Numerator in the Sample Calculation.

Sample Calculations Data Completeness equals Performance Met (a equals 50 patients) plus Performance Not Met (c equals 10 patients) divided by Eligible Population/Denominator (d equals 80 patients). All equals 60 patients divided by 80 patients. All equals 75.00 percent.

Performance Rate equals Performance Met (a equals 50 patients) divided by Data Completeness Numerator (60 patients). All equals 50 patients divided by 60 patients. All equals 83.33 percent.

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 6 of 6 Quality ID #288: Dementia: Education and Support of Caregivers for Patients with Dementia – National Quality Strategy Domain: Communication and Care Coordination – Meaningful Measure Area: Prevention, Treatment, and Management of Mental Health

2021 COLLECTION TYPE: MIPS CLINICAL QUALITY MEASURES (CQMS)

MEASURE TYPE: Process – High Priority

DESCRIPTION: Percentage of patients with dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND were referred to additional resources for support in the last 12 months

INSTRUCTIONS: This measure is to be submitted a minimum of once per performance period for patients with a diagnosis of dementia seen during the performance period. This measure may be submitted by that Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

NOTE: Patient encounters for this measure conducted via telehealth (e.g., encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable.

DENOMINATOR: All patients with dementia

Denominator Criteria (Eligible Cases): All patients regardless of age AND Diagnosis for dementia (ICD-10-CM): A52.17, A81.00, A81.01, A81.89, F01.50, F01.51, F02.80, F02.81, F03.90, F03.91, F05, F10.27, G30.0, G30.1, G30.8, G30.9, G31.01, G31.09, G31.83, G31.85, G31.89, G94 AND Patient encounter during the performance period (CPT): 90791, 90792, 90832, 90834, 90837, 96116, 96130, 96132, 96136, 96138, 96146, 96156, 96158, 96164, 96167, 96170, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99339, 99340, 99341, 99342, 99343, 99344, 99345, 99487, 99490, 99497

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 1 of 9 NUMERATOR: Patients with dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND were referred to additional resources for support in the last 12 months

Definitions: Caregiver - Is broadly defined and the Work Group adopted the definition utilized by the National Quality Forum and Feinberg.(1) Caregiver refers to any relative, partner, friend, or neighbor who has a significant relationship with, and who provides a broad range of assistance for, an older adult or an adult with chronic or disabling conditions.(1) Education - Requires learning and processing information about disease management and health behavior changes. This should also include advising the caregiver that, as a caregiver, he or she is at “increased risk of serious illness (including circulatory and heart conditions and respiratory disease and hypertension), increased physician visits and use of prescription medications, emotional strain, anxiety, and depression.”(2) Providers are encouraged to review state specific guidelines to ensure education is being provided as required. Additional Resources - are defined as situation-specific, tailored programs to assist the caregiver; these included national organizations such as the Alzheimer’s Association, but also include local resources, such as community, senior center and religion-based support groups.

Numerator Instructions: There are a number of assessment tools available for the caregiver. These should be considered as an integral component of comprehensive caregiver education and support. The American Medical Association has developed a Caregiver Health Self-assessment Questionnaire to help caregivers analyze their own behavior and health risks and, with their physician's help, make decisions that will benefit both the caregiver and the patient. This questionnaire is available on the AMA website.

NUMERATOR NOTE: The 12 month look back period is defined as 12 months from the date of the denominator eligible encounter. Denominator Exception(s) are determined on the date of the denominator eligible encounter.

Numerator Options: Performance Met: Caregiver provided with education and referred to additional resources for support (4322F) OR Denominator Exceptions: Patient does not have a caregiver (G2184)

Documentation caregiver is trained and certified in dementia care (G2185)

Patient/caregiver dyad has been referred to appropriate resources and connection to those resources is confirmed (G2186) OR Performance Not Met: Caregiver not provided with education and not referred to additional resources for support, reason not otherwise specified (4322F with 8P)

RATIONALE: By providing education as well as resources to caregivers it is anticipated that caregiver will act on information Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 2 of 9 received connecting to support networks and gain a greater understanding of dementia. As a result, caregiver burden will decrease, caregiver and patient Quality of Life will improve, and caregiver and patient physical health will improve.

CLINICAL RECOMMENDATION STATEMENTS: “Important aspects of psychiatric management include educating patients and families about the illness, its treatment, and sources of additional care and support (e.g., support groups, respite care, nursing homes, and other long-term- care facilities) and advising patients and their families of the need for financial and legal planning due to the patient’s eventual incapacity (e.g., power of attorney for medical and financial decisions, an up-to-date will, and the cost of long-term care) (Category I)… The family should be educated regarding basic principles of care, including

1. recognizing declines in capacity and adjusting expectations appropriately, 2. bringing sudden declines in function and the emergence of new symptoms to professional attention, 3. keeping requests and demands relatively simple, 4. deferring requests if the patient becomes overly upset or angered, 5. avoiding overly complex tasks that may lead to frustration, 6. not confronting patients about their deficits, 7. remaining calm, firm, and supportive and providing redirection if the patient becomes upset, 8. being consistent and avoiding unnecessary change, and 9. providing frequent reminders, explanations, and orientation cues… In addition to providing families with information on support groups, there are a number of benefits of referral to the local chapter or national office of the Alzheimer’s Association (1-800-272-3900; http://www.alz.org), the Alzheimer’s Disease Education and Referral Center (ADEAR) (1-800-438-4380; http://www.nia.nih.gov/Alzheimers/), and other support organizations.”(3) • “Short-term programs directed toward educating family caregivers about AD should be offered to improve caregiver satisfaction” (4). • “Intensive long-term education and support services (when available) should be offered to caregivers of patients with AD to delay time to nursing home placement” (4). • “Staff of long-term care facilities should receive education about AD to reduce the use of unnecessary antipsychotics” (4) • "Support programs for caregivers and patients with dementia significantly decreased the odds of institutionalization and improved caregiver well-being." (5) • “A dementia diagnosis mandates an inquiry to the community for available public health care support programmes (Good Practice Point). Counselling and case/care management amongst caring family members have positive effects on burden and satisfaction for caregivers of people with dementia (Good Practice Point).” (6) • “Following a diagnosis of dementia, health and social care professionals should, unless the person with dementia clearly indicates to the contrary, provide, them and their family with written information about

1. The signs and symptoms of dementia 2. The course and prognosis of the condition 3. Treatments 4. Local care and support services 5. Support groups 6. Sources of financial and legal advice, and advocacy 7. Medico-legal issues, including driving 8. Local information sources, including libraries and voluntary organisations.” (7)

“…emphasise that professional support should have a wide focus that includes helping family and friends to support the person with dementia, rather than being limited to an exclusive and direct focus on the person with dementia.”(8) Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 3 of 9

The American Psychiatric Association’s (APA), PCPI’s, and AMA’s significant past efforts and contributions to the development and updating of the Measure are acknowledged.

CPT® contained in the Measures specifications is copyright 2004-2020 American Medical Association. LOINC® copyright 2004-2020 Regenstrief Institute, Inc. SNOMED CLINICAL TERMS (SNOMED CT®) copyright 2004- 2020. The International Health Terminology Standards Development Organisation (IHTSDO). ICD-10 is copyright 2020 World Health Organization. All Rights Reserved.

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 4 of 9 2021 Clinical Quality Measure Flow for Quality ID #288: Dementia: Education and Support of Caregivers for Patients with Dementia Disclaimer: Refer to the measure specification for specific coding and instructions to submit this measure

Numerator

Start

Caregiver Data Completeness Met + provided with Performance Met education and referred to Yes Denominator 4322F or equivalent additional resources (50 patients) for support a

All patients regardless of age No

Data Completeness Met + Patient does not Denominator Exception Yes have a caregiver G2184 or equivalent (10 patients) b1

Diagnosis No for dementia as listed No in Denominator*

Documentation Data Completeness Met + Not Included in Eligible caregiver is trained Denominator Exception Yes Yes Population/Denominator and certified in G2185 or equivalent

dementia (0 patients) 2 care b

Patient encounter during No No the performance period as listed in Denominator*

Patient/caregiver dyad has been referred Data Completeness Met + Denominator Exception Yes to appropriate resources Yes and connection to those G2186 or equivalent (0 patients) resources is b3 confirmed Include in Eligible Population/Denominator (80 patients) d No

Caregiver not provided with Data Completeness Met + education and not referred Performance Not Met to additional resources for Yes 4322F with 8P or equivalent support, reason (10 patients) not otherwise c specified

Data Completeness Not Met the Quality Data Code or equivalent was not submitted (10 patients)

Data Completeness= Performance Met (a=50 patients) + Denominator Exception (b1+b2+b3=10 patients) + Performance Not Met (c=10 patients) = 70 patients = 87.50% Eligible Population / Denominator (d=80 patients) = 80 patients

Performance Rate= Performance Met (a=50 patients) = 50 patients = 83.33% Data Completeness Numerator (70 patients) – Denominator Exception (b1+b2+b3=10 patients) = 60 patients

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 6 of 9 2021 Clinical Quality Measure Flow Narrative for Quality ID #288: Dementia: Education and Support of Caregivers for Patients with Dementia Disclaimer: Refer to the measure specification for specific coding and instructions to submit this measure.

1. Start with Denominator

2. All patients regardless of age

3. Check Diagnosis for dementia as listed in Denominator*:

a. If Diagnosis for dementia as listed in Denominator* equals No, do not include in Eligible Population/Denominator. Stop Processing.

b. If Diagnosis for dementia as listed in Denominator* equals Yes, proceed to check Patient encounter during the performance period as listed in Denominator*.

4. Check Patient encounter during the performance period as listed in Denominator*:

a. If Patient encounter during the performance period as listed in Denominator* equals No, do not include in Eligible Population/Denominator. Stop Processing.

b. If Patient encounter during the performance period as listed in Denominator* equals Yes, include in Eligible Population/Denominator.

5. Denominator Population:

6. Start Numerator

7. Check Caregiver provided with education and referred to additional resources for support:

a. If Caregiver provided with education and referred to additional resources for support equals Yes, include in Data Completeness Met and Performance Met.

b. If Caregiver provided with education and referred to additional resources for support equals No, proceed to check Patient does not have a caregiver.

8. Check Patient does not have a caregiver:

a. If Patient does not have a caregiver equals Yes, include in Data Completeness Met and Denominator Exception.

b. If Patient does not have a caregiver equals No, proceed to check Documentation caregiver is trained and certified in dementia care: Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 7 of 9 9. Check Documentation caregiver is trained and certified in dementia care.

a. If Documentation caregiver is trained and certified in dementia care equals Yes, include in Data Completeness Met and Denominator Exception.

b. If Documentation caregiver is trained and certified in dementia care equals No, proceed to check Patient/caregiver dyad has been referred to appropriate resources and connection to those resources is confirmed.

10. Check Patient/caregiver dyad has been referred to appropriate resources and connection to those resources is confirmed.

a. If Patient/caregiver dyad has been referred to appropriate resources and connection to those resources is confirmed equals Yes, include in Data Completeness Met and Denominator Exception.

b. If Patient/caregiver dyad has been referred to appropriate resources and connection to those resources is confirmed equals No, proceed to check Caregiver not provided with education and not referred to additional resources for support, reason not otherwise specified.

11. Check Caregiver not provided with education and not referred to additional resources for support, reason not otherwise specified.

a. If Caregiver not provided with education and not referred to additional resources for support, reason not otherwise specified equals Yes, include in Data Completeness Met and Performance Not Met.

• Data Completeness Met and Performance Not Met letter is represented in the Data Completeness and in the Sample Calculation listed at the end of this document. Letter c equals 10 patients in the Sample Calculation.

b. If Caregiver not provided with education and not referred to additional resources for support, reason not otherwise specified equals No, proceed to check Data Completeness Not Met.

12. Check Data Completeness Not Met:

• If Data Completeness Not Met, the Quality Data Code or equivalent was not submitted. 10 patients have been subtracted from the Data Completeness Numerator in the Sample Calculation.

Sample Calculations Data Completeness equals Performance Met (a equals 50 patients) plus Denominator Exception ( b1 plus b2 plus b3 equals 10 patients) plus Performance Not Met (c equals 10 patients) divided by Eligible Population/Denominator (d equals 80 patients). All equals 70 patients divided by 80 patients. All equals 87.5 percent.

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 8 of 9 Performance Rate equals Performance Met (a equals 50 patients) divided by Data Completeness Numerator (70 patients) minus Denominator Exception ( b1 plus b2 plus b3 equals 10 patients). All equals 50 patients divided by 60 patients. All equals 83.33 percent.

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 9 of 9 Quality ID #286: Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia – National Quality Strategy Domain: Patient Safety – Meaningful Measure Area: Prevention, Treatment, and Management of Mental Health

2021 COLLECTION TYPE: MIPS CLINICAL QUALITY MEASURES (CQMS)

MEASURE TYPE: Process – High Priority

DESCRIPTION: Percentage of patients with dementia or their caregiver(s) for whom there was a documented safety concerns screening in two domains of risk: 1) dangerousness to self or others and 2) environmental risks; and if safety concerns screening was positive in the last 12 months, there was documentation of mitigation recommendations, including but not limited to referral to other resources

NOTE: Patient encounters for this measure conducted via telehealth (e.g., encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable.

DENOMINATOR: All patients with dementia

Denominator Criteria (Eligible Cases): All patients regardless of age AND Diagnosis for dementia (ICD-10-CM): A52.17, A81.00, A81.01, A81.89, F01.50, F01.51, F02.80, F02.81, F03.90, F03.91, F05, F10.27, G30.0, G30.1, G30.8, G30.9, G31.01, G31.09, G31.83, G31.85, G31.89, G94 AND Patient encounter during the performance period (CPT): 90791, 90792, 90832, 90834, 90837, 96116, 96130, 96132, 96136, 96138, 96146, 96156, 96158, 96164, 96167, 96170, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99251*, 99252*, 99253*, 99254*, 99255*, 99281, 99282, 99283, 99284, 99285, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327,

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 1 of 10 99328, 99334, 99335, 99336, 99337, 99339, 99340, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99487, 99490, 99497

NUMERATOR: Patients with dementia or their caregiver(s) for whom there was a documented safety concerns screening in two domains of risk: 1) dangerousness to self or others and 2) environmental risks; and if safety concerns screening was positive in the last 12 months, there was documentation of mitigation recommendations, including but not limited to referral to other resources

Definitions: Caregiver(s) - Person(s) who provide care to those who need supervision or assistance in illness or disability. They may provide the care in the home, in a hospital, or in an institution. Although caregiver(s) include trained medical, nursing, and other health personnel, the concept also refers to parents, spouses, or other family members, friends, members of the clergy, teachers, social workers, fellow patients. Safety Concerns - Safety concerns include, but are not limited to: • Fall risk • Gait/balance • Medication management • Financial management • Home safety risks that could arise from cooking or smoking • Physical aggression posing threat to self, family caregiver, or others • Wandering • Access to firearms or other weapons • Access to potentially dangerous materials • Being left alone in home or locked in room • Inability to respond rapidly to crisis/household emergencies • Driving • Operation of hazardous equipment • Suicidality • Abuse or neglect

Numerator Instructions: Mitigation Recommendations should include a discussion with the patient and their caregiver(s) regarding one or more of the above common safety concerns and potential risks to the patient. When appropriate, it should also include a mitigation recommendation or referral or orders for a home safety evaluation.

Note: For nursing home patients, different safety concerns might apply.

A number of organizations have developed educational materials that are recommended to aid implementation of the measure. These materials/tools include: • Alzheimer’s Association Safety Topics. Available on the Alzheimer’s Association website. Alzheimer’s Disease Education and Referral Center’s Home Safety for the Alzheimer’s Patient Available on the National Institute on Aging website.

The following is a non-exhaustive list of safety concerns in the two domains pertinent to this measure. To meet measure requirements a patient’s medical record must have documentation of being screened on at least one concern from each of the two domains.

Dangerousness to self (patient) or others (caregivers and other individuals) • Medication misuse • Physical aggressiveness • Wandering, including addressing precautions that may include physical measures (e.g., locks, Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 2 of 10 fences or hedges), video surveillance, GPS monitoring and Safe Return programs, personal companions, schedule modifications (e.g., adult day care and day programs), rehabilitative measures, and risk mitigation strategies • Inability to respond rapidly to crisis/household emergencies • Financial mismanagement, including being involved in “scams” • Other concerns raised by patient or their caregiver

Environmental risks • Home safety risks that could arise from cooking or smoking • Access to firearms or other weapons • Access to potentially dangerous chemicals and other materials • Access to and operation of tools and equipment • Trip hazards in the home increasing the risk of falling • Other concerns raised by patient or their caregiver

Numerator Options: Performance Met: Safety concerns screen provided and if positive then documented mitigation recommendations (G9922) OR Performance Met: Safety concerns screen provided and negative (G9923) OR Denominator Exception: Documentation patient unable to communicate and informant not available (G2183) OR Performance Not Met: Safety concerns screening not provided, reason not otherwise specified (G9925) OR Performance Not Met: Safety concerns screening positive screen is without provision of mitigation recommendations, including but not limited to referral to other resources (G9926)

RATIONALE: The assessment of safety is an identified gap in dementia care (Black BS, Johnston D, Rabins PV, et al. Unmet Needs of Community-Residing Persons with Dementia and Their Informal Caregivers: Findings from the MIND at Home Study. J Am Geriatr Soc 2013;61(12):2087-2095.) Persons with dementia are at increased risk of having safety concerns for several reasons. Cognitive loss can lead to confusion regarding use of medications, handling of weapons or machinery, or the ability to remember to turn off appliances, such as ranges and stoves. Dementia also impairs the person’s judgment, and as such, increases the risk for financial abuse and exploitation. The risk of falls among persons with dementia is greater, and following injury, persons with dementia are less likely to recover than other seniors (Allan LM, Ballard CG, Rowan EN, Kenny RA. Incidence and prediction of falls in dementia: a prospective study in older people. PLoS ONE. 2009;4). Persons with dementia are at greater risk of burns due to hot water. Similarly, persons with dementia may exhibit aggressive behaviors towards themselves or others (Salzman C, Jeste D, Meyer RE, Cohen-Mansfield j, et.al. Elderly Patients with Dementia-Related Symptoms of Severe Agitation and Aggression: Consensus Statement on Treatment Options, Clinical Trials, Methodology and Policy. J Clin Psychiatry 2008 June:69(6):889-898). These and other types of injuries are preventable through mitigating strategies, however, the risks must be identified. This quality measure requires screening for safety concerns in two risk domains: dangerousness to self/others and environment. Current treatment guidelines for the management of dementia recommend that healthcare providers screen for safety risks. There are community and Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 3 of 10 online resources to facilitate home safety (Alzheimer’s Association. Home Safety. Available at: https://www.alz.org/help-support/caregiving/safety/home-safety. Accessed November 25, 2018). By routinely screening for safety issues, the clinician will also become increasingly more familiar with the range of problems identified, and thus be able to continuously improve the quality of care delivered.

CLINICAL RECOMMENDATION STATEMENTS: The following clinical recommendation statements are quoted verbatim from the referenced clinical guidelines and represent the evidence base for the measure: • “Recommended assessments include evaluation of suicidality, dangerousness to self and others, and the potential for aggression, as well as evaluation of living conditions, safety of the environment, adequacy of supervision, and evidence of neglect or abuse (Category I). Important safety issues in the management of patients with dementia include interventions to decrease the hazards of wandering and recommendations concerning activities such as cooking, driving, hunting, and the operation of hazardous equipment. Caregivers should be referred to available books [and other materials] that provide advice and guidance about maximizing the safety of the environment for patients with dementia…As patients become more impaired, they are likely to require more supervision to remain safe, and safety issues should be addressed as part of every evaluation. Families should be advised about the possibility of accidents due to forgetfulness (e.g., fires while cooking), of difficulties coping with household emergencies, and of the possibility of wandering. Family members should also be advised to determine whether the patient is handling finances appropriately and to consider taking over the paying of bills and other responsibilities. At this stage of the disease [i.e., moderately impaired patients], nearly all patients should not drive.” (1)

For mild to moderate Alzheimer's disease

“Assess for safety risks (e.g., driving, financial management, medication management, home safety risks that could arise from cooking or smoking, potentially dangerous behaviors such as wandering)” (2)

The American Psychiatric Association’s (APA), PCPI’s, and AMA’s significant past efforts and contributions to the development and updating of the Measure are acknowledged.

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 4 of 10 CPT® contained in the Measures specifications is copyright 2004-2020 American Medical Association. LOINC® copyright 2004-2020 Regenstrief Institute, Inc. SNOMED CLINICAL TERMS (SNOMED CT®) copyright 2004- 2020. The International Health Terminology Standards Development Organisation (IHTSDO). ICD-10 is copyright 2020 World Health Organization. All Rights Reserved.

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 5 of 10 2021 Clinical Quality Measure Flow for Quality ID #286: Dementia: Safety Concern Screening and Follow-up for Patients with Dementia Disclaimer: Refer to the measure specification for specific coding and instructions to submit this measure.

Denominator Numerator

Start Safety concerns Data Completeness Met + screen provided and if positive Performance Met Yes then documented mitigation G9922 or equivalent recommendations (20 patients) a1

All patients No regardless of age

Data Completeness Met + Safety concerns screen Performance Met Yes provided and negative G9923 or equivalent (20 patients) a2

Diagnosis for No dementia as listed in No Denominator*

Data Completeness Met + Yes Documentation patient unable to Yes Denominator Exception communicate and informant not G2183 or equivalent available (10 patients) b

Not Included in Patient encounter No Eligible Population/ No during the performance Denominator* period as listed in Denominator*

Data Completeness Met + Safety concerns screening not Performance Not Met Yes provided, reason not otherwise G9925 or equivalent Yes specified (10 patients) c1

Include in Eligible Population/ No Denominator (80 patients) d

Safety concerns screening Data Completeness Met + positive screen is without provision of Performance Not Met Yes mitigation recommendations, including G9926 or equivalent but not limited to referral (10 patients) 2 c to other resources

Data Completeness Not Met the Quality Data Code or equivalent was not submitted (10 patients)

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 6 of 10 SAMPLE CALCULATIONS Data Completeness= Performance Met (a1+a2=40 patients) + Denominator Exception (b=10 patients) + Performance Not Met (c1+c2=20 patients) = 70 patients = 87.50% Eligible Population / Denominator (d=80 patients) = 80 patients

Performance Rate= Performance Met (a1+a2=40 patients) = 40 patients = 66.67% Data Completeness Numerator (70 patients) – Denominator Exception (b=10 patients) = 60patients

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 7 of 10 2021 Clinical Quality Measure Flow Narrative for Quality ID #286: Dementia: Safety Concern Screening and Follow-up for Patients with Dementia Disclaimer: Refer to the measure specification for specific coding and instructions to submit this measure.

1. Start with Denominator

2. All patients regardless of age

3. Check Diagnosis for dementia as listed in Denominator*:

a. If Diagnosis for dementia as listed in Denominator* equals No, do not include in Eligible Population/Denominator. Stop Processing.

b. If Diagnosis for dementia as listed in Denominator* equals Yes, proceed to check Patient encounter during the performance period as listed in Denominator*.

4. Check Patient encounter during the performance period as listed in Denominator*:

a. If Patient encounter during the performance period as listed in Denominator* equals No, do not include in Eligible Population/Denominator. Stop Processing.

b. If Patient encounter during the performance period as listed in Denominator* equals Yes, include in Eligible Population/Denominator.

5. Denominator Population:

6. Start Numerator

7. Check Safety concerns screen provided and if positive then documented mitigation recommendations:

a. If Safety concerns screen provided and if positive then documented mitigation recommendations equals Yes, include in Data Completeness Met and Performance Met.

b. If Safety concerns screen provided and if positive then documented mitigation recommendations equals No, proceed to check Safety concerns screen provided and negative.

8. Check Safety concerns screen provided and negative:

a. If Safety concerns screen provided and negative equals Yes, include in Data Completeness Met and Performance Met.

• Data Completeness Met and Performance Met letter is represented in the Data Completeness and Performance Rate in the Sample Calculation listed at the end of the document. Letter a2 equals 20 patients in the Sample Calculation

b. If Safety concerns screen provided and negative equals No, proceed to check Documentation patient

9. Check Documentation patient unable to communicate and informant not available:

a. If Documentation patient unable to communicate and informant not available equals Yes, include in Data Completeness Met and Denominator Exception.

b. If Documentation patient unable to communicate and informant not available equals No, proceed to check Safety concerns screening not provided, reason not otherwise specified.

10. Check Safety concerns screening not provided, reason not otherwise specified:

a. If Safety concerns screening not provided, reason not otherwise specified equals Yes, include in Data Completeness Met and Performance Not Met.

• Data Completeness Met and Performance Not Met letter is represented in the Data Completeness in the Sample Calculation listed at the end of this document. Letter c1 equals 10 patients in the Sample Calculation.

b. If Safety concerns screening not provided, reason not otherwise specified equals No, proceed to check Safety concerns screening positive screen is without provision of mitigation recommendations, including but not limited to referral to other resources.

11. Check Safety concerns screening positive screen is without provision of mitigation recommendations, including but not limited to referral to other resources:

a. If Safety concerns screening positive screen is without provision of mitigation recommendations, including but not limited to referral to other resources equals Yes, include in Data Completeness Met and Performance Not Met.

• Data Completeness Met and Performance Not Met letter is represented in the Data Completeness in the Sample Calculation listed at the end of this document. Letter c2 equals 10 patients in the Sample Calculation.

b. If Safety concerns screening positive screen is without provision of mitigation recommendations, including but not limited to referral to other resources equals No, proceed to check Data Completeness Not Met.

12. Check Data Completeness Not Met:

• If Data Completeness Not Met, the Quality Data Code or equivalent was not submitted. 10 patients have been subtracted from the Data Completeness Numerator in the Sample Calculation.

Sample Calculations Data Completeness equals Performance Met ( a1 plus a2 equals 40 patients) plus Denominator Exception (b equals 10 patients) plus Performance Not Met ( c1 plus c2 equals 20 patients) divided by Eligible Population/Denominator (d equals 80 patients). All equals 70 patients divided by 80 patients. All equals 87.50 percent. Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 9 of 10 Performance Rate equals Performance Met ( a1 plus a2 equals 40 patients) divided by Data Completeness Numerator (70 patients) minus Denominator Exception (b equals 10 patients). All equals 40 patients divided by 60 patients. All equals 66.67 percent.

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The child neurology measurement set was released in 2017. The specification for the querying for co- morbid conditions of tic disorder and Tourette syndrome measure was modified in January 2018 for implementation in the Axon Registry®. The modification was made to reflect the CMS’ requirement a follow-up action occur after a screening. Changes were made solely for registry implementation. Measure Title Querying for co-morbid conditions of tic disorder (TD) and Tourette syndrome (TS) with follow-up Description Percentage of patients who were queried for psychological and/or behavioral co-morbid conditions of tic disorder (TD) or Tourette syndrome (TS), and if present, treated or referred for treatment of co- morbid conditions Measurement Period January 1, 20xx to December 31, 20xx Eligible Population Eligible Providers Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant (PA), Advanced Practice Registered Nurse (APRN) Care Setting(s) Outpatient Ages Patients less than or equal to 18 years of age Event Patient had an office visit, E/M services performed or supervised by an eligible provider Diagnosis Tic disorder (TD) or Tourette syndrome (TS) Denominator All patients aged < 18 years with the diagnosis of TD* or TS who do not have an existing diagnosis of a comorbid condition.

1 *Tic disorders include: • Chronic or transient (DSM IV) • Persistent or provisional (DSM V) • Motor and vocal • Other tic disorder • Tic disorder not specified Numerator Patients who were queried^ for symptoms of psychological and/or behavioral co-morbid conditions* at least once per year, and if present, patient was treated** or referred*** for treatment of co-morbid conditions.

^Queried is defined as asking or inquiring about the presence or absence of symptoms.

*Co-morbid conditions (to meet measure requirements, must query for all conditions in the list below): • Mood disorders, including depression and anxiety, • Obsessive compulsive disorder (OCD), • Attention Deficit Hyperactivity Disorder (ADHD), • Oppositional Defiant Disorder (ODD)

**Treated is an intervention and/or medication implemented for co- morbid conditions. • Treatment plan reviewed • Prescription written, or dose adjusted

***Referred includes a referral to psychiatry or psychology • Referral initiated Required Exclusions None Allowable Exclusions • Patient/caregiver refuse Exclusion Rationale Exception for patient and caregiver declinations needed as patient and caregivers need to be willing to undergo evaluation for results to be meaningful. Measure Scoring Percentage/Proportion Interpretation of Score Higher Score Indicates Better Quality Measure Type Process Level of Measurement Individual provider, Practice, System Risk Adjustment Not Applicable Relationship to Desired Tic disorder is frequently associated with psychiatric conditions and Outcome presence of these co-morbid conditions can be worse than the tics itself, can significantly impair function and can affective cognitive performance.3 Screening for these conditions will lead to early diagnosis and treatment. Opportunity for It is estimated that between 80% to 90% of patients with Tourette Improvement syndrome have both tics and psychiatric manifestations.5 Their quality of life is impacted by these accompanying psychiatric conditions.5 Harmonization with N/A Existing Measures References 1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association. 2. Cath DC, Hedderly T, Ludolph AG, et al. European clinical guidelines for Tourette syndrome and other tic disorders. Part I: assessment. European Child & Adolescent Psychiatry 2011; 20:155-71. 3. McGuire JF, Kugler BB, Park JM, et al. Evidence-based assessment of compulsive skin picking, chronic tic disorders and trichotillomania in children. Child Psychiatry & Human Development 2012; 43:855-83. 4. Murphy T, Lewin A, Starch E, et al. Practice Parameter for the Assessment and Treatment of Children and Adolescents with Tic Disorders. Journal of the American Academy of Child & Adolescent Psychiatry 2013; 52:1341-59. 5. Rizzo R, Gulisano M, Pellico A, Valeria Cali P, Curatolo P. Tourette Syndrome and Comorbid Conditions: A Spectrum of Different Severities and Complexities. Journal of Child Neurology 2014; 29:1382-1389. 6. Ludolph AG, Toessner V, Munchau A, Muller-Vahl K. Review article: Tourette syndrome and other tic disorders in childhood, adolescence and adulthood. Deutsches Arzteblatt International 2012; 48:821-828. 7. Eapen V, Snedden C, Crncec R, Pick A, Sachdev P. Tourette syndrome, co-morbidities and quality of life. Australian & New Zealand Journal of Psychiatry 2016; 50:82-93.

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Quality ID #386: Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences – National Quality Strategy Domain: Person and Caregiver-Centered Experience and Outcomes – Meaningful Measure Area: End of Life Care according to Preferences

2021 COLLECTION TYPE: MIPS CLINICAL QUALITY MEASURES (CQMS)

MEASURE TYPE: Process – High Priority

DESCRIPTION: Percentage of patients diagnosed with Amyotrophic Lateral Sclerosis (ALS) who were offered assistance in planning for end of life issues (e.g., advance directives, invasive ventilation, hospice) at least once annually

INSTRUCTIONS: This measure is to be submitted a minimum of once per performance period for patients with a diagnosis of ALS during the performance period. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. This measure is appropriate for use in outpatient and long term care (e.g., nursing home, ambulatory). For each of these settings, there should be documentation in the medical record(s) that advance care planning was discussed or documented.

NOTE: Patient encounters for this measure conducted via telehealth (e.g., encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable.

DENOMINATOR: All patients with a diagnosis of Amyotrophic Lateral Sclerosis (ALS)

Denominator Criteria (Eligible Cases): Diagnosis for Amyotrophic Lateral Sclerosis (ICD-10-CM): G12.21, G12.23, G12.24, G12.25 AND Patient encounter during the performance period (CPT): 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99345, 99348, 99349, 99350 AND NOT DENOMINATOR EXCLUSION: Patient in hospice at any time during the measurement period: G9758

NUMERATOR: Patients who were offered assistance in planning for end of life issues (e.g., advance directives, invasive ventilation, or hospice) at least once annually

Definition: Assistance with end of life issues – assessment of patient concerns, desires and needs relating to end of Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 1 of 6 life issues. Bases on patient’s disease progression this may include discussions regarding invasive ventilation, advance directives and hospice.

Numerator Options: Performance Met: Patient offered assistance with end of life issues during the measurement period (G9380)

OR Performance Not Met: Patient not offered assistance with end of life issues during the measurement period (G9382)

RATIONALE: Palliative care should be adopted from the time of diagnosis. Many patients are not adequately informed about advance directives and end of life decision making and many hospice workers are not familiar with ALS. Management of the terminal phase of ALS is unsatisfactory in 33% - 61% of cases in Europe and only 8% of palliative care units are involved from the time of diagnosis. The current system of palliative care in the USA is highly decentralized. Between 60-88% of patients die in a medical facility in some countries and not at home, while over 58% of seriously ill ALS patients do not have hospice care. Approaches to end of life care vary widely and are not standardized either in timing or content.

CLINICAL RECOMMENDATION STATEMENTS: • Advance directives for palliative end-of-life care should be discussed early with the patient and carers, respecting the patient's social and cultural background.1 • Offer assistance in formulating an advance care directive. (GPP)2 • Review the patients’ wishes regarding their care and advance directives regularly. (Level II)3 • Re-discuss the patient’s preferences for life-sustaining treatments every 6 months. (GPP)2 • Initiate discussions on end-of-life issues whenever the patient asks or “opens the door” for end-of-life information and/or interventions. (GPP) 2Treat pain in ALS following accepted guidelines. (GPP)2 • Initiate early referral to hospice or home care teams well in advance of the terminal phase of ALS to facilitate the work of the hospice team. (GPP)2 • Discuss options for respiratory support and end-of-life issues if the patient has dyspnea, other symptoms of hypoventilation or VC <50%. (GPP)2 • Treat terminal dyspnea and/or pain with opioids alone or in combination with benzodiazepines if anxiety is present.(GPP)2

1. Andersen PM, Abrahams S, Borasio GD, et al. EFNS guidelines on the Clinical Management of Amyotrophic Lateral Sclerosis (MALS) - revised report of an EFNS task force. Eur J Neurol 2011; 19(3) 360-375 (GPP=Good Practice Point) 2. Andersen PM, Borasio GD, Dengler R, et al. EFNS task force on management of amyotrophic lateral sclerosis: guidelines for diagnosing and clinical care of patients and relatives. European J of Neurology 2005; 12:921-938 (GPP=Good Practice Point) 3. Heffernan C., Jenkinson C, Holmes T, et al. Management of respiration in MND/ALS patients: An evidence based review. Amyotrophic Lateral Sclerosis 2006; 7(1):5-15

COPYRIGHT: Quality Measures published by the American Academy of Neurology Institute and its affiliates are assessments of current scientific and clinical information provided as an educational service. The information: 1) should not be considered inclusive of all proper treatments, methods of care, or as a statement off the standard of care; 2) is not continually updated and may not reflect the most recent evidence (new evidence may emerge between the time information is developed and when it is published or read); 3) addresses only the question(s) or topic(s) specifically identified; 4) does not mandate any particular course of medical care; and 5) is not intended to substitute for the independent professional judgment of the treating provider, as the information does not account for individual variation among patients. In all cases, the selected course of action should be considered by the treating provider in the context of treating the individual patient. Use of the information is voluntary. AANI provides this information on an “as is” basis, Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 2 of 6 and makes no warranty, expressed or implied, regarding the information. AANI specifically disclaims any warranties of merchantability or fitness for a particular use or purpose. AANI assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this information or for any errors or omissions.

Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary coding sets should obtain all necessary licenses from the owners of these code sets. The AANI and its members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT®) or other coding contained in the specifications. ICD-10 copyright 2020 International Health Terminology Standards Development Organization.

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 3 of 6 2021 Clinical Quality Measure Flow for Quality ID #386: Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences Disclaimer: Refer to measure specification for specific coding and instructions to submit this measure.

Start Numerator

Denominator Patient offered Data Completeness Met + assistance with end of life Performance Met Yes issues during measurement G9380 or equivalent Diagnosis for period (50 patients) Amyotrophic Lateral Sclerosis a No (ALS) as listed in Denominator*

Yes Patient not Data Completeness Met + offered assistance Performance Not Met with end of life issues Yes G9382 or equivalent during measurement (20 patients) period c Patient encounter Not Included in Eligible during the performance No Population/Denominator period as listed in Denominator* No

Data Completeness Not Met Yes the Quality Data Code or equivalent was not submitted Denominator (10 patients) Exclusion

Patient in hospice at any time during Yes measurement period: G9758 or equivalent

Include in Eligible Population/Denominator (80 patients) d

SAMPLE CALCULATIONS

Data Completeness= Performance Met (a=50 patients) + Performance Not Met (c=20 patients) = 70 patients = 87.50% Eligible Population / Denominator (d=80 patients) = 80 patients

Performance Rate= Performance Met (a=50 patients) = 50 patients = 71.43% Data Completeness Numerator (70 patients) = 70 patients

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 4 of 6 2021 Clinical Quality Measure Flow Narrative for Quality ID #386: Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences Disclaimer: Refer to the measure specification for specific coding and instructions to submit this measure.

1. Start with Denominator

2. Check Diagnosis for Amyotrophic Lateral Sclerosis (ALS) as listed in Denominator*:

a. If Diagnosis for Amyotrophic Lateral Sclerosis (ALS) as listed in Denominator* equals No, do not include in Eligible Population/Denominator. Stop Processing.

b. If Diagnosis for Amyotrophic Lateral Sclerosis (ALS) as listed in Denominator* equals Yes, proceed to check Patient encounter during the performance period as listed in Denominator*.

3. Check Patient encounter during the performance period as listed in Denominator*:

a. If Patient encounter during the performance period as listed in Denominator* equals No, do not include in Eligible Population/Denominator. Stop Processing.

b. If Patient encounter during the performance period as listed in Denominator* equals Yes, proceed to check Patient in hospice at any time during measurement period.

4. Check Patient in hospice at any time during measurement period:

a. If Patient in hospice at any time during measurement period equals Yes, do not include in Eligible Population/Denominator. Stop Processing.

b. If Patient in hospice at any time during measurement period equals No, include in Eligible Population/Denominator.

5. Denominator Population:

6. Start Numerator

7. Check Patient offered assistance with end of life issues during measurement period:

a. If Patient offered assistance with end of life issues during measurement period equals Yes, include in Data Completeness Met and Performance Met.

b. If Patient offered assistance with end of life issues during measurement period equals No, proceed to check Patient not offered assistance with end of life issues during measurement period.

8. Check Patient not offered assistance with end of life issues during measurement period:

a. If Patient not offered assistance with end of life issues during measurement period equals Yes, include in the Data Completeness Met and Performance Not Met.

b. If Patient not offered assistance with end of life issues during measurement period equals No, proceed to check Data Completeness Not Met.

9. Check Data Completeness Not Met:

• If Data Completeness Not Met, the Quality Data Code or equivalent was not submitted. 10 patients have been subtracted from the Data Completeness Numerator in the Sample Calculation.

Sample Calculations Data Completeness equals Performance Met (a equals 50 patients) plus Performance Not Met (c equals 20 patients) divided by Eligible Population/Denominator (d equals 80 patients). All equals 70 patients divided by 80 patients. All equals 87.50 percent.

Performance Rate equals Performance Met (a equals 50 patients) divided by Data Completeness Numerator (70 patients). All equals 50 patients divided by 70 patients. All equals 71.43 percent.

Measure Title Quality of Life Assessment (PROMIS-29) and Follow Up Description Percentage of patients age 18 years and older with a neurologic condition who had a PROMIS-29 administered, the results reviewed, and had appropriate follow up. Measurement Period January 1, 20xx to December 31, 20xx Eligible Population Eligible Providers Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant (PA), Advanced Practice Registered Nurse (APRN) Care Setting(s) Outpatient Ages 18 years of age and older Event Patient had an office visit, E/M services performed or supervised by an eligible provider Diagnosis All neurological conditions Denominator Patients aged 18 years and older with a neurologic condition who had a PROMIS-29 administered during the measurement period. Numerator Patients who had their PROMIS-29 administered, the results reviewed, and for patients scoring above 60 had appropriate follow up*.

*Follow-up actions for those scoring above 60 on the PROMIS-29 will be identified in the Axon Registry via use of the following key search terms: appropriate treatment plan. Those who scored 59 or lower do not require follow up action. Required Exclusions None Allowable Exceptions • Unable to complete screening instrument – advance stage dementia, profound psychosis, neurodevelopmental disorder, brain injury, encephalopathy, hydrocephalus, comatose or delirious • Patient declines *For location via search term in a registry, the work group encourages providers to document this exclusion in the following format: “Patient declines assessment” or “Patient refuses assessment”. Exclusion Rationale Patients need to be willing and able to complete the PROMIS-29 tool. Measure Scoring Proportion Interpretation of Higher Score Indicates Better Quality Score Measure Type Patient Reported Outcome & Provider Process Level of Individual provider Measurement Risk Adjustment Not Applicable For Process Measures Relationship to Desired Outcome Process Intermediate Outcome Patient reported Outcomes Improved quality of life data collected and reviewed

Opportunity to Lack of understanding of how patients function outside of disease state and the impact Improve Gap in Care their disease has on their life. Patient reported outcome data is not uniformly collected for neurology.(2) PROMIS data has been demonstrated to be of value to other healthcare conditions.(3) It is anticipated uniform collection of PROMIS data will lead physicians and providers to review the data on a consistent basis and thereby drive changes in treatment planning improving patient outcomes. Harmonization with No other neurology specific measure exists. Existing Measures References 1. Cella D, Yount S, Rothrock N, et al. The Patient-Reported Outcomes Measurement Information System (PROMIS): progress of an NIH Roadmap cooperative group during its first two years. Med Care 2007; 45: Suppl1: S3- S11. 2. Moura L, Schwamm E, Moura Junior V, et al. Feasibility of the collection of patient-reported outcomes in an ambulatory neurology clinic. Neurology 2016; 87:2435-2442. 3. Baumhauer JF. Patient-Reported Outcomes – Are They Living Up to Their Potential? NEJM 2017;377:1.

Quality of Life Outcome for Patients with Epilepsy Measure Title Quality of Life Outcome for Patients with Epilepsy Description Percentage of patients whose quality of life assessment results are maintained or improved during the measurement period. Measurement January 1, 20xx in Year 1 to December 31, 20xx in Year 2 Period Eligible Eligible Providers Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant Population (PA), Advanced Practice Registered Nurse (APRN) Care Setting(s) Outpatient Ages Age 18 years and older Event Office Visit Diagnosis Epilepsy Denominator Patients aged 18 years and older diagnosed with epilepsy who had two office visits during the two- year measurement period which occurred at least 4 weeks apart. Numerator Patients whose most recent QOLIE-10-P score is maintained or improved from the prior QOLIE-10- P score^ obtained in the measurement period.

^For patients who have more than two QOLIE-10-P scores in a calendar year, the last score recorded in the calendar year will be compared to the first score recorded in the calendar year. Required None Exclusions Allowable None Exclusions Exclusion Not Applicable Rationale Measure Percentage Scoring Interpretation Higher Score Indicates Better Quality of Score Measure Type Outcome Level of Provider Measurement Risk See Appendix A AAN Statement on Comparing Outcomes of Patients Adjustment This measure is being made available in advance of development of a risk adjustment strategy. Individuals commenting on the measures are encouraged to provide input on potential risk adjustment or stratification methodologies. The work group identified the following potential data elements that may be used in a risk adjustment methodology for this measure: • Seizure frequency • Co-morbid anxiety and mood disorders • 3 or more comorbid medical conditions Desired The QOLIE-10 has been validated for patients with epilepsy (1) and directly assesses quality of life Outcome from the patient perspective. Measuring quality of life allows patients and providers to identify areas of concern and develop appropriate treatment plan adjustments as needed. Opportunity to Collecting quality of life data via the QOLIE-10-P in a neurology ambulatory setting is feasible.(2) Improve Gap The QOLIE-10-P has been demonstrated to be responsive to changes in epilepsy treatment, although in Care concern has been raised on the strong influence of mood on QOLIE scores.(3) By monitoring quality of life scores, providers may be able to offer interventions to improve patients quality of life, such as medication interventions, surgical interventions, co-morbid conditions, including behavioral health needs, or motivational interviewing.(3-5)

The work group chose the QOLIE-10-P for several reasons (i.e., the brief questionnaire reduces likelihood of respondent fatigue, ease of access for providers to obtain right to use the tool (6), and prior use in the field). The work group will revisit this decision during future updates to the measurement set evaluating the use of the QOLIE-10-P as well as possible similar measures for adolescent and child populations. The QOLIE-10-P requires respondents to provide input on their feelings during the past 4 weeks. The work group incorporated this time frame as a result.

The measurement period for this measure is two years allowing for individuals who see their physician yearly for monitoring to be included in the measurement base. Harmonization There are no known similar measures applicable to patients with epilepsy. The AAN is in the with Existing process of developing a quality of life measure that will apply to all patients with a neurologic Measures condition. Those specifications will be reviewed by this work group once available. References 1. Cramer JA, Perrine K, Devinsky O, et al. A Brief Questionnaire to Screen for Quality of Life in Epilepsy The QOLIE-10. Epilepsia 1996;37(6):577-582 2. Moura LMVR, Schwamm E, Moura Jr V., et al. Feasibility of the collection of patient-reported outcomes in an ambulatory neurology clinic. Neurology. 2016;87:1- 8. 3. Patient-Reported Outcome Measurement Group, Oxford. A Structured Review of Patient-Reported Outcome Measures (PROMs) For Epilepsy: An Update 2009. Available at: http://phi.uhce.ox.ac.uk/pdf/PROMs_Oxford_Epilepsy_17092010.pdf Accessed on August 2, 2017. 4. Wassenaar M, Leijten FSS, Sander JW, et al. on behalf of the OPPEC study group. Anti-epileptic drug changes and quality of life in the community. Acta Neurol Scand 2016; 133:421-426. 5. Hosseini N, Mokhtari S, Momeni E, et al. Effect of motivational interviewing on quality of life in patients with epilepsy. Epilepsy & Behavior 2016;55:70-74. 6. QOLIE Development Group. QOLIE-10 Permission for Academic and Commercial Use. Available at: http://www.epilepsy.com/sites/core/files/atoms/files/permission%20to%20use%20QO LIE-10-P%20web.pdf

Flow Chart Diagram: Quality of Life for Patients with Epilepsy

Was the patient 18 years and older during the measurement period? No Yes

Did the patient have at least two patient

visits with an eligible provider during the measurement period? No Patient NOT Yes Included in Data Submission

Did patient have a diagnosis of epilepsy on any contact OR on their active problem list during the current measurement period? No

Yes

Patient INCLUDED in Eligible Population

Patient INCLUDED in Did the patient complete the QOLIE-10 Denominator during at least two office visits in the Yes measurement period occurring at least 4 weeks apart?

During the measurement period, was the most recent QOLIE10 score was maintained or improved from prior QOLIE10 score? Patient NOT Included in Denominator Yes No

Patient met Patient did numerator NOT meet criteria numerator criteria

34 ©2020. American Academy of Neurology Institute. All Rights Reserved. CPT Copyright 2004-2020 American Medical Association. eCQM Title Depression Remission at Twelve Months eCQM Identifier 159 9.4.000 (Measure eCQM Version Number Authoring Tool)

NQF Number 0710e GUID 8455cd3e-dbb9-4e0c-8084-3ece4068fe94

Measurement January 1, 20XX through December 31, 20XX Period

Measure Steward MN Community Measurement

Measure MN Community Measurement Developer

Endorsed By National Quality Forum

The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major Description depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event.

Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. Mathematica Policy Research disclaims all liability for use or accuracy of any third party codes contained in the specifications. Copyright CPT(R) contained in the Measure specifications is copyright 2004-2019 American Medical Association. LOINC(R) copyright 2004-2019 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2019 International Health Terminology Standards Development Organisation. ICD-10 copyright 2019 World Health Organization. All Rights Reserved.

The performance measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications.

Disclaimer THE MEASURES AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND.

Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].

Measure Scoring Proportion

Measure Type Outcome

Ages 12 to 17 at the time of the index assessment Stratification Ages 18 and older at the time of the index assessment

Risk Adjustment None

Rate None Aggregation

Adults: Depression is a common and treatable mental disorder. 8.1% of American adults age 20 and over had depression in a given 2 week period. Women (10.4%) were almost twice as likely as men (5.5%) to have had depression. The prevalence of depression among adults decreased as family income levels increased. About 80% of adults with depression reported at least some difficulty with work, home, or social activities because of their depression symptoms (Centers for Disease Control and Prevention, 2018).

Depression is a risk factor for development of chronic illnesses such as diabetes and CHD and adversely affects the course, complications and management of chronic medical illness. Both maladaptive health risk behaviors and psychobiological factors associated with depression may explain depression's negative effect on outcomes of chronic illness. (Katon, W.J., 2011)

Adolescents and Adults: The Centers for Disease Control and Prevention states that during 2009-2012 an estimated 7.6% of the U.S. population aged 12 and over had depression, including 3% of Americans with severe depressive symptoms. Almost 43% of persons with severe depressive symptoms reported serious difficulties in work, home and social activities, yet only 35% reported having contact with a mental health professional in the past year. Depression is associated with higher mortality rates in all age groups. People who are depressed are 30 times more Rationale likely to take their own lives than people who are not depressed and five times more likely to abuse drugs. Depression is the leading cause of medical disability for people aged 14 to 44. Depressed people lose 5.6 hours of productive work every week when they are depressed, fifty percent of which is due to absenteeism and short-term disability.

Adolescents: In 2014, an estimated 2.8 million adolescents age 12 to 17 in the United States had at least one major depressive episode (MDE) in the past year. This represented 11.4% of the U.S. population. The same survey found that only 41.2 percent of those who had a MDE received treatment in the past year. The 2013 Youth Risk Behavior Survey of students grades 9 to 12 indicated that during the past 12 months 39.1% (F) and 20.8% (M) indicated feeling sad or hopeless almost every day for at least 2 weeks, planned suicide attempt 16.9% (F) and 10.3% (M), with attempted suicide 10.6% (F) and 5.4% (M). Adolescent-onset depression is associated with chronic depression in adulthood. Many mental health conditions (anxiety, bipolar, depression, eating disorders, and substance abuse) are evident by age 14. The 12-month prevalence of MDEs increased from 8.7% in 2005 to 11.3% in 2014 in adolescents and from 8.8% to 9.6% in young adults (both P < .001). The increase was larger and statistically significant only in the age range of 12 to 20 years. The trends remained significant after adjustment for substance use disorders and sociodemographic factors. Mental health care contacts overall did not change over time; however, the use of specialty mental health providers increased in adolescents and young adults, and the use of prescription medications and inpatient hospitalizations increased in adolescents. In 2015, 9.7% of adolescents in MN who were screened for depression or other mental health conditions, screened positively.

Clinical Adults: Recommendation Source: Institute for Clinical Systems Improvement (ICSI) Health Care Guideline for Adult Depression in Primary Care Statement (Trangle et al., 2016)

Recommendations and algorithm notations supporting depression outcomes and duration of treatment according to ICSI's Health Care Guideline:

Recommendation: Clinicians should establish and maintain follow-up with patients. Appropriate, reliable follow-up is highly correlated with improved response and remission scores. It is also correlated with the improved safety and efficacy of medications and helps prevent relapse.

Proactive follow-up contacts (in person, telephone) based on the collaborative care model have been shown to significantly lower depression severity (Unutzer et al., 2002). In the available clinical effectiveness trials conducted in real clinical practice settings, even the addition of a care manager leads to modest remission rates (Trivedi et al., 2006; Unutzer et al., 2002). Interventions are critical to educating the patient regarding the importance of preventing relapse, safety and efficacy of medications, and management of potential side effects. Establish and maintain initial follow-up contact intervals (office, phone, other) (Hunkeler et al., 2000; Simon et al., 2000).

PHQ-9 as monitor and management tool. The PHQ-9 is an effective management tool, as well, and should be used routinely for subsequent visits to monitor treatment outcomes and severity. It can also help the clinician decide if/how to modify the treatment plan (Duffy et al., 2008; Lowe et al., 2004). Using a measurement-based approach to depression care, PHQ-9 results and side effect evaluation should be combined with treatment algorithms to drive patients toward remission. A five-point drop in PHQ-9 score is considered the minimal clinically significant difference (Trivedi, 2009).

The goals of treatment should be to achieve remission, reduce relapse and recurrence, and return to previous level of occupational and psychosocial function.

If using a PHQ-9 tool, remission translates to PHQ-9 score of less than 5 (Kroenke, 2001). Results from the STAR*D study showed that remission rates lowered with more treatment steps, but the overall cumulative rate was 67% (Rush et al., 2006).

Response and remission take time. In the STAR*D study, longer times than expected were needed to reach response or remission. In fact, one-third of those who ultimately responded did so after six weeks. Of those who achieved remission by Quick Inventory of Depressive Symptomatology (QIDS), 50% did so only at or after six weeks of treatment (Trivedi et al., 2006). If the primary care clinician is seeing some improvement, continue working with that patient to augment or increase dosage to reach remission. This can take up to three months.

This measure assesses achievement of remission, which is a desired outcome of effective depression treatment and monitoring.

Adult Depression in Primary Care - Guideline Aims - Increase the percentage of patients with major depression or persistent depressive disorder who have improvement in outcomes from treatment for major depression or persistent depressive disorder. - Increase the percentage of patients with major depression or persistent depressive disorder who have follow-up to assess for outcomes from treatment. - Improve communication between the primary care physician and the mental health care clinician (if patient is co- managed).

Adolescents: Source: American Academy of Child and Adolescent Psychiatry Practice Parameter for the Assessment and Treatment of Children and Adolescents with Depressive Disorders (2007) http://www.jaacap.com/article/S0890-8567(09)62053-0/pdf

Recommendations: Recommendations supporting depression outcomes and duration of treatment according to AACAP guideline: - Treatment of depressive disorders should always include an acute and continuation phase; some children may also require maintenance treatment. The main goal of the acute phase is to achieve response and ultimately full symptomatic remission (definitions below). - Each phase of treatment should include psychoeducation, supportive management, and family and school involvement. - Education, support, and case management appear to be sufficient treatment for the management of depressed children and adolescents with an uncomplicated or brief depression or with mild psychosocial impairment. - For children and adolescents who do not respond to supportive psychotherapy or who have more complicated depressions, a trial with specific types of psychotherapy and/or antidepressants is indicated.

Sources: Guidelines for Adolescent Depression in Primary Care (GLAD-PC) (2018) http://pediatrics.aappublications.org/content/141/3/e20174081 Guidelines for adolescent depression in primary care (GLAD-PC): II. Treatment and ongoing management http://pediatrics.aappublications.org/content/141/3/e20174082

Recommendations supporting depression outcomes and duration of treatment according to GLAD-PC: Recommendations for Ongoing Management of Depression: - Mild depression: consider a period of active support and monitoring before starting other evidence-based treatment - Moderate or severe major clinical depression or complicating factors: -- consultation with mental health specialist with agreed upon roles -- evidence based treatment (CBT or IPT and/or antidepressant SSRI) - Monitor for adverse effects during antidepressant therapy -- clinical worsening, suicidality, unusual changes in behavior - Systematic and regular tracking of goals and outcomes -- improvement in functioning status and resolution of depressive symptoms Regardless of the length of treatment, all patients should be monitored on a monthly basis for 6 to 12 months after the full resolution of symptoms

Improvement Higher score indicates better quality Notation

Duffy, F. F., Chung, H., Trivedi, M., et al. (2008, October). Systematic use of patient-rated depression severity Reference monitoring: Is it helpful and feasible in clinical psychiatry? Psychiatric Services, 59(10), 1148-1154.

Hunkeler, E. M., Meresman, J. F., Hargreaves, W. A., et al. (2000, August). Efficacy of nurse telehealth care and peer Reference support in augmenting treatment of depression in primary care. Archives of Family Medicine, 9(8), 700-708.

Katon, W.J. (2011) Epidemiology and treatment of depression in patients with chronic medical illness Dialogues in Reference Clinical Neuroscience v.13(1) PMC3181964

Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Reference Journal of General Internal Medicine, 16(9), 606-613. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495268/

Lowe, B., Unutzer, J., Callahan, C. M., et al. (2004). Monitoring depression treatment outcomes with the Patient Reference Health Questionnaire-9. Medical Care, 42(12), 1194-1201.

Rush, A. J., Trivedi, M. H., Wisniewski, S. R., et al. (2006). Acute and longer-term outcomes in depressed outpatients Reference requiring one or several treatment steps: A STAR*D report. American Journal of Psychiatry, 163, 1905-1917.

Simon, G. E., Van Korff, M., Rutter, C., et al. (2000). Randomised trial of monitoring, feedback, and management of Reference care by telephone to improve treatment of depression in primary care. BMJ, 320, 550-554.

Trangle , M., Gursky, J., Haight, R., et al. Depression, adults in primary care. (Updated 2016, March). Retrieved from Reference https://www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines/catalog_behavioral_health_g uidelines/depression/

Trivedi, M. H. (2009). Tools and strategies for ongoing assessment of depression: A measurement-based approach to Reference remission. Journal of Clinical Psychiatry, 70, 26-31.

Trivedi, M. H., Rush, A. J., Wisniewski, S. R., et al. (2006). Evaluation of outcomes with citalopram for depression Reference using measurement-based care in STAR*D: Implications for clinical practice. American Journal of Psychiatry, 163(1), 28-40.

Unutzer, J., Katon, W., Callahan, C. M., et al. (2002). Collaborative care management of late-life depression in the Reference primary care setting: A randomized controlled trial. JAMA, 288, 2836-2845.

Definition Denominator Identification Period: The period in which eligible patients can have an index event. The denominator identification period occurs prior to the measurement period and is defined as 14 months to two months prior to the start of the measurement period. For patients with an index event, there needs to be enough time following index for the patients to have the opportunity to reach remission twelve months +/- 60 days after the index event date. Index Event Date: The date in which the first instance of elevated PHQ-9 or PHQ-9M greater than nine and diagnosis of depression or dysthymia occurs during the denominator identification measurement period. Patients may be screened using PHQ-9 and PHQ-9M up to 7 days prior to the office visit (including the day of the office visit).

Measure Assessment Period: The index event date marks the start of the measurement assessment period for each patient which is 14 months (12 months +/- 60 days) in length to allow for a follow-up PHQ-9 or PHQ-9M between 10 and 14 months following the index event. This assessment period is fixed and does not start over with a higher PHQ-9 or PHQ-9M that may occur after the index event date.

Remission is defined as a PHQ-9 or PHQ-9M score of less than five.

Twelve months is defined as the point in time from the index event date extending out twelve months and then allowing a grace period of sixty days prior to and sixty days after this date. The most recent PHQ-9 or PHQ-9M score less than five obtained during this four month period is deemed as remission at twelve months, values obtained prior to or after this period are not counted as numerator compliant (remission).

When a baseline assessment is conducted with PHQ 9M, the follow-up assessment can use either a PHQ 9M or PHQ 9.

This eCQM is a patient-based measure. Guidance This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

Transmission TBD Format

Adolescent patients 12 to 17 years of age and adult patients 18 years of age and older with a diagnosis of major Initial depression or dysthymia and an initial PHQ-9 or PHQ-9M score greater than nine during the index event. Patients may Population be screened using PHQ-9 and PHQ-9M up to 7 days prior to the office visit (including the day of the office visit).

Denominator Equals Initial Population

1: Patients who died 2: Patients who received hospice or palliative care services 3: Patients who were permanent nursing home residents Denominator 4: Patients with a diagnosis of bipolar disorder Exclusions 5: Patients with a diagnosis of personality disorder emotionally labile 6: Patients with a diagnosis of schizophrenia or psychotic disorder 7: Patients with a diagnosis of pervasive developmental disorder

Adolescent patients 12 to 17 years of age and adult patients 18 years of age and older who achieved remission at Numerator twelve months as demonstrated by a twelve month (+/- 60 days) PHQ-9 or PHQ-9M score of less than five

Numerator Not Applicable Exclusions

Denominator None Exceptions

Supplemental For every patient evaluated by this measure also identify payer, race, ethnicity and sex Data Elements

Table of Contents

• Population Criteria • Definitions • Functions • Terminology • Data Criteria (QDM Data Elements) • Supplemental Data Elements • Risk Adjustment Variables

Population Criteria

Initial Population

exists ( ["Patient Characteristic Birthdate": "Birth date"] BirthDate with "Index Depression Assessment" IndexAssessment such that Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, IndexAssessment.relevantDatetime ) >= 12 and "Index Depression Assessment" is not null )

Denominator

"Initial Population"

Denominator Exclusions

"Has An Order For Palliative or Hospice Care" or "Has Palliative Care Encounter" or "Has Long Term Care Encounter" or "Patient Expired" or "Has Disorder Diagnoses"

Numerator

Last(["Assessment, Performed": "PHQ 9 and PHQ 9M Tools"] DepressionAssessment where Global."ToDate"(DepressionAssessment.relevantDatetime)during "Measure Assessment Period" sort by relevantDatetime ).result < 5

Numerator Exclusions

None

Denominator Exceptions None

Stratification 1

Stratification 2

Definitions

Denominator

"Initial Population"

Denominator Exclusions

"Has An Order For Palliative or Hospice Care" or "Has Palliative Care Encounter" or "Has Long Term Care Encounter" or "Patient Expired" or "Has Disorder Diagnoses"

Denominator Identification Period

Interval[start of "Measurement Period" - 14 months, start of "Measurement Period" - 2 months )

Depression Assessments Greater than 9

["Assessment, Performed": "PHQ 9 and PHQ 9M Tools"] DepressionAssessment where DepressionAssessment.result > 9

Depression Diagnoses

["Diagnosis": "Major Depression Including Remission"] union ["Diagnosis": "Dysthymia"]

Depression Encounter

["Encounter, Performed": "Contact or Office Visit"] ValidEncounter with "Depression Diagnoses" Depression such that ValidEncounter.relevantPeriod overlaps Depression.prevalencePeriod and ValidEncounter.relevantPeriod ends during "Denominator Identification Period"

Has An Order For Palliative or Hospice Care

exists ( ["Intervention, Order": "Palliative or Hospice Care"] PalliativeCareOrder where PalliativeCareOrder.authorDatetime occurs before end of "Measure Assessment Period" )

Has Disorder Diagnoses

exists ( ( ["Diagnosis": "Bipolar Disorder"] union ["Diagnosis": "Personality Disorder Emotionally Labile"] union ["Diagnosis": "Schizophrenia or Psychotic Disorder"] union ["Diagnosis": "Pervasive Developmental Disorder"] ) DisorderDiagnoses where DisorderDiagnoses.prevalencePeriod starts before end of "Measure Assessment Period" )

Has Long Term Care Encounter

exists ( ["Encounter, Performed": "Care Services in Long-Term Residential Facility"] EncounterLongTermCare where EncounterLongTermCare.relevantPeriod starts before end of "Measure Assessment Period" )

Has Palliative Care Encounter

exists ( ["Encounter, Performed": "Palliative Care Encounter"] PalliativeCareEncounter where PalliativeCareEncounter.relevantPeriod starts before end of "Measure Assessment Period" )

Index Depression Assessment

First("Depression Assessments Greater than 9" DepressionAssessment with "Depression Encounter" DepressionEncounter such that DepressionAssessment.relevantDatetime is not null and DepressionAssessment.relevantDatetime in Interval[Global."ToDate"((start of DepressionEncounter.relevantPeriod)- 7 days), end of DepressionEncounter.relevantPeriod] sort by relevantDatetime )

Initial Population

Measure Assessment Period

"Index Depression Assessment" FirstIndexAssessment return Interval[Global."ToDate" ( FirstIndexAssessment.relevantDatetime ) + 12 months - 60 days, Global."ToDate" ( FirstIndexAssessment.relevantDatetime ) + 12 months + 60 days]

Numerator

Patient Expired

exists ( ["Patient Characteristic Expired": "Dead (finding)"] Deceased where Deceased.expiredDatetime occurs before end of "Measure Assessment Period" )

SDE Ethnicity

["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

["Patient Characteristic Payer": "Payer"]

SDE Race

["Patient Characteristic Race": "Race"]

SDE Sex

["Patient Characteristic Sex": "ONC Administrative Sex"]

Stratification 1

Stratification 2

Functions

Global.CalendarAgeInYearsAt(BirthDateTime DateTime, AsOf DateTime)

years between ToDate(BirthDateTime)and ToDate(AsOf)

Global.ToDate(Value DateTime)

DateTime(year from Value, month from Value, day from Value, 0, 0, 0, 0, timezoneoffset from Value)

Terminology

• code "Birth date" ("LOINC Code (21112-8)") • code "Dead (finding)" ("SNOMEDCT Code (419099009)") • valueset "Bipolar Disorder" (2.16.840.1.113883.3.67.1.101.1.128) • valueset "Care Services in Long-Term Residential Facility" (2.16.840.1.113883.3.464.1003.101.12.1014) • valueset "Contact or Office Visit" (2.16.840.1.113762.1.4.1080.5) • valueset "Dysthymia" (2.16.840.1.113883.3.67.1.101.1.254) • valueset "Ethnicity" (2.16.840.1.114222.4.11.837) • valueset "Major Depression Including Remission" (2.16.840.113883.3.67.1.101.3.2444) • valueset "ONC Administrative Sex" (2.16.840.1.113762.1.4.1) • valueset "Palliative Care Encounter" (2.16.840.1.113883.3.600.1.1575) • valueset "Palliative or Hospice Care" (2.16.840.1.113883.3.600.1.1579) • valueset "Payer" (2.16.840.1.114222.4.11.3591) • valueset "Personality Disorder Emotionally Labile" (2.16.840.1.113883.3.67.1.101.1.246) • valueset "Pervasive Developmental Disorder" (2.16.840.1.113883.3.464.1003.105.12.1152) • valueset "PHQ 9 and PHQ 9M Tools" (2.16.840.1.113883.3.67.1.101.1.263) • valueset "Race" (2.16.840.1.114222.4.11.836) • valueset "Schizophrenia or Psychotic Disorder" (2.16.840.1.113883.3.464.1003.105.12.1104)

Data Criteria (QDM Data Elements)

• "Assessment, Performed: PHQ 9 and PHQ 9M Tools" using "PHQ 9 and PHQ 9M Tools (2.16.840.1.113883.3.67.1.101.1.263)" • "Diagnosis: Bipolar Disorder" using "Bipolar Disorder (2.16.840.1.113883.3.67.1.101.1.128)" • "Diagnosis: Dysthymia" using "Dysthymia (2.16.840.1.113883.3.67.1.101.1.254)" • "Diagnosis: Major Depression Including Remission" using "Major Depression Including Remission (2.16.840.113883.3.67.1.101.3.2444)" • "Diagnosis: Personality Disorder Emotionally Labile" using "Personality Disorder Emotionally Labile (2.16.840.1.113883.3.67.1.101.1.246)" • "Diagnosis: Pervasive Developmental Disorder" using "Pervasive Developmental Disorder (2.16.840.1.113883.3.464.1003.105.12.1152)" • "Diagnosis: Schizophrenia or Psychotic Disorder" using "Schizophrenia or Psychotic Disorder (2.16.840.1.113883.3.464.1003.105.12.1104)" • "Encounter, Performed: Care Services in Long-Term Residential Facility" using "Care Services in Long-Term Residential Facility (2.16.840.1.113883.3.464.1003.101.12.1014)" • "Encounter, Performed: Contact or Office Visit" using "Contact or Office Visit (2.16.840.1.113762.1.4.1080.5)" • "Encounter, Performed: Palliative Care Encounter" using "Palliative Care Encounter (2.16.840.1.113883.3.600.1.1575)" • "Intervention, Order: Palliative or Hospice Care" using "Palliative or Hospice Care (2.16.840.1.113883.3.600.1.1579)" • "Patient Characteristic Birthdate: Birth date" using "Birth date (LOINC Code 21112-8)" • "Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity (2.16.840.1.114222.4.11.837)" • "Patient Characteristic Expired: Dead (finding)" using "Dead (finding) (SNOMEDCT Code 419099009)" • "Patient Characteristic Payer: Payer" using "Payer (2.16.840.1.114222.4.11.3591)" • "Patient Characteristic Race: Race" using "Race (2.16.840.1.114222.4.11.836)" • "Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex (2.16.840.1.113762.1.4.1)"

Supplemental Data Elements

SDE Ethnicity

["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

["Patient Characteristic Payer": "Payer"]

SDE Race

["Patient Characteristic Race": "Race"]

SDE Sex

["Patient Characteristic Sex": "ONC Administrative Sex"]

Risk Adjustment Variables

None

Measure Set None COMPOSITE MEASURE BPPV: Dix-Hallpike and Canalith Repositioning

Measure Title BPPV: Dix-Hallpike and Canalith Repositioning

Description Percentage of patients with BPPV who had a Dix-Hallpike maneuver performed AND who had therapeutic canalith repositioning procedure (CRP) performed or who were referred for physical therapy or to a provider who can perform CRP if identified with posterior canal BPPV Measurement January 1, 20xx to December 31, 20xx Period Eligible Eligible Providers Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant Population (PA), Advanced Practice Registered Nurse (APRN), Physical Therapist, Occupational Therapist, Audiologist Care Setting(s) Outpatient Ages All Event Office Visit Diagnosis BPPV Denominator 1. Patients diagnosed with BPPV 2. Patients diagnosed with posterior canal BPPV Numerator 1. Patients who had a Dix-Hallpike maneuver performed 2. Patients who had therapeutic CRP performed or were referred to a provider who can perform CRP, or were prescribed or referred for physical therapy Required For Denominator 2 Only: Exclusions • Patients diagnosed with anterior or lateral BPPV • Patients with unspecified canal BPPV Allowable • Patient has a history of BPPV, but is not currently experiencing positional Exclusions dizziness/vertigo consistent with active BPPV. • Patient has refused or declined Dix-Hallpike maneuver and/or CRP. (To be captured via search terms, this exclusion should be written as “patient refuses (or declines) Dix- Hallpike or CRP.” • Patient has cervical spinal disease (i.e., cervical stenosis, severe kyphoscoliosis, limited cervical range of motion, Down’s syndrome, severe rheumatoid arthritis, cervical radiculopathies, Paget’s disease, ankylosing spondylitis, low back dysfunction, spinal cord injuries, spinal fractures) • Patient unable to lay flat (i.e., severe heart disease) • Patient has severe atherosclerotic disease or recent dissection involving the anterior or posterior cerebral circulation. • Unable to be seated in exam chair (i.e., morbidly obese), or maneuver cannot be safely performed given morbid obesity

Key phrases to meet the measure via Registry search function include:

• “No active vertigo” • “No active dizziness” • “No current vertigo” • “No current dizziness” • “BPPV not active” • “Patient asymptomatic” • “Patient asymptotic” • “Dix-Hallpike not indicated” • “DH not indicated” • “CRP not indicated” (For Component 2 only)

Measure SEE CHART BELOW: Scoring Date Completeness = Performance Met (a1+a2) + Denominator Exceptions (b1+b2)+Performance Not Met (c1+c2) Eligible Population (d1+d2)

Performance Rate = Performance Met (a1+a2) Date Completeness Numerator – Denominator Exceptions (b1+b2)

Interpretation Higher Score Indicates Better Quality of Score Measure Type Process Level of Provider Measurement Risk Not Applicable Adjustment Flow Chart Diagram: Reporting Criteria 1: Dix-Hallpike Maneuver Performed for Patients with BPPV

Patient NOT Included in Data Submission

No No

Did patient have a diagnosis of BPPV on any Did the patient have at least one new or contact during the current or prior established patient visit with an eligible measurement period OR on their active problem provider during the measurement period? Yes list during the measurement period?

Yes

Patient NOT Patient Included in Yes Did patient refuse or decline Dix- INCLUDED in Denominator Hallpike? Eligible Population d1

b1 No

Yes Did patient have a cervical spinal disease?

Was patient unable to be seated in Yes an exam chair?

Yes Was patient unable to lay flat?

? No Was Dix-Hallpike performed

No Yes Patient INCLUDED in Patient did Patient met Denominator NOT meet numerator numerator criteria a1 criteria c1 Flow Chart Diagram: Reporting Criteria 2 Canalith Repositioning Procedure Performed for Patients with Posterior Canal BPPV

Did the patient have at least one new or Patient NOT

established patient visit with an eligible No Included in provider during the measurement period? Data Submission Yes

Did patient have a diagnosis of Posterior Canal Yes BPPV on any contact during the current or prior measurement period OR on their active problem No Did patient have a diagnosis of anterior canal or list during the measurement period? lateral canal anal BPPV on any contact during the current or prior measurement period OR on their active problem list during the Yes measurement period?

Patient NOT Patient Included in Yes Did patient refuse or decline Canalith INCLUDED in Denominator Repositioning Procedure (CRP)? Eligible Population d2

b2 No

Yes Did patient have a cervical spinal disease?

Was patient unable to be seated in Yes an exam chair?

Yes Was patient unable to lay flat? Was CRP performed OR patient referred for physical therapy or to a provider who can No perform CRP?

No Yes Patient INCLUDED in Patient did Patient met Denominator NOT meet numerator numerator criteria a2 criteria c2

Measure Title Pediatric Medication Reconciliation Description Percentage of pediatric patients who had a medication review at every encounter and a medication list present in the medical record. Measurement January 1, 20xx to December 31, 20xx Period Eligible Eligible Providers Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant Population (PA), Advanced Practice Registered Nurse (APRN), Clinical Pharmacist Care Setting(s)  Outpatient,  On admission to inpatient or residential facility,  ED and Urgent Care Ages All patients 0-17 years of age Event Patient had an office visit, E/M services performed or supervised by an eligible provider, admitted to an inpatient or residential facility, seen for consultation in the ED or urgent care. Diagnosis A neurologic condition Denominator All patients 0-17 years of age Numerator Medication review+ conducted at every encounter* during the measurement year and the presence of a medication list^ in the medical record.

+Medication review is a review of all patient’s medications, including prescription medications, over-the-counter (OTC) medications and herbal or supplemental therapies by a prescribing provider or clinical pharmacist

*Encounter: Face-to-face visit with provider. Includes CPT codes 99201-99205, 99211- 99215, 99241-99245.

^Medication list: current medication in the medical record and must contain the medication name, and dosage, and frequency, and route of administration.

To perform well on this measure, we suggest using key phrases: Medication review completed, medication list updated, medication list up to date Required None Exclusions Allowable  Patient and/or caregiver is unable or unwilling to do this activity. Exclusions  Procedure visit (i.e., EEG, nerve conduction study) where no sedation occurs. Exclusion It is appropriate to exclude patients who decline or are unwilling to participate in medication Rationale reconciliation. A visit where a procedure is performed is typically preceded by an office visit where medication reconciliation would have been completed. Measure Scoring Percentage Interpretation of Higher Score Indicates Better Quality Score Measure Type Process Level of Provider, Practice, System Measurement Risk Adjustment N/A

For Process Measures Relationship to Desired Outcome

Process Outcomes •Medication reconciliation •Reduction in adverse events •Medication documented •Reduction of medical errors in medical record

Opportunity to Medication reconciliation reduces the risk of medication errors and supports the management Improve Gap in of patients with chronic conditions1. Polypharmacy increases the complexity of medication Care errors. In addition, to review at every encounter, all patients should have medication list reviewed and updated as appropriate at time of discharge from inpatient facilities. Harmonization This is a variation of the NCQA measure on medication review for adults 66 years of age and with Existing older5. A modification is needed to take neurology patients into account who are generally Measures younger but still have complicated conditions with comorbidities and polypharmacy. Additionally, many measures in CMS’ MIPS payment program include similar measures for those age 18 and above. The Work Group felt it was necessary to include children as many pediatric neurologic conditions also involve polypharmacy. References 1. National Institute of Clinical Excellent. Medicines optimization: the safe and effective use of medicines to enable the best possible outcomes.

Supporting Evidence:  Administration on Aging (AOA). A profile of older Americans. Washington (DC): U.S. Department of Health and Human Services; 2009. 15 p.  Bikowski RM, Ripsin CM, Lorraine VL. Physician-patient congruence regarding medication regimens. J Am Geriatr Soc. 2001 Oct;49(10):1353-7.  Chodosh J, Solomon DH, Roth CP, Chang JT, MacLean CH, Ferrell BA, Shekelle PG, Wenger NS. The quality of medical care provided to vulnerable older patients with chronic pain. J Am Geriatr Soc. 2004 May;52(5):756-61.  National Committee for Quality Assurance (NCQA). HEDIS 2016: Healthcare Effectiveness Data and Information Set. Vol. 1, narrative. Washington (DC): National Committee for Quality Assurance (NCQA); 2015. various p.  Task Force on Medicines Partnership. The national collaborative medicines management services programme. Room for review. A guide to medication review. [internet]. 2002.  Sorensen, L., J.A. Stokes, D.M. Purdie, M. Woodward, R. Elliott, M.S. Roberts. Medication reviews in the community: results of a randomized, controlled effectiveness trial. Br. J. Clin. Pharmacol. 2004. 648-64.  Nassaralla CL, Naessens JM, Chaudhry R, et al. Implementation of a medication reconciliation process in an ambulatory internal medicine clinic. Qual Saf Health Care 2007;16: 90-94.  Pronovost P, Weast B, Schwarz M, et al. Medication Reconciliation: A Practical Tool to Reduce the Risk of Medication Errors. J Crit Care. 2003;18(4):201-5.  Institute of Medicine (IOM). Preventing Medication Errors. National Academies Press, Washington D.C. 2006. - Institute of Medicine (IOM): Committee on Quality Health Care in America. To err is human: building a safer health system. Washington, D.C: National Academy Press. 2002.  Gurwitz JH, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. 2003; 289: 1107-16.  George J, Elliott RA, Stewart DC. A systematic review of interventions to improve medication taking in elderly patients prescribed multiple medications. Drugs Aging. 2008; 25:307-24.  Vinks Th, Egberts TC, de Lange TM, De Koning FH. Pharmacist-based medication review reduces potential drug-related problems in the elderly: the SMOG controlled trial. Drugs Aging. 2009;26:123-33.  Hanlon JT, Lindblad CI, Gray SL. Can clinical pharmacy services have a positive impact on drug-related problems and health outcomes in community-based older adults? Am J Geriatr Pharmacother. 2004;2:3-13.  Gillespie U, Alassaad A, Henrohn D, et al. A Comprehensive Pharmacist Intervention to Reduce Morbidity in Patients 80 Years or Older. Arch Intern Med. 2009;169:894- 900.  Zermansky AG, Silcock J. Is medication review by primary-care pharmacists for older people cost effective?: a narrative review of the literature focusing on costs and benefits. Pharmacoeconomics. 2009; 27:11-24.  Krska J, Cromarty JA, Arris F, et al. Pharmacist-led medication review in patients over 65: a randomized, controlled trial in primary care. Age Ageing, 2001;30:205- 211.  Knight, E.L., J. Avorn. Quality indicators for appropriate medication use in vulnerable elders. Ann. Intern. Med. 2001. 703-10.

Avoidance of Dopamine-Blocking Medications in Patients with Parkinson’s Disease Measure Description Percentage of patients with PD prescribed a contraindicated dopamine-blocking agent* (i.e., anti-psychotic, anti-nausea, anti-Gastroesophageal Reflux Disease (GERD)).

Note: A lower score is desirable. Measure Components Numerator Patients with PD prescribed a contraindicated dopamine blocking agent* Statement (i.e., anti-psychotic, anti-nausea, anti-GERD).

*Dopamine blocking agents are: Acepromazine, amisulpride, amoxapine, asenapine, azaperone, aripiprazole, benperidol, bromopride, butaclamol, chlorpromazine, chloprothixene, clomipramine, clopenthixol, droperidol, eticlopride, flupenthixol, fluphenazine, haloperidol, hydroxyzine, iodobenzamide, levomepromazine, loxapine, mesoridazine, metoclopramide, nafadotride, nemonapride, olanzapine, paliperidone, penfluridol, perazine, perphenazine, pimozide, prochlorperazine, promazine, promethazine, raclopride, remoxipride, reserpine, risperidone, spipersone, spiroxatrine, stepholidine, sulpride, sultopride, tetrabenazine, tetrahydropalmatine, thiethylperazine, thioridazine, thiothixene, tiapride, trifluoperazine, trifluperidol, triflupromazine, trimipramine, and ziprasidone. Exceptions: clozapine, quetiapine

Denominator All patients with a diagnosis of PD. Statement Denominator None Exceptions Supporting The following clinical recommendation statements are quoted verbatim Guideline & from the referenced clinical guidelines and represent the evidence base Other for the measure: References  For patients with PD and psychosis, olanzapine should not be routinely considered (Level B).(1)  When encountering a psychotic PD patient it is critical that the treating healthcare providers be aware that only two medications have been shown in double-blind placebo-controlled trials to not worsen motor dysfunction in PD; quetiapine and clozapine.(2)  Randomized Clinical Trials support the previous designation of clozapine as being efficacious for the treatment of psychosis in PD.(3)  The use of olanzapine has an unacceptable risk of motor deterioration. Furthermore, atypical and conventional antipsychotics are associated with a similarly increased risk for all-cause mortality and cerebrovascular events in elderly patients with dementia.

Olanzapine therefore has an unacceptable risk for the treatment of psychosis in PD.(3) Measure Importance Relationship to Dopamine-blocking agents are often given to PD patients with psychotic, Desired gastrointestinal, or sleep symptoms. Measuring how many patients with PD Outcome were prescribed these medications will result in reduced inappropriate prescriptions thereby preventing worsening of motor features of PD and avoiding medical errors and shortening the length of inpatient admissions. Opportunity Clozapine and quetiapine have been shown to be effective without for significant worsening of motor symptoms.(1) Improvement Appropriate high dopamine levels are needed to adequately control PD symptoms, but elevated dopamine levels can trigger a worsening of some symptoms including psychosis and dyskinesia. Antipsychotics are commonly prescribed for patients with PD despite potential to worsen motor symptoms.(4) Noyes noted that taking neuroleptic drugs increased an individual’s chances of a diagnosis of PD within a year by 94%.(5) Hallucinations occur in approximately 1/3 of patients with PD treated chronically with dopaminergic drugs.(6) Using VA data, Weintraub found 50% of patients with PD having a diagnosis of psychosis were prescribed an antipsychotic.(7) Quetiapine was most frequently prescribed, but approximately 30% received a high dose antipsychotic (fluphenazine, haloperidol, perphenazine, trifluperazine, or thiothixene.)(7) National ☐ Patient and Family Engagement Quality ☒ Patient Safety Strategy ☐Care Coordination Domains ☐ Population/Public Health ☒ Efficient Use of Healthcare Resources ☒ Clinical Process/Effectiveness Exception Not applicable Justification Harmonization Not applicable with Existing Measures Measure Designation Measure ☒ Quality improvement Purpose ☒ Accountability (Check all that apply) Type of ☒Process Measure ☐ Outcome (Check all that ☐ Structure apply) Level of ☒ Individual Provider Measurement ☒ Practice

(Check all that ☒ System apply) Care Setting ☒ Outpatient (Check all that ☒ Inpatient apply) ☒ Skilled Nursing Home ☒ Emergency Departments and Urgent Care Data Source ☒ Electronic health record (EHR) data (Check all that ☒Administrative Data/Claims apply) ☐ Chart Review ☒ Registry References 1. Miyasaki JM, Shannon K, Voon V, et al. Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter: evaluation and treatment of depression, psychosis, and dementia in Parkinson disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2006;66(7):996-1002. 2. Aminoff MJ, Christine CW, Friedman JH, et. al., Management of the hospitalized patient with Parkinson's disease: Current state of the field and need for guidelines. Parkin Rel Disord. 2011. 139-145. 3. Seppi K, Weintraub D, Coelho M, et al. The Movement Disorder Society Evidence-Based Medicine Review Update: Treatments for the Non-Motor Symptoms of Parkinson's Disease. Mov Disord. 2011;26(0 3): S42–S80. 4. Lertxundi U, Ruiz AI, Aspiazu MA, et al. Adverse reactions to antipsychotics in Parkinson disease: an analysis of the Spanish pharmacovigilance database. Clinical Neuropharmacology 2015; 38(3):69-84. 5. Noyes K, Hangsheng L, and Holloway RG. What is the risk of developing parkinsonism following neuroleptic use? Neurology 2006;66:941-943. 6. Goetz CG, Blasucci LM, Leurgans S, et al. Olanzapine and clozapine: comparative effects on motor function in hallucinating PD patients. Neurology 2000 Sep 26;55(6):789e94. 7. Weintraub D, Chen P, Ignacio RV, et al. Patterns and Trends in Antipsychotic Prescribing for Parkinson Disease Psychosis. Arch Neurol. 1011;68(7):899-904. Technical Specifications: Electronic Health Record (EHR) Data The AAN is in the process of creating code value sets and the logic required for electronic capture of the quality measures with EHRs. A listing of the quality data model elements, code value sets, and measure logic (through the CMS Measure Authoring Tool) for each of the PD measures will be made available at a later date. Technical Specifications: Administrative Data (Claims) Administrative claims data collection requires users to identify the eligible population (denominator) and numerator using codes recorded on claims or billing forms (electronic or paper). Users report a rate based on all patients in a given practice for whom data are available and who meet the eligible population/ denominator criteria. Denominator ICD-9 Code ICD-10 Code (Eligible 332.0 (Paralysis agitans) G20 Parkinson’s Disease Population) Hemiparkinsonism Idiopathic Parkinsonism or Parkinson’s Disease Paralysis agitans Parkinsonims or Parkinson’s disease NOS Primary Parkinsonism or Parkinson’s disease

AND

CPT E/M Service Code: 99201, 99202, 99203, 99204, 99205 (Office or other outpatient visit-New Patient);

Measure Title Activity counseling for back pain Description Percentage of patients 18 to 65 years of age with back pain who were counseled to remain active and exercise or were referred to physical therapy Measurement Period January 1, 20xx to December 31, 20xx Eligible Population Eligible Providers Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant (PA), Advanced Practice Registered Nurse (APRN) Care Setting(s) Outpatient, Inpatient, ED or Urgent Care, Residential (SNF, home care) Ages Patients aged 18 to 65 years of age Event Patient had an office visit, E/M services performed or supervised by an eligible provider, admitted to an inpatient or residential facility, seen for consultation in the ED or urgent care. Diagnosis Back pain Denominator Patients aged 18 to 65 years of age seen for an initial visit for diagnosis of back pain Numerator Patients who were counseled* to remain active and exercise OR were referred to physical therapy^ at initial visit for diagnosis of back pain

*Counseling: advise on the maintenance or resumption of activities AND education on the importance of an active lifestyle and exercise.

^Documentation that physical therapy was recommended

To perform well on this measure, we suggest using key phrases: exercise education, exercise counseling, activity counseling, return to regular activity as soon as possible, resumption of activity, referral to physical therapy Required Exclusions Patients with existing diagnosis of back pain. Allowable Exclusions • Co-morbid condition that deems the patient unfit to participate in physical activity • Patient has a history of cancer • Patient is on immunosuppression medications • Patient has a diagnosis of cauda equina syndrome • Patient has risk factors for fractures • Existing order for physical therapy from different provider Exclusion Rationale Several medical conditions indicated above would exclude a patient as they require a more conservative approach to management of back pain. Measure Scoring Percentage Interpretation of Higher Score Indicates Better Quality Score Measure Type Process Level of Provider, Practice, System Measurement Specifying at a system level so it’s available when an outcome measure is developed. Risk Adjustment N/A For Process Measures Relationship to Desired Outcome

Process Intermediate Outcomes Outcomes •Counseling on activity level •Reduction in pain •Return to work/school and exercise •Improved physical function and/or less absences •Or physical therapy referral

Opportunity to Back pain is a frequent cause of sick days for those in the work force1. In 1990 it was Improve Gap in Care reported that low back pain was the fifth most common reason to see a physician2. A 2002 National Health Interview Survey indicated that one fourth of U.S. adults reported back pain in the last 3-month period3. A 2006 socioeconomic study showed total costs attributable to low back pain in the United States were estimated at $100 billion, two thirds of which were indirect costs of lost wages and productivity4.

The Work Group debated how best to define counseling for this measure. Many studies recommended counseling patients on the use of heat and against the use of bed rest. After much discussion, these recommendations were removed as the intent of the measure is to remain active. Additionally, bed rest may be appropriate in some cases for a limited time span. The Work Group will reconsider these concepts in 3 years when the measures are updated. Harmonization with This is a variation of the ICSI measure on back pain. The modified measure was created to Existing Measures account for the role of neurologists in dealing with all types of back pain, not just low back and sciatica.

https://qualitymeasures.ahrq.gov/summaries/summary/39391/adult-acute-and-subacute- low-back-pain-percentage-of-patients-who-were-advised-on-maintenance-or-resumption- of-activities-against-bed-rest-use-of-heat-education-on-importance-of-active-lifestyle-and- exercise-and-recommendation-to-take-antiinflammatory-or-analg?q=back+pain References 1. Schaafsma FG, Whelan K, van der Beek AJ, et al. Physical conditioning as part of a return to work strategy to reduce sickness absence for workers with back pain. Cochrane Database of Systematic Reviews 2013, Issue 8. 2. Hart L, Deyo R, Cherkin D. Physician Office Visits for Low Back Pain: Frequency, Clinical Evaluation, and Treatment Patterns From a U.S. National Survey. Spine 1995; 20(1):11-9. 3. Deyo R, Mirza S. Back Pain Prevalence and Visit Rates: Estimates From U.S. National Surveys, 2002. Spine 2006; 31(23):2724-2727. 4. Qaseem A, Wilt TJ, McLean RM, Forciea MA, Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017 Apr 4;166(7):514-30.

Supporting Evidence: • Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Internal Med 2007; 147:478-491. • National Guideline Centre. Low back pain and sciatica in over 16s: assessment and management. London (UK): National Institute for Health and Care Excellence (NICE); 2016 Nov 30. 18 p. (NICE guideline; no. 59). • Goertz M, Thorson D, Bonsell J, et al. Adult acute and subacute low back pain. Institute for Clinical Systems Improvement (ICSI); 2012 Nov.

Flow Chart Diagram

Is the patient between 18 and 65 years No of age during the measurement period?

Yes

No Is the patient being seen for an initial Patient NOT visit for diagnosis of back pain? included in eligible population

Yes Yes

Does the patient have an existing diagnosis of back pain?

Patient INCLUDED

in eligible population

Does the patient have a co-morbid condition that deems the patient unfit to participate in physical activity?

Yes No

Does the patient have a history of cancer? Yes

Yes Is the patient on immunosuppression medications?

Patient NOT No included in Yes denominator Does the patient have a diagnosis of cauda equine syndrome?

Yes No

Does the patient have risk factors for fractures?

Yes No

Is there an existing order for physical

therapy from a different provider?

Patient INCLUDED in denominator

Was the patient counseled on remaining active and exercise or referred to physical therapy at initial visit for diagnosis of back pain?

Yes No

Patient met Patient did numerator NOT meet criteria numerator criteria

Quality ID #431 (NQF 2152): Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling – National Quality Strategy Domain: Community/Population Health – Meaningful Measure Area: Prevention and Treatment of Opioid and Substance Use Disorders

2021 COLLECTION TYPE: MIPS CLINICAL QUALITY MEASURES (CQMS)

MEASURE TYPE: Process

DESCRIPTION: Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 12 months AND who received brief counseling if identified as an unhealthy alcohol user

INSTRUCTIONS: This measure is to be submitted once per performance period for patients seen during the performance period. This measure is intended to reflect the quality of services provided for preventive screening for unhealthy alcohol use. There is no diagnosis associated with this measure. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. For the purposes of the measure, the most recent denominator eligible encounter should be used to determine if the numerator action for the submission criteria was performed within the 12-month look back period.

This measure will be calculated with 3 performance rates: 1) Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 12 months 2) Percentage of patients aged 18 years and older who were identified as unhealthy alcohol users who received brief counseling 3) Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 12 months AND who received brief counseling if identified as unhealthy alcohol users

The denominator of submission criteria 2 is a subset of the resulting numerator for submission criteria 1, as submission criteria 2 is limited to assessing if patients identified as unhealthy alcohol users received brief counseling. For all patients, submission criteria 1 and 3 are applicable, but submission criteria 2 will only be applicable for those patients who are identified as unhealthy alcohol users. Therefore, data for every patient that meets the age and encounter requirements will only be submitted for submission criteria 1 and 3, whereas data submitted for submission criteria 2 will be for a subset of patients who meet the age and encounter requirements, as the denominator has been further limited to those who were identified as unhealthy alcohol users. NOTE: Patient encounters for this measure conducted via telehealth (e.g., encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable.

THERE ARE THREE SUBMISSION CRITERIA FOR THIS MEASURE: 1) All patients who were screened for unhealthy alcohol use using a systematic screening method

AND

2) All patients who were identified as unhealthy alcohol users who received brief counseling

AND

3) All patients who were screened for unhealthy alcohol use using a systematic screening method and, if identified as unhealthy alcohol users received brief counseling, or were not identified as unhealthy alcohol users This measure contains three submission criteria which aim to identify patients who were screened for unhealthy alcohol use using a systematic screening method (submission criteria 1), patients who were identified as unhealthy alcohol users and who received brief counseling (submission criteria 2), and a comprehensive look at the overall performance on unhealthy alcohol use screening and brief counseling (submission criteria 3). By separating this measure into various submission criteria, the MIPS eligible professional or MIPS eligible clinician will be able to better ascertain where gaps in performance exist, and identify opportunities for improvement. The overall rate (submission criteria 3) should be utilized to compare performance to published versions of this measure prior to the 2021 performance year, when the measure had a single performance rate. For accountability reporting in the CMS MIPS program, the rate for submission criteria 2 is used for performance.

SUBMISSION CRITERIA 1: ALL PATIENTS WHO WERE SCREENED FOR UNHEALTHY ALCOHOL USE

DENOMINATOR (SUBMISSION CRITERIA 1): All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period

Denominator Criteria (Eligible Cases): Patients aged ≥ 18 years AND At least two patient encounters during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90845, 96156, 96158, 97165, 97166, 97167, 97168, 97802, 97803, 97804, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, G0270, G0271 OR At least one preventive encounter during the performance period (CPT or HCPCS): 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99429*, G0438, G0439

NUMERATOR (SUBMISSION CRITERIA 1): Patients who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 12 months

Definitions: Systematic screening method – For purposes of this measure, one of the following systematic methods to assess unhealthy alcohol use must be utilized. "Systematic screening methods” and thresholds for defining unhealthy alcohol use include: • AUDIT Screening Instrument (score ≥ 4) Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 2 of 18 • AUDIT-C Screening Instrument (score ≥ 4 for men; score ≥ 3 for women) • Single Question Screening - How many times in the past year have you had 5 (for men) or 4 (for women and all adults older than 65 years) or more drinks in a day? (response ≥ 1)

NUMERATOR NOTE: To satisfy the intent of this measure, a patient must have at least one screening for unhealthy alcohol use during the 12-month period. If a patient has multiple screenings for unhealthy alcohol use during the 12- month period, only the most recent screening, which has a documented status of unhealthy alcohol user or unhealthy alcohol non-user, will be used to satisfy the measure requirements.

Denominator Exception(s) are determined on the date of the most recent denominator eligible encounter.

Numerator Options: Performance Met: Patient identified as an unhealthy alcohol user when screened for unhealthy alcohol use using a systematic screening method (G2196) OR Performance Met: Patient screened for unhealthy alcohol use using a systematic screening method and not identified as an unhealthy alcohol user (G2197) OR Denominator Exception: Documentation of medical reason(s) for not screening for unhealthy alcohol use using a systematic screening method (e.g., limited life expectancy, other medical reasons) (G2198) OR Performance Not Met: Patient not screened for unhealthy alcohol use using a systematic screening method, reason not given (G2199)

SUBMISSION CRITERIA 2: ALL PATIENTS WHO WERE IDENTIFIED AS UNHEALTHY ALCOHOL USERS AND WHO RECEIVED BRIEF COUNSELING

DENOMINATOR (SUBMISSION CRITERIA 2): All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period who were screened for unhealthy alcohol use and identified as an unhealthy alcohol user

DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B PFS. These non-covered services should be counted in the denominator population for MIPS CQMs.

Denominator Criteria (Eligible Cases): Patients aged ≥ 18 years AND All eligible instances when G2196 is submitted for Performance Met (patient identified as an unhealthy alcohol user when screened for unhealthy alcohol use using a systematic screening method) in the numerator of Submission Criteria 1 AND At least two patient encounters during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90845, 96156, 96158, 97165, 97166, 97167, 97168, 97802, 97803, 97804, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, G0270, G0271 Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 3 of 18 OR At least one preventive encounter during the performance period (CPT or HCPCS): 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99429*, G0438, G0439

NUMERATOR (SUBMISSION CRITERIA 2): Patients who received brief counseling

Definitions: Brief counseling – “Brief counseling” for unhealthy alcohol use refers to one or more counseling sessions, a minimum of 5-15 minutes, which may include: feedback on alcohol use and harms; identification of high risk situations for drinking and coping strategies; increased motivation and the development of a personal plan to reduce drinking.

NUMERATOR NOTE: In the event that a patient is screened for unhealthy alcohol use and identified as an unhealthy user but did not receive brief alcohol cessation counseling submit G2202.

Denominator Exception(s) are determined on the date of the most recent denominator eligible encounter for all submission criteria.

Numerator Options: Performance Met: Patient identified as an unhealthy alcohol user received brief counseling (G2200) OR Denominator Exception: Documentation of medical reason(s) for not providing brief counseling (e.g., limited life expectancy, other medical reasons) (G2201) OR Performance Not Met: Patient did not receive brief counseling if identified as an unhealthy alcohol user, reason not given (G2202)

SUBMISSION CRITERIA 3: ALL PATIENTS WHO WERE SCREENED FOR UNHEALTHY ALCOHOL USE AND, IF IDENTIFIED AS AN UNHEALTHY ALCOHOL USER RECEIVED BRIEF COUNSELING, OR WERE NOT IDENTIFIED AS AN UNHEALTHY ALCOHOL USER

DENOMINATOR (SUBMISSION CRITERIA 3): All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 4 of 18 99387*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99429*, G0438, G0439

NUMERATOR (SUBMISSION CRITERIA 3): Patients who were screened for unhealthy alcohol use using a systematic screening method at least once within 12 months AND who received brief counseling if identified as an unhealthy alcohol user

NUMERATOR NOTE: To satisfy the intent of this measure, a patient must have at least one unhealthy alcohol use screening during the 12-month period. If a patient has multiple unhealthy alcohol use screenings during the 12-month period, only the most recent screening, which has a documented status of unhealthy alcohol user or unhealthy alcohol non-user, will be used to satisfy the measure requirements.

In the event that a patient is screened for unhealthy alcohol use and identified as an unhealthy user but did not receive brief alcohol cessation counseling submit G9624.

Denominator Exception(s) are determined on the date of the most recent denominator eligible encounter for all submission criteria.

Numerator Options: Performance Met: Patient identified as an unhealthy alcohol user when screened for unhealthy alcohol use using a systematic screening method and received brief counseling (G9621) OR Performance Met: Patient not identified as an unhealthy alcohol user when screened for unhealthy alcohol use using a systematic screening method (G9622) OR Denominator Exception: Documentation of medical reason(s) for not screening for unhealthy alcohol use (e.g., limited life expectancy, other medical reasons) (G9623) OR Denominator Exception: Documentation of medical reason(s) for not providing brief counseling if identified as an unhealthy alcohol user (e.g., limited life expectancy, other medical reasons) (G2203)

OR Performance Not Met: Patient not screened for unhealthy alcohol use using a systematic screening method or patient did not receive brief counseling if identified as an unhealthy alcohol user, reason not given (G9624)

RATIONALE: This measure is intended to promote unhealthy alcohol use screening and brief counseling which have been shown to be effective in reducing alcohol consumption, particularly in primary care settings. Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 5 of 18 A number of studies, including patient and provider surveys, have documented low rates of alcohol misuse screening and counseling in primary care settings. According to a study analyzing the quality of health care in the United States, on average, 45% of patients (n=6,676) were screened for problem drinking. (MCGlynn, et. al, 2003). In the national Healthcare for Communities Survey, only 8.7% of problem drinkers reported having been asked and counseled about their alcohol use in the last 12 months. (D’Amico, et. al., 2005)) A nationally representative sample of 648 primary care physicians were surveyed to determine how such physicians identify--or fail to identify-- substance abuse in their patients, what efforts they make to help these patients and what are the barriers to effective diagnosis and treatment. Of physicians who conducted annual health histories, less than half ask about the quantity and frequency of alcohol use (45.3 percent). Only 31.8 percent say they ever administer standard alcohol or drug use screening instruments to patients. (CASA, 2000) A national systematic sample of 2,000 physicians practicing general internal medicine, family medicine, obstetrics-gynecology, and psychiatry were surveyed to determine the frequency of screening and intervention for alcohol problems. Of the 853 respondent physicians, 88% usually or always ask new outpatients about alcohol use. When evaluating patients who drink, 47% regularly inquire about maximum amounts on an occasion, and 13% use formal alcohol screening tools. Only 82% routinely offer intervention to diagnosed problem drinkers. (Friedman, et. al., 2000). In 2014, the CDC analyzed data from 17 states and the District of Columbia via the Behavioral Risk Factor Surveillance System to estimate the prevalence of adults who reported receiving elements of alcohol screening and brief intervention. While 77.7% of adults reported being asked about alcohol use by a health professional, only 32.9% were asked about binge-level alcohol consumption and among binge drinkers only 37.2% reported being counseled on the harms of binge drinking. Only 18.1% reported being advised to cut down on alcohol consumption or to quit drinking. (McKnight-Eily, et. al., 2017). A multi-site, cross-sectional survey of primary care residents from six primary care residency programs administered from March 2010 through December 2012 found that a minority of the residents appropriately screen or provide intervention for at risk alcohol users. While 60% (125/208) stated they screen patients at an initial visit, only 17% (35/208) screened patients at subsequent visits. 54% (108/202) reported they did not feel they had adequate training to provide brief intervention to patients found to be at-risk alcohol users and 21% (43/208) felt they could really help at-risk drinkers. (Barnes et. al., 2015). A study evaluating self-reported prevalence of alcohol screening using information drawn from the ConsumerStyles survey (a random internet panel) found that only 24.7% (n=2,592) of adults reported being asked about their alcohol use While prevalence among men and women were about the same, there was lower prevalence of screening among Black non-Hispanics than white non-Hispanics (16.2% vs. 26.9%) and college graduates reported a higher prevalence of screening than those with a high school degree or less (38.1% vs. 20.8%). (Denny et. al., 2015). A cross-sectional analysis using 2016 DocStyles data that evaluated with use of different screening tools used to screen for alcohol misuse by 1,506 primary care providers found that while most providers screen for alcohol misuse (96%) only 38% reported using a USPSTF recommended screening tool. (Tan et. al., 2018).

CLINICAL RECOMMENDATION STATEMENTS: The USPSTF recommends screening for unhealthy alcohol use in primary care settings in adults 18 years or older, including pregnant women, and providing persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce unhealthy alcohol use. (Grade B recommendation) (USPSTF, 2018)

COPYRIGHT: This Physician Performance Measure (Measure) and related data specifications are owned and copyrighted by the National Committee for Quality Assurance (NCQA). NCQA is not responsible for any use of the Measure. The Measure is not a clinical guideline and does not establish a standard of medical care and has not been tested for all potential applications.

THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.

NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications.

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 6 of 18 The Measure can be reproduced and distributed, without modification, for noncommercial purposes (e.g., use by healthcare providers in connection with their practices) without obtaining approval from NCQA. Commercial use is defined as the sale, licensing, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain. All commercial uses or requests for modification must be approved by NCQA and are subject to a license at the discretion of NCQA. The PCPI’s and AMA’s significant past efforts and contributions to the development and updating of the measure are acknowledged.

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 7 of 18 2021 Clinical Quality Measure Flow for Quality ID #431 (NQF 2152): Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling Submission Criteria One

Disclaimer: Refer to the measure specification for specific coding and instructions to submit this measure.

Multiple Performance Rates

Denominator Numerator

Patient identified as an Data Completeness Met + Start unhealthy alcohol user when Performance Met screened for unhealthy alcohol Yes G2196 or equivalent use using a systematic (50 patients) 1 screening method a

Not included in Patients aged No Patient screened for Eligible Population/ ≥ 18 years Data Completeness Met + Denominator unhealthy alcohol use using a Performance Met systematic screening method and not Yes G2197 or equivalent

identified as an unhealthy (20 patients) 2 alcohol user a No Yes

At least At least one preventive two patient encounter during the encounters during the Documentation performance period No performance period of medical reason(s) for not Data Completeness Met + Denominator Exception as listed in as listed in screening for unhealthy alcohol use Yes Denominator* Denominator* G2198 or equivalent using a systematic 1 screening method (10 patients) b

Yes Yes No

Include in Eligible Patient not screened for Data Completeness Met + Population/Denominator unhealthy alcohol use using a Performance Not Met (100 patients) Yes 1 G2199 or equivalent d systematic screening method, (10 patients) 1 reason not given c

Data Completeness Not Met the Quality Data Code or equivalent was not submitted (10 patients)

SAMPLE CALCULATIONS: SUBMISSION CRITERIA ONE

Data Completeness= 1 1 1 Performance Met (a +a2=70 patients) + Denominator Exception (b =10 patients) + Performance Not Met (c =10 patients) = 90 patients = 90.00% Eligible Population / Denominator (d1=100 patients) = 100 patients

Performance Rate= 1 Performance Met (a +a2=70 patients) = 70 patients = 87.50% Data Completeness Numerator (90 patients) – Denominator Exception (b1=10 patients) = 80 patients

*See the posted measure specification for specific coding and instructions to submit this measure. Note: Submission Frequency: Patient-Process CPT only copyright 2020 American Medical Association. All rights reserved. The measure diagrams were developed by CMS as a supplemental resource to be used in conjunction with the measure specifications. They should not be used alone or as a substitution for the measure specification. v5

Denominator Numerator

Start

Data Completeness Met + Patient identified as Performance Met an unhealthy alcohol user received Yes G2200 or equivalent brief counseling (20 patients) a3

Not included in Patients aged No Eligible Population/ ≥ 18 years No Denominator

Yes Data Completeness Met + Documentation of medical Denominator Exception Yes reason(s) for not providing brief G2201 or equivalent counseling (10 patients) 2 b

All eligible instances when G2196 is submitted for Performance No Met (patient identified as an No unhealthy alcohol user when screened for unhealthy alcohol use using a systematic screening method) in the numerator Patient did not receive Data Completeness Met + Performance Not Met** of Submission brief counseling if identified as an Yes Criteria 1 unhealthy alcohol user, reason G2202 or equivalent No (10 patients) 2 not given c

Yes No

At least one At least two Data Completeness Not Met preventive encounter patient encounters the Quality Data Code or during the performance No during the performance equivalent was not submitted period as listed in period as listed in (10 patients) Denominator* Denominator*

Yes Yes

Include in Eligible Population/Denominator (50 patients) d2

SAMPLE CALCULATIONS: SUBMISSION CRITERIA TWO

Data Completeness= Performance Met (a3=20 patients) + Denominator Exception (b2=10 patients) + Performance Not Met (c2=10 patients) = 40 patients = 80.00% Eligible Population / Denominator (d2=50 patients) = 50 patients

Performance Rate= Performance Met (a3=20 patients) = 20 patients = 66.67% Data Completeness Numerator (40 patients) – Denominator Exception (b2=10 patients) = 30 patients

*See the posted measure specification for specific coding and instructions to submit this measure. **In the event that a patient is screened for unhealthy alcohol use and identified as an unhealthy user but did not receive brief alcohol cessation counseling submit G2202. CPT only copyright 2020 American Medical Association. All rights reserved. Note: Submission Frequency: Patient-Process The measure diagrams were developed by CMS as a supplemental resource to be used in conjunction with the measure specifications. They should not be used alone or as a substitution for the measure specification. v5

Denominator Numerator Patient identified as an unhealthy alcohol user when Data Completeness Met + Performance Met** Start screened for unhealthy alcohol Yes use using a systematic screening G9621 or equivalent (20 patients) 4 method and received brief a counseling

Not included in Patients aged No Eligible Population/ ≥ 18 years Patient not identified as Data Completeness Met + Denominator an unhealthy alcohol user when Performance Met screened for unhealthy alcohol use Yes G9622 or equivalent using a systematic screening (20 patients) 5 method a No Yes

At least At least one preventive two patient encounter during the encounters during the Data Completeness Met + performance period No performance period Documentation of medical Denominator Exception reason(s) for not screening for Yes as listed in as listed in G9623 or equivalent Denominator* Denominator* unhealthy alcohol use (10 patients) b3

No Yes Yes

Documentation of medical Data Completeness Met + reason(s) for not providing brief Denominator Exception Yes Include in Eligible counseling if identified as an G2203 or equivalent Population/Denominator (10 patients) 4 unhealthy alcohol user b (100 patients) d3 No

Patient not screened for unhealthy alcohol use using a Data Completeness Met + systematic screening method or patient Performance Not Met*** Yes did not receive brief counseling if G9624 or equivalent identified as an unhealthy alcohol (20 patients) 3 c user, reason not given

Data Completeness Not Met the Quality Data Code or equivalent was not submitted (20 patients)

Data Completeness= Performance Met (a4+a5=40 patients) + Denominator Exception (b3+b4=20 patients) + Performance Not Met (c3=20 patients) = 80 patients = 80.00% Eligible Population / Denominator (d3=100 patients) = 100 patients

Performance Rate= Performance Met (a4+a5=40 patients) = 40 patients = 66.67% Data Completeness Numerator (80 patients) – Denominator Exception (b3+b4=20 patients) = 60 patients

*See the posted measure specification for specific coding and instructions to submit this measure. **Brief counseling for unhealthy alcohol use refers to one or more counseling sessions, a minimum of 5-15 minutes, which may include: feedback on alcohol use and harms; identification of high risk situations for drinking and coping strategies; increased motivation and the development of a personal plan to reduce drinking. ***In the event that a patient is screened for unhealthy alcohol use and identified as an unhealthy user but did not receive brief alcohol cessation counseling submit G9624. CPT only copyright 2020 American Medical Association. All rights reserved. Note: Submission Frequency: Patient-Process The measure diagrams were developed by CMS as a supplemental resource to be used in conjunction with the measure specifications. They should not be used alone or as a substitution for the measure specification. v5

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 11 of 18 2021 Clinical Quality Measure Flow Narrative for Quality ID #431 (NQF 2152): Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling Disclaimer: Refer to the measure specification for specific coding and instructions to submit this measure.

Multiple Performance Rates

Submission Criteria One:

1. Start with Denominator

2. Check Patients aged greater than or equal to 18 years:

a. If Patients aged greater than or equal to 18 years equals No, do not include in Eligible Population/Denominator. Stop processing.

b. If Patients aged greater than or equal to 18 years equals Yes, proceed to check At least two patient encounters during the performance period as listed in Denominator*.

3. Check At least two patient encounters during the performance period as listed in Denominator*:

a. If At least two patient encounters during the performance period as listed in Denominator* equals No, proceed to check At least one preventive encounter during the performance period as listed in Denominator*.

b. If At least two patient encounters during the performance period as listed in Denominator* equals Yes, include in Eligible Population/Denominator.

4. Check At least one preventive encounter during the performance period as listed in Denominator*:

a. If At least one preventive encounter during the performance period as listed in Denominator* equals No, do not include in Eligible Population/Denominator. Stop processing.

b. If At least one preventive encounter during the performance period as listed in Denominator* equals Yes, include in Eligible Population/Denominator.

5. Denominator Population:

6. Start Numerator

7. Check Patient identified as an unhealthy alcohol user when screened for unhealthy alcohol use using a systematic screening method:

a. If Patient identified as an unhealthy alcohol user when screened for unhealthy alcohol use using a systematic screening method equals Yes, include in Data Completeness Met and Performance Met.

b. If Patient identified as an unhealthy alcohol user when screened for unhealthy alcohol use using a

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 12 of 18 systematic screening method equals No, proceed to check Patient screened for unhealthy alcohol use using a systematic screening method and not identified as an unhealthy alcohol user.

8. Check Patient screened for unhealthy alcohol use using a systematic screening method and not identified as an unhealthy alcohol user:

a. If Patient screened for unhealthy alcohol use using a systematic screening method and not identified as an unhealthy alcohol user equals Yes, include in Data Completeness Met and Performance Met.

b. If Patient screened for unhealthy alcohol use using a systematic screening method and not identified as an unhealthy alcohol user equals No, proceed to check Documentation of medical reason(s) for not screening for unhealthy alcohol use using a systematic screening method.

9. Check Documentation of medical reason(s) for not screening for unhealthy alcohol use using a systematic screening method:

a. If Documentation of medical reason(s) for not screening for unhealthy alcohol use using a systematic screening method equals Yes, include in Data Completeness Met and Denominator Exception.

b. If Documentation of medical reason(s) for not screening for unhealthy alcohol use using a systematic screening method equals No, proceed to check Patient not screened for unhealthy alcohol use using a systematic screening method, reason not given.

10. Check Patient not screened for unhealthy alcohol use using a systematic screening method, reason not given:

a. If Patient not screened for unhealthy alcohol use using a systematic screening method, reason not given equals Yes, include in Data Completeness Met and Performance Not Met.

b. If Patient not screened for unhealthy alcohol use using a systematic screening method, reason not given equals No, proceed to check Data Completeness Not Met.

11. Check Data Completeness Not Met:

a. If Data Completeness Not Met, the Quality Data Code or equivalent was not submitted. 10 patients have been subtracted from the Data Completeness Numerator in the Sample Calculation.

Sample Calculations: Submission Criteria One

Data Completeness equals Performance Met ( a1 plus a2 equals 70 patients) plus Denominator Exception (b1 equals 10 patients) plus Performance Not Met ( c1 equals 10 patients) divided by Eligible Population / Denominator ( d1 equals 100 patients). All equals 90 patients divided by 100 patients. All equals 90.00 percent. Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 13 of 18 Performance Rate equals Performance Met ( a1 plus a2 equals 70 patients) divided by Data Completeness Numerator (90 patients) minus Denominator Exception (b1 equals 10 patients). All equals 70 patients divided by 80 patients. All equals 87.50 percent.

*See the posted measure specification for specific coding and instructions to submit this measure.

Note: Submission Frequency: Patient-Process

Submission Criteria Two:

1. Start with Denominator

2. Check Patients aged greater than or equal to 18 years:

a. If Patients aged greater than or equal to 18 years equals No, do not include in Eligible Population/Denominator. Stop processing.

b. If Patients aged greater than or equal to 18 years equals Yes, proceed to check All eligible instances of Performance Met when patient identified as an unhealthy alcohol user when screened for unhealthy alcohol use using a systematic screening method in the numerator of Submission Criteria 1.

3. Check All eligible instances of Performance Met when patient identified as an unhealthy alcohol user when screened for unhealthy alcohol use using a systematic screening method in the numerator of Submission Criteria 1:

a. If All eligible instances of Performance Met when patient identified as an unhealthy alcohol user when screened for unhealthy alcohol use using a systematic screening method in the numerator of Submission Criteria 1 equals No, do not include in Eligible Population/Denominator. Stop processing.

b. If All eligible instances of Performance Met when patient identified as an unhealthy alcohol user when screened for unhealthy alcohol use using a systematic screening method in the numerator of Submission Criteria 1 equals Yes, proceed to check At least two patient encounters during the performance period as listed in Denominator*.

4. Check At least two patient encounters during the performance period as listed in Denominator*:

b. If At least two patient encounters during the performance period as listed in Denominator* equals Yes, include in Eligible Population/Denominator.

5. Check At least one preventive encounter during the performance period as listed in Denominator*:

a. If At least one preventive encounter during the performance period as listed in Denominator* equals No, do not include in Eligible Population/Denominator. Stop processing.

b. If At least one preventive encounter during the performance period as listed in Denominator* equals Yes, include in Eligible Population/Denominator. Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 14 of 18 6. Denominator Population:

7. Start Numerator

8. Check Patient identified as an unhealthy alcohol user received brief counseling:

a. If Patient identified as an unhealthy alcohol user received brief counseling equals Yes, include in Data Completeness Met and Performance Met.

b. If Patient identified as an unhealthy alcohol user received brief counseling equals No, proceed to check Documentation of medical reason(s) for not providing brief counseling.

9. Check Documentation of medical reason(s) for not providing brief counseling:

a. If Documentation of medical reason(s) for not providing brief counseling equals Yes, include in Data Completeness Met and Denominator Exception.

b. If Documentation of medical reason(s) for not providing brief counseling equals No, proceed to check Patient did not receive brief counseling if identified as an unhealthy alcohol user, reason not given.

10. Check Patient did not receive brief counseling if identified as an unhealthy alcohol user, reason not given:

a. If Patient did not receive brief counseling if identified as an unhealthy alcohol user, reason not given equals Yes, include in Data Completeness Met and Performance Not Met**.

• Data Completeness Met and Performance Not Met** letter is represented in the Data Completeness in the Sample Calculation listed at the end of this document. Letter c2 equals 10 patients in the Sample Calculation.

b. If Patient did not receive brief counseling if identified as an unhealthy alcohol user, reason not given equals No, proceed to check Data Completeness Not Met.

11. Check Data Completeness Not Met:

a. If Data Completeness Not Met, the Quality Data Code or equivalent was not submitted. 10 patients have been subtracted from the Data Completeness Numerator in the Sample Calculation.

Sample Calculations: Submission Criteria Two

Data Completeness equals Performance Met ( a3 equals 20 patients) plus Denominator Exception (b2 equals 10 patients) plus Performance Not Met ( c2 equals 10 patients) divided by Eligible Population / Denominator ( d2 equals 50 patients). Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 15 of 18 All equals 40 patients divided by 50 patients. All equals 80.00 percent.

Performance Rate equals Performance Met ( a3 equals 20 patients) divided by Data Completeness Numerator (40 patients) minus Denominator Exception (b2 equals 10 patients). All equals 20 patients divided by 30 patients. All equals 66.67 percent.

*See the posted measure specification for specific coding and instructions to submit this measure.

**In the event that a patient is screened for unhealthy alcohol use and identified as an unhealthy alcohol user but did not receive brief alcohol cessation counseling submit G2202.

Note: Submission Frequency: Patient-Process

Submission Criteria Three:

1. Start with Denominator

2. Check Patients aged greater than or equal to 18 years:

a. If Patients aged greater than or equal to 18 years equals No, do not include in Eligible Population/Denominator. Stop processing.

b. If Patients aged greater than or equal to 18 years equals Yes, proceed to check At least two patient encounters during the performance period as listed in Denominator*.

3. Check At least two patient encounters during the performance period as listed in Denominator*:

b. If At least two patient encounters during the performance period as listed in Denominator* equals Yes, include in Eligible Population/Denominator.

4. Check At least one preventive encounter during the performance period as listed in Denominator*:

a. If At least one preventive encounter during the performance period as listed in Denominator* equals No, do not include in Eligible Population/Denominator. Stop processing.

b. If At least one preventive encounter during the performance period as listed in Denominator* equals Yes, include in Eligible Population/Denominator.

5. Denominator Population:

6. Start Numerator

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 16 of 18 7. Check Patient identified as an unhealthy alcohol user when screened for unhealthy alcohol use using a systematic screening method and received brief counseling:

a. If Patient identified as an unhealthy alcohol user when screened for unhealthy alcohol use using a systematic screening method and received brief counseling equals Yes, include in Data Completeness Met and Performance Met**.

• Data Completeness Met and Performance Met** letter is represented in the Data Completeness and Performance Rate in the Sample Calculation listed at the end of this document. Letter a4 equals 20 patients in the Sample Calculation.

b. If Patient identified as an unhealthy alcohol user when screened for unhealthy alcohol use using a systematic screening method and received brief counseling equals No, proceed to check Patient not identified as an unhealthy alcohol user when screened for unhealthy alcohol use using a systematic screening method.

8. Check Patient not identified as an unhealthy alcohol user when screened for unhealthy alcohol use using a systematic screening method:

a. If Patient not identified as an unhealthy alcohol user when screened for unhealthy alcohol use using a systematic screening method equals Yes, include in Data Completeness Met and Performance Met.

b. If Patient not identified as an unhealthy alcohol user when screened for unhealthy alcohol use using a systematic screening method equals No, proceed to check Documentation of medical reason(s) for not screening for unhealthy alcohol use.

9. Check Documentation of medical reason(s) for not screening for unhealthy alcohol use:

a. If Documentation of medical reason(s) for not screening for unhealthy alcohol use equals Yes, include in Data Completeness Met and Denominator Exception.

b. If Documentation of medical reason(s) for not screening for unhealthy alcohol use equals No, proceed to check Documentation of medical reason(s) for not providing brief counseling if identified as an unhealthy alcohol user.

10. Check Documentation of medical reason(s) for not providing brief counseling if identified as an unhealthy alcohol user:

a. If Documentation of medical reason(s) for not providing brief counseling if identified as an unhealthy alcohol user equals Yes, include in Data Completeness Met and Denominator Exception.

b. If Documentation of medical reason(s) for not providing brief counseling if identified as an unhealthy

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 17 of 18 alcohol user equals No, proceed to check Patient not screened for unhealthy alcohol use using a systematic screening method or patient did not receive brief counseling if identified as an unhealthy alcohol user, reason not given.

11. Check Patient not screened for unhealthy alcohol use using a systematic screening method or patient did not receive brief counseling if identified as an unhealthy alcohol user, reason not given:

a. If Patient not screened for unhealthy alcohol use using a systematic screening method or patient did not receive brief counseling if identified as an unhealthy alcohol user, reason not given equals Yes, include in Data Completeness Met and Performance Not Met***.

• Data Completeness Met and Performance Not Met*** letter is represented in the Data Completeness in the Sample Calculation listed at the end of this document. Letter c3 equals 20 patients in the Sample Calculation.

b. If Patient not screened for unhealthy alcohol use using a systematic screening method or patient did not receive brief counseling if identified as an unhealthy alcohol user, reason not given equals No, proceed to check Data Completeness Not Met.

12. Check Data Completeness Not Met:

a. If Data Completeness Not Met, the Quality Data Code or equivalent was not submitted. 20 patients have been subtracted from the Data Completeness Numerator in the Sample Calculation.

Sample Calculations: Submission Criteria Three

Data Completeness equals Performance Met ( a4 plus a5 equals 40 patients) plus Denominator Exception (b3 plus b4 equals 20 patients) plus Performance Not Met ( c3 equals 20 patients) divided by Eligible Population / Denominator ( d3 equals 100 patients). All equals 80 patients divided by 100 patients. All equals 80.00 percent.

Performance Rate equals Performance Met ( a4 plus a5 equals 40 patients) divided by Data Completeness Numerator (80 patients) minus Denominator Exception (b3 plus b4 equals 20 patients). All equals 40 patients divided by 60 patients. All equals 66.67 percent.

*See the posted measure specification for specific coding and instructions to submit this measure.

**Brief counseling for unhealthy alcohol use refers to one or more counseling sessions, a minimum of 5-15 minutes, which may include: feedback on alcohol use and harms; identification of high risk situations for drinking and coping strategies; increased motivation and the development of a personal plan to reduce drinking.

***In the event that a patient is screened for unhealthy alcohol use and identified as an unhealthy user but did not receive brief alcohol cessation counseling submit G9624.

Note: Submission Frequency: Patient-Process

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 18 of 18 Quality of Life Outcome for Patients with Neurologic Conditions Measure Title Quality of Life Outcome for Patients with Neurologic Conditions Description Percentage of patients whose quality of life assessment results are maintained or improved during the measurement period. Measurement January 1, 20xx to December 31, 20xx(See below denominator identification period.) Period Eligible Eligible Providers Medical Doctor (MD), Doctor of Osteopathy (DO), Nurse Population Practitioners (NP), Physician Assistant (PA), Advanced Practice Registered Nurse (APRN) Care Setting(s) Outpatient Ages Age 18 years and older Event An index event date occurs when ALL of the following criteria are met during a face-to-face visit: • An active diagnosis of a neurologic condition • The first instance a PROMIS Global Health-10 score was recorded • The patient is NOT in a prior index period.(The first instance in the denominator identification period). An index period begins with an index visit and is 10-14 months in duration. Diagnosis See Appendix A Diagnostic codes include amyotrophic lateral sclerosis, attention deficit disorders, autism, cerebral palsy, cognitive impairment and related dementias, developmental delays, headache and migraine, movement disorders, multiple sclerosis, muscular dystrophy, neoplasms of brain and spine, polyneuropathy, seizure and epilepsy, stroke, tic disorders, vertigo and related neuro-otology disorders, and other neurologic conditions. Denominator Patients aged 18 years and older diagnosed with neurologic condition Denominator The period in which eligible patients can have an index event. The denominator identification Identification period occurs prior to the measurement period and is defined as 14 months to two months prior to Period the start of the measurement period. For example, the denominator identification period for the 2019 calendar year is from 11/1/2017 to 10/31/2018. For patients with an index event, there needs to be enough time following index for the patients to have the opportunity to reach comparison twelve months +/- 60 days after the index event date. Numerator Patients whose PROMIS Global Health-10 score(1)* at twelve months (+/-60 days) was maintained or improved from the index score^.

*For patients with more than 2 scores present at twelve months (+/- 60 days) the last score recorded shall be compared to the index visit score. Required • Patients who died Exclusions • Second PROMIS Global Health-10 score not collected at twelve months (+/-60 days) Allowable • None Exclusions Allowable Allowable exclusions can only help measure performance. If a patient has an allowable exclusion Exclusion but is found to meet the numerator that patient is included in the count to meet the measure. Inclusion Logic Exclusion Patients who have died are appropriate to exclude from a quality of life measure requiring patient Rationale report of outcomes. Similarly if a follow-up score was not collected performance cannot be calculated and are appropriate for exclusion. Measure Percentage Scoring Interpretation Higher Score Indicates Better Quality of Score Measure Type Patient Reported Outcome Performance Measure Level of Provider Measurement Risk See Appendix B AAN Statement on Comparing Outcomes of Patients Adjustment This measure is being made available in advance of development of a risk adjustment strategy. Individuals commenting on the measures are encouraged to provide input on potential risk adjustment or stratification methodologies. The work group identified the following potential data elements that may be used in a risk adjustment methodology for this measure: • Co-morbidity (other neurologic or neurobehavioral/neuropsychological disorders) • Co-morbidities (medical conditions) • Cognitive impairment and abilities • Trauma exposure • High healthcare utilizer • Duration of the neurology diagnosis • Polypharmacy • Activity level – physical function • Use of an interpreter and primary spoken language Desired Measuring quality of life allows patients and providers to identify areas of concern and develop Outcome appropriate treatment plan adjustments as needed. Opportunity to Collecting quality of life data in a neurology ambulatory setting is feasible and found to be Improve Gap meaningful.(2,3) in Care Harmonization There are no known similar measures applicable to patients with neurologic conditions. with Existing Measures References 1. Hays RD, Bjorner JB, Revicki DA, et al. Development of physical and mental health summary scores from the patient-reported outcomes measurement information system (PROMIS) global items. Qual Life Res. 2009;18:873–880. 2. Moura LMVR, Schwamm E, Moura Jr V., et al. Feasibility of the collection of patient-reported outcomes in an ambulatory neurology clinic. Neurology. 2016;87:1-8. 3. Katzan IL, Lapin B. PROMIS GH (Patient-Reported Outcomes Measurement Information System Global Health) Scale in Stroke: A Validation Study. Stroke 2018; 49(1): 147-154. Code System Code Code Description CPT 99201-99205 Office or Other Outpatient Visit - New Patient (E/M Codes) CPT 99211-99215 Office or Other Outpatient Visit - Established Patient (E/M Codes) CPT 99241-99245 Office or Other Outpatient Consultation – New or Established Patient AND ICD-10 See Appendix A

Flow Chart Diagram: Quality of Life Outcome for Patients with Neurologic Conditions

Was the patient 18 years and older during the measurement period? Patient NOT No Included in

Yes Eligible Population

Did patient have a neurologic diagnosis at the index visit? No

Yes

Did the patient have an index visit during the measurement period and a second encounter 12-months (+/- 60 days) after index visit? No or N/A

Yes

Patient INCLUDED in Eligible Population

Did patient die during the measurement period? Yes Remove from No or N/A denominator*

Did the patient not have a PROMIS Global *Do not remove/exclude if Health 10 score recorded at 12 months from Yes patient meets the index visit (+/-60 days)? numerator

No or N/A

Patient INCLUDED in Denominator Was the patient’s PROMIS Global Health 10 raw score maintained or improved at twelve months (+/- 60 days) from the index visit score?

Yes No

Patient did Patient met NOT meet numerator numerator criteria criteria Step-by-Step Calculation: Quality of Life Outcome for Patients with Neurologic Conditions Start with Denominator 1. Check Patient Age a. If the Age is less than 18 years on Date of Service and equals No during the measurement period, do not include in Eligible Patient Population. Stop processing. b. If the Age is greater than or equal to 18 years on Date of Service and equals Yes during the measurement period, proceed to check Diagnosis, Neurologic Condition. 2. Check Diagnosis, Neurologic Condition a. If there is no diagnosis of neurologic condition on the Date of Service, and equals No during the measurement period, do not include in Eligible Patient Population. Stop processing. b. If there is a diagnosis of neurologic condition on the Date of Service, and equals Yes during the measurement period, proceed to check Encounter Performed. 3. Check Index Visit Performed a. If Index Visit Performed in the Denominator equals No, do not include in Eligible Patient Population. Stop processing. b. If Index Visit Performed in the Denominator equals Yes, include in Eligible Patient Population. 4. Check for Required Exclusions a. If Patient met Required Exclusions equals Yes, do not include in Eligible Patient Population. Stop processing. b. If Patient met Required Exclusions equals No, proceed to Denominator Population. 5. Denominator Population a. Denominator population is all Eligible Patients in the denominator. Denominator is represented as Denominator in the Sample Calculation listed at the end of this document. Letter d equals 90 patients in the Sample Calculation. Start Numerator 6. Check Patient Quality of Life Maintained or Improved a. If Patient Quality of Life Maintained or Improved (i.e., patient raw score at twelve months (+/- 60 days) was equal to or greater than an index visit raw score) equals Yes, include in Data Completeness Met and Performance Met. b. Data completeness met and performance met letter is represented in the Data Completeness and Performance Rate in the Sample Calculation listed at the end of this document. Letter a equals 35 patients in the Sample Calculation. c. If Patient Quality of Life Maintained or Improved equals No, proceed to Check if Patient Quality of Life Worsened. 7. Check Patient Quality of Life Worsened. a. If Patient Quality of Life Worsened (i.e., patient raw score at twelve months (+/- 60 days) was less than an index visit raw score) equals Yes, include in Data Completeness Met and Performance NOT Met. b. Data completeness met and performance NOT met letter is represented in the Data Completeness and Performance Rate in the Sample Calculation listed at the end of this document. Letter c equals 40 patients in the Sample Calculation. c. If Patient Quality of Life Worsened equals No, proceed to Data Completeness NOT Met. 8. Check Data Completeness Not Met a. If Data Completeness Not Met equals No, Quality Data Code or equivalent not submitted. 15 patients have been subtracted from the Data Completeness Numerator in the Sample Calculation.

Sample Calculations

Data Completeness*=

Performance Met (a=30 + b=5) + Performance Not Met (c=40) =75 Patients =83.3%

Eligible Population/ Denominator (d=90) 90 Patients

Performance Rate =

Performance Met (a=30 + b=5) =35 Patients =38.8%

Eligible Population/ Denominator (d=90) 90 Patients

CMS maintains a data completeness threshold for reporting in its Merit-based Incentive Payment System (MIPS). The data completeness threshold changes each year and varies based on which reporting mechanism a provider is using.

• For 2018 and 2019 quality measures reported via Medicare Part B claims, providers must report on 60% of the individual MIPS eligible clinician’s Medicare Part B patients for the performance period. • For 2019 quality measures reported via administrative claims, providers must report on 100% of the individual MIPS eligible clinician’s Medicare Part B patients for the performance period. • For 2018 and 2019 quality measures reported via a QCDR, MIPS CQMs and eCQMs, eligible clinicians must report on 60% of the individual MIPS eligible clinician’s patients across all payers for the performance period.

Comprehensive Epilepsy Care Center Referral or Discussion for Patients with Intractable Epilepsy Measure Title Comprehensive Epilepsy Care Center Referral or Discussion for Patients with Intractable Epilepsy Description Percentage of patients who were referred or had a discussion of evaluation at a comprehensive epilepsy care center*. Measurement January 1, 20xx to December 31, 20xx Period Eligible Eligible Providers Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant Population (PA), Advanced Practice Registered Nurse (APRN) Care Setting(s) Outpatient Care Ages All Event Office visit Diagnosis Epilepsy Denominator Patients diagnosed with intractable epilepsy (See Appendix of Codes) OR Patients diagnosed with epilepsy who were prescribed three or more distinct anti-seizure medications in past 2 years.

The work group has chosen to use the term intractable epilepsy for this document to reflect what is also known as drug-resistant epilepsy, refractory epilepsy, and pharmacoresistant epilepsy. The work group chose to use intractable epilepsy given its appearance in ICD-9 and ICD-10 systems. For location via a registry it is recommended ICD-10 codes be utilized, and ICD-9 codes used for historical data. For location search term in a registry, the work group recognizes the alternate terms: “drug-resistant epilepsy”, “refractory epilepsy”, and “pharmacoresistant epilepsy”.

The work group provided a list of distinct anti-seizure medications below. Please note that extended release trials would not be distinct from medications of the same type. For example, a patient who receives both topiramate and topiramate XR would be viewed as having one distinct anti-seizure medication for purposes of this measure. Numerator Patients with an order for referral to a comprehensive epilepsy care center, who had a discussion of evaluation at a comprehensive epilepsy care center, OR who received treatment at a comprehensive epilepsy care center during the measurement period.

*Comprehensive Epilepsy Care Center: Epilepsy centers that provide comprehensive diagnostic and treatment modalities and access to multidisciplinary teams to address comorbidities that are common in epilepsy. The National Association of Epilepsy Centers has provided details of the essential services, personnel, and facilities at comprehensive epilepsy centers.(1) In general, comprehensive centers will provide diagnostic evaluation including inpatient video electroencephalogram (EEG) monitoring, epilepsy surgery evaluation, access to epilepsy surgery, and staff to address psychiatric and psychosocial issues. The Work Group notes the intent of the referral to a Comprehensive Epilepsy Care Center is to reinforce detection of refractory cases, confirm classification of epilepsy, improve access to other treatments including ketogenic diet and neuromodulation, and evaluation of potential co-morbid symptom or social counseling, and not solely for presurgical evaluation and surgery.

For location via search term in a registry, the work group encourages providers to document comprehensive epilepsy care center in following format: • “Comprehensive epilepsy care center”, “CEC”, or “CECC” • “Level 3 epilepsy care center” • “Level 4 epilepsy care center” Required None Exclusions

Allowable None Exclusions Measure will be evaluated for future updates to address potential unintended consequences that may include false positive identifications in the denominator of patients with migraine or other neurological conditions warranting prescription of anti-seizure medications. Exclusion None Rationale Measure Percentage Scoring Interpretation Higher Score Indicates Better Quality of Score Measure Type Process Level of Provider Measurement Risk Not Applicable Adjustment For Process Appropriate evaluation must occur for patients diagnosed with intractable epilepsy or who have Measures indications of treatment resistant epilepsy, as suggested by three distinct seizure medication Relationship to prescriptions. By creating a measure ensuring these patient populations are referred or have Desired comprehensive epilepsy care center services discussed it is anticipated that there will be an Outcome increase in appropriate evaluations, which would confirm diagnostic accuracy and result in offering of effective non-drug and non-surgical treatment options. This may include psychiatric, psychological, and social counseling to address consequences of epilepsy.

Evidence suggests that epilepsy surgery is superior to medical treatment in controlling seizures, improving quality of life, rates of unemployment and school attendance. (2-5) Prolonged unsuccessful medical treatment can lead to unnecessary disability and even death. (3) Most importantly, in patients with either temporal lobe or extratemporal lobe epilepsy, favorable and seizure-free outcome rates remained stable after surgery over long-term follow-up. Therefore, presurgical evaluation should be considered in all patients with refractory epilepsy. (5)

Additionally, referral to comprehensive epilepsy centers may result in earlier diagnosis of psychogenic seizures; remission of psychogenic nonepileptic seizures is more likely the earlier diagnosis is made related to onset. (6)

Process Process Outcomes • Referral to comprehensive • Assessed at a comprehensive • Increased surgical and epilpesy care center epilepsy care center refractory seizure interventions • Discussion of evaluation at provided comprehensive epilepsy care • Reduced seizures center • Improved QOL • Early correct diagnosis of nonepileptic spells

Opportunity to Despite the strong evidence of superior outcomes among those who receive epilepsy surgery and Improve Gap in other specialized services at comprehensive epilepsy centers, only a small fraction of patients are Care referred within 2 years of developing drug-resistant epilepsy, and many years of delay before referral for epilepsy surgery is common (7-9). Contributors to the delay in referral include gaps in knowledge related to epilepsy surgery guidelines and definition of drug resistance (10). Among those ultimately found to have psychogenic seizures, history of multiple seizure medication prescriptions is associated with delay to diagnosis (11). This measure aims to increase awareness of the need for timely referral among practitioners. Harmonization There are no known similar measures. with Existing Measures References 1. Labiner DM, Bagic AI, Herman ST, et al.; for the National Association of Epilepsy Centers. Essential services, personnel, and facilities in specialized epilepsy centers. Revised 2010 guidelines. Epilepsia 2010;51:2322-2333 2. Wiebe S, Blume WT, Girvin JP, et al. A Randomized, Controlled Trial of Surgery for Temporal-Lobe Epilepsy N Engl J Med 2001; 345:311-318. 3. Wasade VS, Elisevich K, Tahir R, et al. Long-term seizure and psychosocial outcomes after resective surgery for intractable epilepsy. Epilepsy Behav. 2015; 43: 122-127. 4. Gonzalez-Martinez et al. Epilepsy Surgery of the Temporal Lobe in Pediatric Population: A Retrospective Analysis Neurosurgery (2012) 70 (3): 684-692. 5. Scottish Intercollegiate Guidelines Network(SIGN). Diagnosis and management of epilepsy in adults. Edinburgh. SIGN publication no. 143. May 2015. Available at: http://www.sign.ac.uk Accessed on June 21, 2017. 6. Selwa L, Geyer J, Nikakhtar N, et al. Nonepileptic seizure outcome varies by type of spell and duration of illness. Epilepsia. 2000; 41: 1330-1334. 7. Jette N, Sander J, Keezer M. Surgical treatment for epilepsy: the potential gap between evidence and Practice. Lancet Neurology. 2016 ; 15: 982-984. 8. Burneo J, Shariff S, Liu K, et al. Disparities in epilepsy surgery among patients with epilepsy in a universal health system. Neurology. 2016; 86: 72-78.

9. Pieters H, Iwaki T, Vickrey B, et al. “It was five years of hell”: Parental experiences of navigating and processing the slow and arduous time to pediatric resective epilepsy surgery. Epilepsy Behavior. 2016; 62: 276-284. 10. Roberts J, Hrazdil C, Wiebe S, et al. Neurologists’ knowledge of and attitudes toward epilepsy surgery: a national survey. Neurology. 2015; 84: 159-166. 11. Rodriguez-Urrutia A, Toledo M, Eiroa-Orosa F, et al. Psychosocial factors and antiepileptic drug use related to delayed diagnosis of refractory psychogenic nonepileptic seizures. Cogn Behav Neurol. 2014; 27: 199-205.

Flow Chart Diagram: Comprehensive Epilepsy Care Center Referral or Discussion

Did the patient have at least one new or No Patient NOT established patient visit with an eligible provider during the measurement period? Included in Data Submission

Yes No

Did patient have a diagnosis of intractable Did patient have a diagnosis of epilepsy on any contact epilepsy on any contact during the current or No during the current or prior measurement period OR on prior measurement period OR on their active their active problem list during the measurement period problem list during the measurement AND have 3 prescriptions or more for distinct anti- period? seizure medication the past 2 years?

Yes Yes

Patient INCLUDED in Eligible Population

Patient Patient met Yes During the measurement period was No INCLUDED in numerator patient receiving care at a comprehensive epilepsy care center? Denominator criteria

During the measurement period, did the patient have referral documentation to a comprehensive epilepsy care center or a discussion of evaluation at a comprehensive epilepsy care center?

No Yes

Patient did Patient met NOT meet numerator numerator criteria criteria 22 ©2020. American Academy of Neurology Institute. All Rights Reserved. CPT Copyright 2004-2020 American Medical Association. Neuropsychological/neurodevelopmental screening

Measure Description Percentage of patients with epilepsy screened for neurodevelopmental or neuropsychological deficits Measure Components Numerator Patients who were screened* or referred for screening for neurodevelopmental Statement and/or neuropsychological deficits within 1 year of initial epilepsy diagnosis

*Screened is defined as using a validated instrument or querying the patient or caregiver to determine the presence or absence of symptoms.

Denominator Patients aged 1 month and older diagnosed with epilepsy within the past 12 months Statement without severe or profound intellectual disability who are not currently under the care of a psychiatrist/psychologist

Denominator  Patient/caregiver refuse Exceptions Exception Some children have significant intellectual inability that preclude them for being Justification able to participate adequately in testing. A patient or caregiver have the right to refuse testing. If a patient already has neuropsychological or neurodevelopmental services, they would not need additional screening or referrals. Supporting The following statements are quoted verbatim from the referenced supporting Guideline & articles: Other  “Establishing the presence of a deficit in a particular area of cognition that References is hypothesized to be related to a deficit in academic achievement (e.g., working memory in reading) should be part of the process of determining the presence of an SLD [specific learning disability] according to some definitions of SLD.”1  “Given the high rate of neurobehavioral comorbidity in childhood epilepsy and noted under recognition, screening of all children for cognitive and behavioral difficulties would seem warranted, as has been previously recommended.”2  “Given general brain development and changes/vulnerabilities to seizures and comorbid behavioral health symptoms in puberty, screening should take place at seizure onset and throughout the developmental course of the youth’s epilepsy to achieve optimal quality of life.”3  “Neuropsychological assessment should be considered in children, young people and adults in whom it is important to evaluate learning disabilities and cognitive dysfunction, particularly in regard to language and memory.”4  “Referral for a neuropsychological assessment is indicated: - When a child, young person or adult with epilepsy is having educational or occupational difficulties - When an MRI has identified abnormalities in cognitively important brain regions - When a child, young person or adult complains of memory or other cognitive deficits and/or cognitive decline”4

 “Screening for developmental delay is important for all young children and especially those with epilepsy.”5  “Formal screening, as recommended by the American Academy of pediatrics, with a well-validated measure such as the ASQ-3 is ideal and should be done whenever feasible.”5 Measure Importance Relationship to Increase the percent of patients who get neuropsychological testing in order to Desired Outcome address issues and obtain proper treatment

Opportunity for Literature suggests that neuropsychological deficits are present in many children Improvement with epilepsy independent from control of seizures.6,7,8,9,10

Eom et al., discuss the lack of implementation of screening guidelines into clinical practice which results in a gap in high quality care.5 When interventions are initiated earlier for neuropsychological or neurodevelopmental issues there is an increase in developmental attainment that benefits the patient long term.11

The Work Group identified the following questionnaire-based tools to assist in screening:  Child Behavior Checklist (CBCL)  Behavior Assessment System for Children, 3rd edition (BASC-3)  Behavior Rating Inventory of Executive Function, 2nd edition (BRIEF-2)  Conners’ third edition (Conners-3) (ADHD rating scale)  NICHQ Vanderbilt Assessment Scale  Ages & Stages Questionnaires, Third Edition (ASQ-3)  Strengths & Difficulties Questionnaires (SDQ)  Pediatric Quality of Life Inventory (PedsQL)  Neuro QoL/PROMIS measures  Child Depression Inventory, 2nd edition (CDI-2)  Multidimensional Anxiety Scale for Children, 2nd edition (MASC-2)  Psychosocial Assessment Tool (PAT)

National Quality ☐ Patient and Family Engagement Strategy ☐ Patient Safety Domains ☐ Care Coordination ☐ Population/Public Health ☐ Efficient Use of Healthcare Resources ☒ Clinical Process/Effectiveness Harmonization This measure does harmonize with an existing adult measure on screening for with Existing psychological co-morbidities as they would be identified on this testing. This Measures measure is needed as it expands the screening to include other disorders that are commonly seen in children that do not necessarily apply to the adult epilepsy population. Measure Designation

11. Eom S, Fisher B, Dezort C, Berg A. Routine developmental, autism, behavioral, and psychological screening in epilepsy care settings. Developmental Medicine & Child Neurology 2014; 56:1100-5. Denominator ICD-10 Code (Eligible R56.8 Seizures (otherwise unspecified) Population) G40.xx Epilepsy (otherwise unspecified)

AND CPT E/M Service Code 99201, 99202, 99203, 99204, 99205 Office or other outpatient visit 10, 20, 30, 45, or 60 minutes for the evaluation and management of a new patient; 99211, 99212, 99213, 99214, 99215 Office or other outpatient visit 5, 10, 15, 25, or 40 minutes for the evaluation and management of an established patient

Measure #5: Querying about Pain and Pain Interference with Function

Measure Description Percentage of patient visits for patient age 18 years and older with a diagnosis of distal symmetric polyneuropathy who was queried about pain and pain interference with function using a valid and reliable instrument.

Measure Components Numerator Patient visits with the patient queried about pain and pain interference with Statement function using a valid and reliable instrument (eg Graded Chronic Pain Scale).

Note: Neuropathic pain can be assessed using one of a number of available valid and reliable instruments available from medical literature. Examples include, but are not limited to: • Graded Chronic Pain Scale49 Denominator All visits for patients age 18 years and older with a diagnosis of distal symmetric Statement polyneuropathy. Denominator • Documentation of a medical reason for not querying the patient about pain Exceptions and pain interference with function (eg patient cognitively impaired and unable to respond) • Documentation of a patient reason for not querying the patient about pain and pain interference with function (eg patient declines to respond to questions) Supporting The following evidence statements are quoted verbatim from the referenced Guideline & clinical guidelines: Other • Assessment of neuropathic pain (NP) should focus on identifying and treating References the underlying disease processes and peripheral or central nervous system lesions, response to prior therapies, and comorbid conditions that can be affected by therapy. Particular attention should be paid to identifying coexisting depression, anxiety, sleep disturbances, and other adverse impacts of NP on health-related quality of life, and both pain and its adverse effects should be reassessed frequently. Patient education and support are critical components of the successful management of NP. Careful explanation of the cause of NP and the treatment plan are essential. Patient and provider expectations regarding treatment effectiveness and tolerability must be discussed, and realistic treatment goals should be established with patients.(Strength not available)30

Measure Importance Relationship to Treatment of chronic painful diabetic neuropathy remains a challenge for desired physicians as individual tolerability remains a major aspect in any treatment outcome decision.1 In the case of painful diabetic neuropathy it is a chronic disease that is often treated with analgesics, there is little data regarding the efficacy of any chronic treatment regimen. Improved patient outcomes and preventing complications such as neuropathic pain and complications such as microvascular ©2019. American Academy of Neurology. All Rights Reserved. 33 CPT Copyright 2008-2019 American Medical Association.

diabetic neuropathy may significantly improve the quality of life in certain populations. Patients with severe pain may present with very few clinical symptoms which can lead often lead to a misdiagnosis or under-diagnosis, persistent pain over time can lead to disability and impaired quality of life.1

The use of a valid and reliable assessment instrument for neuropathic pain may prevent complications and improve the patient’s quality of life.1

Opportunity At least one of four diabetic patients is affected by distal symmetric for polyneuropathy1, which represents a major health problem, since it may present Improvement with partly excruciating neuropathic pain and is responsible for substantial morbidity, increased mortality, and impaired quality of life. IOM Domains • Safe of Health Care • Effective Quality • Efficient Addressed • Patient-Centered

Exception In patients who are cognitively impaired, it may not be possible to obtain this Justification information (medical exception). Patients may also refuse to answer questions about pain and function (patient exception). Harmonization There are no other measures currently available that are similar to this measure or with Existing need to be harmonized with this measure. Measures

Measure Designation Measure purpose • Quality improvement • Accountability Type of measure • Process Level of • Individual practitioner Measurement Care setting • Ambulatory care Data source • Electronic health record (EHR) data • Administrative Data/Claims (outpatient claims) • Administrative Data/Claims Expanded (multiple-source) • Paper medical record

Technical Specifications: Administrative/Claims Data Administrative claims data collection requires users to identify the eligible population (denominator) and numerator using codes recorded on claims or billing forms (electronic or paper). Users report a rate based on all patients in a given practice for whom data are available and who meet the eligible population/denominator criteria.

The specifications listed below are those needed for performance calculation. Additional CPT II codes may be required depending on how measures are implemented in reporting programs versus performance assessment programs.

©2019. American Academy of Neurology. All Rights Reserved. 34 CPT Copyright 2008-2019 American Medical Association. eCQM Title Preventive Care and Screening: Screening for Depression and Follow-Up Plan eCQM Identifier 2 10.2.000 (Measure eCQM Version Number Authoring Tool)

NQF Number 0418e GUID 9a031e24-3d9b-11e1-8634-00237d5bf174

Measurement January 1, 20XX through December 31, 20XX Period

Measure Steward Centers for Medicare & Medicaid Services (CMS)

Measure PCPI(R) Foundation (PCPI[R]) Developer

Endorsed By National Quality Forum

Percentage of patients aged 12 years and older screened for depression on the date of the encounter or up to 14 days Description prior to the date of the encounter using an age-appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the eligible encounter

Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. PCPI disclaims all liability for use or accuracy of any Current Procedural Terminology (CPT[R]) or other coding contained in the specifications. Copyright CPT(R) contained in the Measure specifications is copyright 2004-2019 American Medical Association. LOINC(R) is copyright 2004-2019 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2019 International Health Terminology Standards Development Organisation. ICD-10 is copyright 2019 World Health Organization. All Rights Reserved.

Due to technical limitations, registered trademarks are indicated by (R) or [R].

Measure Scoring Proportion

Measure Type Process

Stratification None

Risk Adjustment None

Rate None Aggregation

Depression is a serious medical illness associated with higher rates of chronic disease, increased health care utilization, and impaired functioning (Katon, 2003; Wells et al., 1989). 2016 U.S. survey data indicate that 12.8 percent of adolescents (3.1 million adolescents) had a major depressive episode (MDE) in the past year, with nine percent of adolescents (2.2 million adolescents) having one MDE with severe impairment. The same data indicate that 6.7 percent of adults aged 18 or older (16.2 million adults) had at least one MDE with 4.3 percent of adults (10.3 million adults) having one MDE with severe impairment in the past year (Substance Abuse and Mental Health Services Administration, 2017). Data indicate that severity of depressive symptoms factor into having difficulty with work, home, or social activities. For example, as the severity of depressive symptoms increased, rates of having difficulty with work, home, or social activities related to depressive symptoms increased. For those twelve and older with mild depressive symptoms, 45.7% reported difficulty with activities and those with severe depressive symptoms, 88.0% reported difficulty (Pratt & Brody, 2014). Children and teens with major depressive disorder (MDD) have been found to have difficulty carrying out their daily activities, relating to others, growing up healthy, and also are at an increased risk of suicide (Siu on behalf of the U.S. Preventive Services Task Force [USPSTF], 2016). Additionally, perinatal depression (considered here as depression arising in the period from conception to the end of the first postnatal year) affects up to 12% of women (Woody, Ferrari, Siskind, Whiteford, & Harris, 2017). Depression and other mood disorders, such as bipolar disorder and anxiety disorders, especially during the perinatal period, can have devastating effects on women, infants, and families (American College of Obstetricians and Gynecologists, 2018). Maternal suicide rates rise over hemorrhage and hypertensive disorders as a cause of maternal mortality (Palladino, Singh, Campbell, Flynn, & Gold, 2011). Rationale Negative outcomes associated with depression make it crucial to screen in order to identify and treat depression in its early stages. While Primary Care Providers (PCPs) serve as the first line of defense in the detection of depression, studies show that PCPs fail to recognize up to 50% of depressed patients (Borner, Braunstein, St. Victor, & Pollack, 2010). "In nationally representative U.S. surveys, about eight percent of adolescents reported having major depression in the past year. Only 36% to 44% of children and adolescents with depression receive treatment, suggesting that the majority of depressed youth are undiagnosed and untreated" (Siu on behalf of USPSTF, 2016, p. 360 & p. 364). Evidence supports that screening for depression in pregnant and postpartum women is of moderate net benefit and treatment options for positive depression screening should be available for patients twelve and older including pregnant and postpartum women.

If preventing negative patient outcomes is not enough, the substantial economic burden of depression for individuals and society alike makes a case for screening for depression on a regular basis. Depression imposes economic burden through direct and indirect costs: "In the United States, an estimated $22.8 billion was spent on depression treatment in 2009, and lost productivity cost an additional estimated $23 billion in 2011" (Siu & USPSTF, 2016, p. 383-384).

This measure seeks to align with clinical guideline recommendations as well as the Healthy People 2020 recommendation for routine screening for mental health problems as a part of primary care for both children and adults (U.S. Department of Health and Human Services, 2014) and makes an important contribution to the quality domain of community and population health.

Adolescent Recommendation (12-18 years):

"The USPSTF recommends screening for MDD in adolescents aged 12 to 18 years. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up (B recommendation)" (Siu on behalf of USPSTF, 2016, p. 360).

Adult Recommendation (18 years and older): Clinical "The USPSTF recommends screening for depression in the general adult population, including pregnant and Recommendation postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, Statement effective treatment, and appropriate follow-up (B recommendation)" (Siu & USPSTF, 2016, p. 380).

The Institute for Clinical Systems Improvement (ICSI) health care guideline, Adult Depression in Primary Care, provides the following recommendations: 1. "Clinicians should routinely screen all adults for depression using a standardized instrument." 2. "Clinicians should establish and maintain follow-up with patients." 3. "Clinicians should screen and monitor depression in pregnant and post-partum women." (Trangle et al., 2016, p. 8-10).

Improvement Higher score indicates better quality Notation Reference American College of Obstetricians and Gynecologists, Committee on Obstetric Practice. (2018). ACOG Committee Opinion Number 757: Screening for perinatal depression. Obstetrics and Gynecology, 132(5), e208-e212. doi: 10.1097/AOG.0000000000002927

Borner, I., Braunstein, J. W., St. Victor, R., & Pollack, J. (2010). Evaluation of a 2-question screening tool for Reference detecting depression in adolescents in primary care. Clinical Pediatrics, 49(10), 947-995. doi:10.1177/0009922810370203

Katon, W. J. (2003). Clinical and health services relationships between major depression, depressive symptoms, and Reference general medical illness. Biological Psychiatry, 54(3), 216-226. doi: 10.1016/s0006-3223(03)00273-7

Palladino, C. L., Singh, V., Campbell, J., Flynn, H., & Gold, K. (2011). Homicide and suicide during the perinatal Reference period: Findings from the National Violent Death Reporting System. Obstetrics and Gynecology, 118(5), 1056-1063. doi:10.1097/AOG.0b013e31823294da

Pratt, L. A., & Brody, D. J. (2014). Depression in the U.S. household population, 2009-2012. NCHS Data Brief No. Reference 172. Hyattsville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. Retrieved from https://www.cdc.gov/nchs/data/databriefs/db172.pdf

Siu, A. L., on behalf of USPSTF. (2016). Screening for depression in children and adolescents: U.S. Preventive Reference Services Task Force recommendation statement. Annals of Internal Medicine, 164(5), 360-366. doi:10.7326/M15- 2957

Siu, A. L., & USPSTF. (2016). Screening for depression in adults: U.S. Preventive Services Task Force Reference recommendation statement. Journal of the American Medical Association, 315(4), 380-387. doi:10.1001/jama.2015.18392.

Substance Abuse and Mental Health Services Administration. (2017). Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health. Rockville, MD: Center for Reference Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.htm

Trangle, M., Gursky, J., Haight, R., Hardwig, J., Hinnenkamp, T., Kessler, D.,… Myszkowski, M. (2016). Adult Reference depression in primary care. Bloomington, MN: Institute for Clinical Systems Improvement. Retrieved from https://www.icsi.org/guideline/depression/

U.S. Department of Health and Human Services. (2014). Healthy People 2020: Mental health and mental disorders. Reference Washington, DC: U.S. Department of Health and Human Services. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=28

Wells, K. B., Stewart, A., Hays, R. D., Burnam, M. A., Rogers, W., Daniels, M., … Ware, J. (1989). The functioning and Reference well-being of depressed patients. Results from the Medical Outcomes Study. Journal of the American Medical Association, 262(7), 914-919. Abstract retrieved from https://www.ncbi.nlm.nih.gov/pubmed/2754791

Woody, C. A., Ferrari, A. J., Siskind, D. J., Whiteford, H. A., & Harris, M. G. (2017). A systematic review and meta- Reference regression of the prevalence and incidence of perinatal depression. Journal of Affective Disorders, 219, 88-92. doi:10.1016/j.jad.2017.05.003

Screening: Completion of a clinical or diagnostic tool used to identify people at risk of developing or having a certain disease or condition, even in the absence of symptoms.

Standardized Depression Screening Tool: A normalized and validated depression screening tool developed for the patient population in which it is being utilized.

Examples of standardized depression screening tools include but are not limited to: * Adolescent Screening Tools (12-17 years) * Patient Health Questionnaire for Adolescents (PHQ-A) * Beck Depression Inventory-Primary Care Version (BDI-PC) * Mood Feeling Questionnaire (MFQ) * Center for Epidemiologic Studies Depression Scale (CES-D) * Patient Health Questionnaire (PHQ-9) * Pediatric Symptom Checklist (PSC-17) * PRIME MD-PHQ2 * Adult Screening Tools (18 years and older) * Patient Health Questionnaire (PHQ9) * Beck Depression Inventory (BDI or BDI-II) * Center for Epidemiologic Studies Depression Scale (CES-D) * Depression Scale (DEPS) Definition * Duke Anxiety-Depression Scale (DADS) * Geriatric Depression Scale (GDS) * Cornell Scale for Depression in Dementia (CSDD) * PRIME MD-PHQ2 * Hamilton Rating Scale for Depression (HAM-D) * Quick Inventory of Depressive Symptomatology Self-Report (QID-SR) * Computerized Adaptive Testing Depression Inventory (CAT-DI) * Computerized Adaptive Diagnostic Screener (CAD-MDD) * Perinatal Screening Tools * Edinburgh Postnatal Depression Scale * Postpartum Depression Screening Scale * Patient Health Questionnaire 9 (PHQ-9) * Beck Depression Inventory * Beck Depression Inventory-II * Center for Epidemiologic Studies Depression Scale * Zung Self-rating Depression Scale

Follow-Up Plan: Documented follow-up for a positive depression screening must include one or more of the following: * Referral to a practitioner who is qualified to diagnose and treat depression * Pharmacological interventions * Other interventions or follow-up for the diagnosis or treatment of depression

Guidance A depression screen is completed on the date of the encounter or up to 14 days prior to the date of the encounter using an age-appropriate standardized depression screening tool AND if positive, a follow-up plan must be documented on the date of the encounter, such as referral to a practitioner who is qualified to treat depression, pharmacological interventions or other interventions for the treatment of depression.

This eCQM is a patient-based measure. Depression screening is required once per measurement period, not at all encounters.

The intent of the measure is to screen for depression in patients who have never had a diagnosis of depression or bipolar disorder prior to the eligible encounter used to evaluate the numerator. Patients who have ever been diagnosed with depression or bipolar disorder will be excluded from the measure.

Screening Tools: * An age-appropriate, standardized, and validated depression screening tool must be used for numerator compliance. * The name of the age-appropriate standardized depression screening tool utilized must be documented in the medical record. * The depression screening must be reviewed and addressed in the office of the provider, filing the code, on the date of the encounter. Positive pre-screening results indicating a patient is at high risk for self-harm should receive more urgent intervention as determined by the provider practice. * The screening should occur during a qualifying encounter or up to 14 days prior to the date of the qualifying encounter. * The measure assesses the most recent depression screening completed either during the eligible encounter or within the 14 days prior to that encounter. Therefore, a clinician would not be able to complete another screening at the time of the encounter to count towards a follow-up, because that would serve as the most recent screening. In order to satisfy the follow-up requirement for a patient screening positively, the eligible clinician would need to provide one of the aforementioned follow-up actions, which does not include use of a standardized depression screening tool.

Follow-Up Plan:

The follow-up plan must be related to a positive depression screening, for example: "Patient referred for psychiatric evaluation due to positive depression screening."

Examples of a follow-up plan include but are not limited to: * Referral to a practitioner or program for further evaluation for depression, for example, referral to a psychiatrist, psychologist, social worker, mental health counselor, or other mental health service such as family or group therapy, support group, depression management program, or other service for treatment of depression * Other interventions designed to treat depression such as behavioral health evaluation, psychotherapy, pharmacological interventions, or additional treatment options

Should a patient screen positive for depression, a clinician should opt to complete a suicide risk assessment when appropriate and based on individual patient characteristics. However, for the purposes of this measure, a suicide risk assessment or additional screening using a standardized tool will not qualify as a follow-up plan.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

Transmission TBD Format

Initial All patients aged 12 years and older at the beginning of the measurement period with at least one eligible encounter Population during the measurement period

Denominator Equals Initial Population

Denominator Patients who have been diagnosed with depression or with bipolar disorder Exclusions

Patients screened for depression on the date of the encounter or up to 14 days prior to the date of the encounter Numerator using an age-appropriate standardized tool AND if positive, a follow-up plan is documented on the date of the eligible encounter

Numerator Not Applicable Exclusions

Patient Reason(s) Patient refuses to participate OR Denominator Medical Reason(s) Exceptions Documentation of medical reason for not screening patient for depression (e.g., cognitive, functional, or motivational limitations that may impact accuracy of results; patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient's health status)

Supplemental For every patient evaluated by this measure also identify payer, race, ethnicity and sex Data Elements

Table of Contents

• Population Criteria • Definitions • Functions • Terminology • Data Criteria (QDM Data Elements) • Supplemental Data Elements • Risk Adjustment Variables

Population Criteria

Initial Population

"Patient Age 12 Years or Older at Start of Measurement Period" and exists ( "Qualifying Encounter During Measurement Period" )

Denominator

"Initial Population"

Denominator Exclusions

exists "History of Bipolar or Depression Diagnosis Before Qualifying Encounter"

Numerator

( "Patient Age 12 to 16 Years at Start of Measurement Period" and ( "Has Most Recent Adolescent Screening Negative" or exists "Most Recent Adolescent Screening Positive and Follow Up Provided" ) ) or ( "Patient Age 17 Years at Start of Measurement Period" and ( "Has Most Recent Adolescent Screening Negative" or exists "Most Recent Adolescent Screening Positive and Follow Up Provided" or "Has Most Recent Adult Screening Negative" or exists "Most Recent Adult Depression Screening Positive and Follow Up Provided" ) ) or ( "Patient Age 18 Years or Older at Start of Measurement Period" and ( "Has Most Recent Adult Screening Negative" or exists "Most Recent Adult Depression Screening Positive and Follow Up Provided" ) )

Numerator Exclusions

None

Denominator Exceptions

( exists "Medical or Patient Reason for Not Screening Adolescent for Depression" and not "Has Adolescent Depression Screening" ) or ( exists "Medical or Patient Reason for Not Screening Adult for Depression" and not "Has Adult Depression Screening" )

Stratification

None

Definitions

Denominator

"Initial Population"

Denominator Exceptions

Denominator Exclusions

exists "History of Bipolar or Depression Diagnosis Before Qualifying Encounter"

Follow Up For Positive Adolescent Depression Screening

["Medication, Order": "Adolescent Depression Medications"] union ["Intervention, Order": "Referral for Adolescent Depression"] union ["Intervention, Performed": "Follow Up for Adolescent Depression"]

Follow Up for Positive Adult Depression Screening

["Medication, Order": "Adult Depression Medications"] union ["Intervention, Order": "Referral for Adult Depression"] union ["Intervention, Performed": "Follow Up for Adult Depression"]

Has Adolescent Depression Screening

exists ( ["Assessment, Performed": "Adolescent depression screening assessment"] AdolescentScreening with "Qualifying Encounter During Measurement Period" QualifyingEncounter such that AdolescentScreening.relevantDatetime 14 days or less on or before day of start of QualifyingEncounter.relevantPeriod and AdolescentScreening.result is not null )

Has Adult Depression Screening

exists ( ["Assessment, Performed": "Adult depression screening assessment"] AdultScreening with "Qualifying Encounter During Measurement Period" QualifyingEncounter such that AdultScreening.relevantDatetime 14 days or less on or before day of start of QualifyingEncounter.relevantPeriod and AdultScreening.result is not null )

Has Most Recent Adolescent Screening Negative

( "Most Recent Adolescent Depression Screening" AdolescentScreen where AdolescentScreen.result in "Negative Depression Screening" ) is not null

Has Most Recent Adult Screening Negative

( "Most Recent Adult Depression Screening" AdultScreen where AdultScreen.result in "Negative Depression Screening" ) is not null

History of Bipolar or Depression Diagnosis Before Qualifying Encounter

( ["Diagnosis": "Bipolar Diagnosis"] union ["Diagnosis": "Depression Diagnosis"] ) DiagnosisBipolarorDepression with "Qualifying Encounter During Measurement Period" QualifyingEncounter such that DiagnosisBipolarorDepression.prevalencePeriod starts before QualifyingEncounter.relevantPeriod

Initial Population

"Patient Age 12 Years or Older at Start of Measurement Period" and exists ( "Qualifying Encounter During Measurement Period" )

Medical or Patient Reason for Not Screening Adolescent for Depression

["Assessment, Not Performed": "Adolescent depression screening assessment"] NoAdolescentScreen with "Qualifying Encounter During Measurement Period" QualifyingEncounter such that NoAdolescentScreen.authorDatetime during QualifyingEncounter.relevantPeriod where ( NoAdolescentScreen.negationRationale in "Patient Declined" or NoAdolescentScreen.negationRationale in "Medical Reason" )

Medical or Patient Reason for Not Screening Adult for Depression

["Assessment, Not Performed": "Adult depression screening assessment"] NoAdultScreen with "Qualifying Encounter During Measurement Period" QualifyingEncounter such that NoAdultScreen.authorDatetime during QualifyingEncounter.relevantPeriod where ( NoAdultScreen.negationRationale in "Patient Declined" or NoAdultScreen.negationRationale in "Medical Reason" )

Most Recent Adolescent Depression Screening

Last(["Assessment, Performed": "Adolescent depression screening assessment"] AdolescentDepressionScreening with "Qualifying Encounter During Measurement Period" QualifyingEncounter such that AdolescentDepressionScreening.relevantDatetime 14 days or less on or before day of start of QualifyingEncounter.relevantPeriod and AdolescentDepressionScreening.result is not null sort by relevantDatetime )

Most Recent Adolescent Screening Positive and Follow Up Provided

from "Most Recent Adolescent Depression Screening" LastAdolescentScreen, "Follow Up For Positive Adolescent Depression Screening" FollowUpPositiveAdolescentScreen, "Qualifying Encounter During Measurement Period" QualifyingEncounter where LastAdolescentScreen.relevantDatetime 14 days or less on or before day of start of QualifyingEncounter.relevantPeriod and LastAdolescentScreen.result in "Positive Depression Screening" and ( FollowUpPositiveAdolescentScreen.authorDatetime same day as end of QualifyingEncounter.relevantPeriod or FollowUpPositiveAdolescentScreen.relevantDatetime same day as end of QualifyingEncounter.relevantPeriod )

Most Recent Adult Depression Screening

Last(["Assessment, Performed": "Adult depression screening assessment"] AdultDepressionScreening with "Qualifying Encounter During Measurement Period" QualifyingEncounter such that AdultDepressionScreening.relevantDatetime 14 days or less on or before day of start of QualifyingEncounter.relevantPeriod and AdultDepressionScreening.result is not null sort by relevantDatetime )

Most Recent Adult Depression Screening Positive and Follow Up Provided

from "Most Recent Adult Depression Screening" LastAdultScreen, "Follow Up for Positive Adult Depression Screening" FollowUpPositiveAdultScreen, "Qualifying Encounter During Measurement Period" QualifyingEncounter where LastAdultScreen.relevantDatetime 14 days or less on or before day of start of QualifyingEncounter.relevantPeriod and LastAdultScreen.result in "Positive Depression Screening" and ( FollowUpPositiveAdultScreen.authorDatetime same day as end of QualifyingEncounter.relevantPeriod or FollowUpPositiveAdultScreen.relevantDatetime same day as end of QualifyingEncounter.relevantPeriod )

Numerator

Patient Age 12 to 16 Years at Start of Measurement Period

exists ["Patient Characteristic Birthdate": "Birth date"] BirthDate where Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) < 17

Patient Age 12 Years or Older at Start of Measurement Period

exists ["Patient Characteristic Birthdate": "Birth date"] BirthDate where Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) >= 12

Patient Age 17 Years at Start of Measurement Period

exists ["Patient Characteristic Birthdate": "Birth date"] BirthDate where Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) = 17

Patient Age 18 Years or Older at Start of Measurement Period

exists ["Patient Characteristic Birthdate": "Birth date"] BirthDate where Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) >= 18

Qualifying Encounter During Measurement Period

( ["Encounter, Performed": "Encounter to Screen for Depression"] union ["Encounter, Performed": "Physical Therapy Evaluation"] ) ValidEncounter where ValidEncounter.relevantPeriod during "Measurement Period" SDE Ethnicity

["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

["Patient Characteristic Payer": "Payer"]

SDE Race

["Patient Characteristic Race": "Race"]

SDE Sex

["Patient Characteristic Sex": "ONC Administrative Sex"]

Functions

Global.CalendarAgeInYearsAt(BirthDateTime DateTime, AsOf DateTime)

years between ToDate(BirthDateTime)and ToDate(AsOf)

Global.ToDate(Value DateTime)

DateTime(year from Value, month from Value, day from Value, 0, 0, 0, 0, timezoneoffset from Value)

Terminology

• code "Adolescent depression screening assessment" ("LOINC Code (73831-0)") • code "Adult depression screening assessment" ("LOINC Code (73832-8)") • code "Birth date" ("LOINC Code (21112-8)") • valueset "Adolescent Depression Medications" (2.16.840.1.113883.3.526.3.1567) • valueset "Adult Depression Medications" (2.16.840.1.113883.3.526.3.1566) • valueset "Bipolar Diagnosis" (2.16.840.1.113883.3.600.450) • valueset "Depression Diagnosis" (2.16.840.1.113883.3.600.145) • valueset "Encounter to Screen for Depression" (2.16.840.1.113883.3.600.1916) • valueset "Ethnicity" (2.16.840.1.114222.4.11.837) • valueset "Follow Up for Adolescent Depression" (2.16.840.1.113883.3.526.3.1569) • valueset "Follow Up for Adult Depression" (2.16.840.1.113883.3.526.3.1568) • valueset "Medical Reason" (2.16.840.1.113883.3.526.3.1007) • valueset "Negative Depression Screening" (2.16.840.1.113883.3.526.3.1564) • valueset "ONC Administrative Sex" (2.16.840.1.113762.1.4.1) • valueset "Patient Declined" (2.16.840.1.113883.3.526.3.1582) • valueset "Payer" (2.16.840.1.114222.4.11.3591) • valueset "Physical Therapy Evaluation" (2.16.840.1.113883.3.526.3.1022) • valueset "Positive Depression Screening" (2.16.840.1.113883.3.526.3.1565) • valueset "Race" (2.16.840.1.114222.4.11.836) • valueset "Referral for Adolescent Depression" (2.16.840.1.113883.3.526.3.1570) • valueset "Referral for Adult Depression" (2.16.840.1.113883.3.526.3.1571)

Data Criteria (QDM Data Elements)

• "Assessment, Not Performed: Adolescent depression screening assessment" using "Adolescent depression screening assessment (LOINC Code 73831-0)" • "Assessment, Not Performed: Adult depression screening assessment" using "Adult depression screening assessment (LOINC Code 73832-8)" • "Assessment, Performed: Adolescent depression screening assessment" using "Adolescent depression screening assessment (LOINC Code 73831-0)" • "Assessment, Performed: Adult depression screening assessment" using "Adult depression screening assessment (LOINC Code 73832-8)" • "Diagnosis: Bipolar Diagnosis" using "Bipolar Diagnosis (2.16.840.1.113883.3.600.450)" • "Diagnosis: Depression Diagnosis" using "Depression Diagnosis (2.16.840.1.113883.3.600.145)" • "Encounter, Performed: Encounter to Screen for Depression" using "Encounter to Screen for Depression (2.16.840.1.113883.3.600.1916)" • "Encounter, Performed: Physical Therapy Evaluation" using "Physical Therapy Evaluation (2.16.840.1.113883.3.526.3.1022)" • "Intervention, Order: Referral for Adolescent Depression" using "Referral for Adolescent Depression (2.16.840.1.113883.3.526.3.1570)" • "Intervention, Order: Referral for Adult Depression" using "Referral for Adult Depression (2.16.840.1.113883.3.526.3.1571)" • "Intervention, Performed: Follow Up for Adolescent Depression" using "Follow Up for Adolescent Depression (2.16.840.1.113883.3.526.3.1569)" • "Intervention, Performed: Follow Up for Adult Depression" using "Follow Up for Adult Depression (2.16.840.1.113883.3.526.3.1568)" • "Medication, Order: Adolescent Depression Medications" using "Adolescent Depression Medications (2.16.840.1.113883.3.526.3.1567)" • "Medication, Order: Adult Depression Medications" using "Adult Depression Medications (2.16.840.1.113883.3.526.3.1566)" • "Patient Characteristic Birthdate: Birth date" using "Birth date (LOINC Code 21112-8)" • "Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity (2.16.840.1.114222.4.11.837)" • "Patient Characteristic Payer: Payer" using "Payer (2.16.840.1.114222.4.11.3591)" • "Patient Characteristic Race: Race" using "Race (2.16.840.1.114222.4.11.836)" • "Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex (2.16.840.1.113762.1.4.1)"

Supplemental Data Elements

SDE Ethnicity

["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

["Patient Characteristic Payer": "Payer"]

SDE Race

["Patient Characteristic Race": "Race"]

SDE Sex

["Patient Characteristic Sex": "ONC Administrative Sex"]

Risk Adjustment Variables

None

Measure Set Preventive Care and Screening eCQM Title Use of High-Risk Medications in Older Adults eCQM Identifier 156 9.3.000 (Measure eCQM Version Number Authoring Tool)

NQF Number Not Applicable GUID a3837ff8-1abc-4ba9-800e-fd4e7953adbd

Measurement January 1, 20XX through December 31, 20XX Period

Measure Steward National Committee for Quality Assurance

Measure National Committee for Quality Assurance Developer

Endorsed By None

Description Percentage of patients 65 years of age and older who were ordered at least two of the same high-risk medications.

This Physician Performance Measure (Measure) and related data specifications are owned and stewarded by the Centers for Medicare & Medicaid Services (CMS). CMS contracted (Contract HHSM-500-2011-00079C) with the National Committee for Quality Assurance (NCQA) to develop this electronic measure. NCQA is not responsible for any use of the Measure. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications.

Copyright Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. NCQA disclaims all liability for use or accuracy of any third party codes contained in the specifications.

CPT(R) contained in the Measure specifications is copyright 2004-2019 American Medical Association. LOINC(R) copyright 2004-2019 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2019 International Health Terminology Standards Development Organisation. ICD-10 copyright 2019 World Health Organization. All Rights Reserved.

The performance Measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications. THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND. Disclaimer Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].

Measure Scoring Proportion

Measure Type Process

Stratification None

Risk Adjustment None

Rate None Aggregation

Certain medications (MacKinnon & Hepler, 2003) are associated with increased risk of harm from drug side-effects and drug toxicity and pose a concern for patient safety. There is clinical consensus that these drugs pose increased risks in older adults (Kaufman, Brodin, & Sarafian, 2005). Potentially inappropriate medication use in older adults has been connected to significantly longer hospital stay lengths and increased hospitalization costs (Hagstrom et al., 2015) as well as increased risk of death (Lau et al. 2004).

Older adults receiving inappropriate medications are more likely to report poorer health status at follow-up, compared to those who receive appropriate medications (Fu, Liu, & Christensen, 2004). A study of the prevalence of potentially inappropriate medication use in older adults found that 40 percent of individuals 65 and older filled at least one prescription for a potentially inappropriate medication and 13 percent filled two or more (Fick et al., 2008). While some adverse drug events are unavoidable, studies estimate that between 30 and 80 percent of adverse drug events in older adults are preventable (MacKinnon & Hepler, 2003). Rationale Reducing the number of inappropriate prescriptions can lead to improved patient safety and significant cost savings. Conservative estimates of extra costs due to potentially inappropriate medications in older adults average $7.2 billion a year (Fu et al., 2007 ). Medication use by older adults will likely increase further as the U.S. population ages, new drugs are developed, and new therapeutic and preventive uses for medications are discovered (Rothberg et al., 2008). The annual direct costs of preventable adverse drug events (ADEs) in the Medicare population have been estimated to exceed $800 million (Institute of Medicine, 2007). By the year 2030, nearly one in five U.S. residents is expected to be aged 65 years or older; this age group is projected to more than double in number from 38.7 million in 2008 to more than 88.5 million in 2050. Likewise, the population aged 85 years or older is expected to increase almost four-fold, from 5.4 million to 19 million between 2008 and 2050. As the older adult population continues to grow, the number of older adults who present with multiple medical conditions for which several medications are prescribed will continue to increase, resulting in polypharmacy concerns (Gray & Gardner, 2009).

The measure is based on recommendations from the American Geriatrics Society Beers Criteria[R] for Potentially Inappropriate Medication Use in Older Adults (2019 Update). The criteria were developed through key clinical expert consensus processes by Beers in 1997, Zhan in 2001 and an updated process by Fick et al. in 2003, 2012, 2015, and Clinical 2019. The Beers Criteria identifies lists of drugs that are potentially inappropriate for all older adults and drugs that Recommendation are potentially inappropriate in older adults based on various high-risk factors such as dosage, days supply and Statement underlying diseases or conditions. NCQA's Geriatric Measurement Advisory Panel recommended a subset of drugs that should be used with caution in older adults for inclusion in the measure based upon the recommendations in the Beers Criteria.

Improvement Lower score indicates better quality Notation

American Geriatrics Society 2015 Beers Criteria Update Expert Panel. (2015). American Geriatrics Society 2015 Reference updated Beers criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 63(11), 2227-2246.

Beers, M. H. (1997). Explicit criteria for determining potentially inappropriate medication use by the elderly. Archives Reference of Internal Medicine, 157, 1531-1536.

Campanelli, C. M. (2012). American Geriatrics Society updated Beers criteria for potentially inappropriate medication Reference use in older adults: The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. Journal of the American Geriatrics Society, 60(4), 616.

Fick, D. M., Cooper J. W., Wade, W. E., et al. (2003). Updating the Beers criteria for potentially inappropriate Reference medication use in older adults. Archives of Internal Medicine, 163(22), 2716-2724.

Fick, D. M., Mion, L. C., Beers, M. H., et al. (2008). Health outcomes associated with potentially inappropriate Reference medication use in older adults. Research in Nursing & Health, 31(1), 42-51.

Fu, A. Z., Liu, G. G., & Christensen, D. B. (2004). Inappropriate medication use and health outcomes in the elderly. Reference Journal of the American Geriatrics Society, 52(11), 1934-1939.

Reference Gray, C. L., & Gardner, C. (2009). Adverse drug events in the elderly: An ongoing problem. Journal of Managed Care & Specialty Pharmacy, 15(7), 568-571.

Hagstrom, K., Nailor, M., Lindberg, M., Hobbs, L., & Sobieraj, D. M. 2015. Association Between Potentially Reference Inappropriate Medication Use in Elderly Adults and Hospital-Related Outcomes. Journal of the American Geriatrics Society, 63(1), 185-186.

Institute of Medicine, Committee on Identifying and Preventing Medication Errors. (2007). Preventing medication Reference errors. Aspden, P., Wolcott, J. A., Bootman, J. L., & Cronenwatt, L. R. (eds.). Washington, DC: National Academy Press.

Kaufman, M. B., Brodin, K. A., & Sarafian, A. (2005, April/May). Effect of prescriber education on the use of Reference medications contraindicated in older adults in a managed Medicare population. Journal of Managed Care & Specialty Pharmacy, 11(3), 211-219.

Lau, D.T., J.D., Kasper, D.E., Potter, A. Lyles. (2004). Potentially Inappropriate Medication Prescriptions Among Reference Elderly Nursing Home Residents: Their Scope and Associated Resident and Facility Characteristics. Health Services Research, 39(5), 1257-1276.

MacKinnon, N. J., & Hepler, C. D. (2003). Indicators of preventable drug-related morbidity in older adults: Use within Reference a managed care organization. Journal of Managed Care & Specialty Pharmacy, 9(2), 134-141.

Rothberg, M. B., Perkow, P. S., Liu, F., et al. (2008). Potentially inappropriate medication use in hospitalized elders. Reference Journal of Hospital Medicine, 3(2), 91-102.

Zhan, C., Sangl, J., Bierman, A. S., et al. (2001). Potentially inappropriate medication use in the community-dwelling Reference elderly. JAMA, 286(22), 2823-2868.

2019 American Geriatrics Society Beers Criteria Update Expert Panel. (2019). American Geriatrics Society 2019 Reference Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society, 67(4), 674-694.

A high-risk medication is identified by either of the following: Definition a. A prescription for medications classified as high risk at any dose and for any duration b. Prescriptions for medications classified as high risk at any dose with greater than a 90 day supply

The intent of the measure is to assess if the patient has been prescribed at least two of the same high-risk medications on different days.

The intent of the measure is to assess if the reporting provider ordered the high-risk medication(s). If the patient had a high-risk medication previously prescribed by another provider, they would not be counted towards the numerator Guidance unless the reporting provider also ordered a high-risk medication for them.

This eCQM is a patient-based measure.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

Transmission TBD Format

Initial Patients 65 years and older who had a visit during the measurement period Population

Denominator Equals Initial Population

Denominator Exclude patients whose hospice care overlaps the measurement period Exclusions

Numerator Patients with at least two orders for the same high-risk medication on different days during the measurement period

Numerator Not Applicable Exclusions

Denominator None Exceptions

Supplemental For every patient evaluated by this measure also identify payer, race, ethnicity and sex Data Elements

Table of Contents

• Population Criteria • Definitions • Functions • Terminology • Data Criteria (QDM Data Elements) • Supplemental Data Elements • Risk Adjustment Variables

Population Criteria

Initial Population

exists ["Patient Characteristic Birthdate": "Birth date"] BirthDate where Global."CalendarAgeInYearsAt" ( BirthDate.birthDatetime, start of "Measurement Period" ) >= 65 and exists ( "Qualifying Encounters" )

Denominator

"Initial Population"

Denominator Exclusions

Hospice."Has Hospice"

Numerator

exists ( "Same High Risk Medications Ordered on Different Days" ) or ( "Two High Risk Medications With Prolonged Duration" )

Numerator Exclusions

None Denominator Exceptions

None

Stratification

None

Definitions

AntiInfectives During Measurement Period

["Medication, Order": "Anti Infectives, other"] AntiInfectives where AntiInfectives.authorDatetime during "Measurement Period"

Denominator

"Initial Population"

Denominator Exclusions

Hospice."Has Hospice"

Hospice.Has Hospice

exists ( ["Encounter, Performed": "Encounter Inpatient"] DischargeHospice where ( DischargeHospice.dischargeDisposition ~ "Discharge to home for hospice care (procedure)" or DischargeHospice.dischargeDisposition ~ "Discharge to healthcare facility for hospice care (procedure)" ) and DischargeHospice.relevantPeriod ends during "Measurement Period" ) or exists ( ["Intervention, Order": "Hospice care ambulatory"] HospiceOrder where HospiceOrder.authorDatetime during "Measurement Period" ) or exists ( ["Intervention, Performed": "Hospice care ambulatory"] HospicePerformed where HospicePerformed.relevantPeriod overlaps "Measurement Period" )

Hypnotics During Measurement Period

["Medication, Order": "Nonbenzodiazepine hypnotics"] Hypnotics where Hypnotics.authorDatetime during "Measurement Period"

Initial Population

More than One AntiInfective Order

//Anti Infectives, other exists ( "More Than One of Same Medication Order"(["Medication, Order": "Anti Infectives, other"]))

More than One Nonbenzodiazepine Hypnotics Order

//Nonbenzodiazepine hypnotics exists ( "More Than One of Same Medication Order"(["Medication, Order": "Nonbenzodiazepine hypnotics"]))

Numerator

exists ( "Same High Risk Medications Ordered on Different Days" ) or ( "Two High Risk Medications With Prolonged Duration" )

Qualifying Encounters

( ["Encounter, Performed": "Office Visit"] union ["Encounter, Performed": "Ophthalmologic Services"] union ["Encounter, Performed": "Preventive Care Services - Established Office Visit, 18 and Up"] union ["Encounter, Performed": "Discharge Services - Nursing Facility"] union ["Encounter, Performed": "Nursing Facility Visit"] union ["Encounter, Performed": "Care Services in Long-Term Residential Facility"] union ["Encounter, Performed": "Preventive Care Services-Initial Office Visit, 18 and Up"] union ["Encounter, Performed": "Annual Wellness Visit"] union ["Encounter, Performed": "Home Healthcare Services"] ) ValidEncounter where ValidEncounter.relevantPeriod during "Measurement Period"

Same High Risk Medications Ordered on Different Days

( from ["Medication, Order": "List of Single RxNorm Code Concepts for High Risk Drugs for the Elderly"] MedicationOrder1, ["Medication, Order": "List of Single RxNorm Code Concepts for High Risk Drugs for the Elderly"] MedicationOrder2 where MedicationOrder1.authorDatetime during "Measurement Period" and MedicationOrder2.authorDatetime during "Measurement Period" and MedicationOrder1.authorDatetime 1 day or more after MedicationOrder2.authorDatetime and MedicationOrder1.code ~ MedicationOrder2.code return MedicationOrder1 ) union "More Than One of Same Medication Order"(["Medication, Order": "Amobarbital"]) union "More Than One of Same Medication Order"(["Medication, Order": "Amitriptyline Hydrochloride"]) union "More Than One of Same Medication Order"(["Medication, Order": "Amoxapine"]) union "More Than One of Same Medication Order"(["Medication, Order": "Orphenadrine"]) union "More Than One of Same Medication Order"(["Medication, Order": "Atropine"]) union "More Than One of Same Medication Order"(["Medication, Order": "Benztropine"]) union "More Than One of Same Medication Order"(["Medication, Order": "Brompheniramine"]) union "More Than One of Same Medication Order"(["Medication, Order": "Butabarbital"]) union "More Than One of Same Medication Order"(["Medication, Order": "Butalbital"]) union "More Than One of Same Medication Order"(["Medication, Order": "Carbinoxamine"]) union "More Than One of Same Medication Order"(["Medication, Order": "Carisoprodol"]) union "More Than One of Same Medication Order"(["Medication, Order": "Chlorpheniramine"]) union "More Than One of Same Medication Order"(["Medication, Order": "Chlorpropamide"]) union "More Than One of Same Medication Order"(["Medication, Order": "Chlorzoxazone"]) union "More Than One of Same Medication Order"(["Medication, Order": "Clemastine"]) union "More Than One of Same Medication Order"(["Medication, Order": "Clomipramine"]) union "More Than One of Same Medication Order"(["Medication, Order": "Conjugated Estrogens"]) union "More Than One of Same Medication Order"(["Medication, Order": "Cyclobenzaprine Hydrochloride"]) union "More Than One of Same Medication Order"(["Medication, Order": "Cyproheptadine"]) union "More Than One of Same Medication Order"(["Medication, Order": "Desiccated Thyroid"]) union "More Than One of Same Medication Order"(["Medication, Order": "Desipramine"]) union "More Than One of Same Medication Order"(["Medication, Order": "Dexbrompheniramine"]) union "More Than One of Same Medication Order"(["Medication, Order": "Dexchlorpheniramine"]) union "More Than One of Same Medication Order"(["Medication, Order": "Dicyclomine"]) union "More Than One of Same Medication Order"(["Medication, Order": "Dimenhydrinate"]) union "More Than One of Same Medication Order"(["Medication, Order": "Diphenhydramine"]) union "More Than One of Same Medication Order"(["Medication, Order": "Diphenhydramine Hydrochloride"]) union "More Than One of Same Medication Order"(["Medication, Order": "Dipyridamole"]) union "More Than One of Same Medication Order"(["Medication, Order": "Disopyramide"]) union "More Than One of Same Medication Order"(["Medication, Order": "Doxylamine"]) union "More Than One of Same Medication Order"(["Medication, Order": "Ergoloid Mesylates"]) union "More Than One of Same Medication Order"(["Medication, Order": "Esterified Estrogens"]) union "More Than One of Same Medication Order"(["Medication, Order": "Estradiol"]) union "More Than One of Same Medication Order"(["Medication, Order": "Estropipate"]) union "More Than One of Same Medication Order"(["Medication, Order": "Glyburide"]) union "More Than One of Same Medication Order"(["Medication, Order": "Guanfacine"]) union "More Than One of Same Medication Order"(["Medication, Order": "Hydroxyzine"]) union "More Than One of Same Medication Order"(["Medication, Order": "Hyoscyamine"]) union "More Than One of Same Medication Order"(["Medication, Order": "Imipramine"]) union "More Than One of Same Medication Order"(["Medication, Order": "Indomethacin"]) union "More Than One of Same Medication Order"(["Medication, Order": "Isoxsuprine"]) union "More Than One of Same Medication Order"(["Medication, Order": "Ketorolac Tromethamine"]) union "More Than One of Same Medication Order"(["Medication, Order": "Meclizine"]) union "More Than One of Same Medication Order"(["Medication, Order": "Megestrol"]) union "More Than One of Same Medication Order"(["Medication, Order": "Meperidine"]) union "More Than One of Same Medication Order"(["Medication, Order": "Meprobamate"]) union "More Than One of Same Medication Order"(["Medication, Order": "Metaxalone"]) union "More Than One of Same Medication Order"(["Medication, Order": "Methocarbamol"]) union "More Than One of Same Medication Order"(["Medication, Order": "Methyldopa"]) union "More Than One of Same Medication Order"(["Medication, Order": "Nifedipine"]) union "More Than One of Same Medication Order"(["Medication, Order": "Nortriptyline"]) union "More Than One of Same Medication Order"(["Medication, Order": "Paroxetine"]) union "More Than One of Same Medication Order"(["Medication, Order": "Pentobarbital"]) union "More Than One of Same Medication Order"(["Medication, Order": "Phenobarbital"]) union "More Than One of Same Medication Order"(["Medication, Order": "Promethazine Hydrochloride"]) union "More Than One of Same Medication Order"(["Medication, Order": "Protriptyline"]) union "More Than One of Same Medication Order"(["Medication, Order": "Propantheline"]) union "More Than One of Same Medication Order"(["Medication, Order": "Scopolamine"]) union "More Than One of Same Medication Order"(["Medication, Order": "Secobarbital"]) union "More Than One of Same Medication Order"(["Medication, Order": "Trihexyphenidyl"]) union "More Than One of Same Medication Order"(["Medication, Order": "Trimipramine"]) union "More Than One of Same Medication Order"(["Medication, Order": "Triprolidine"])

SDE Ethnicity

["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

["Patient Characteristic Payer": "Payer"]

SDE Race

["Patient Characteristic Race": "Race"]

SDE Sex

["Patient Characteristic Sex": "ONC Administrative Sex"]

Two High Risk Medications With Prolonged Duration

( "Cumulative Medication Duration"("AntiInfectives During Measurement Period")>= 90 and "More than One AntiInfective Order" ) or ( "Cumulative Medication Duration"("Hypnotics During Measurement Period")>= 90 and "More than One Nonbenzodiazepine Hypnotics Order" )

Functions

Cumulative Medication Duration(Medication List<"Medication, Order">)

Sum((collapse(Medication.relevantPeriod))CumulativeDosages return all duration in days of CumulativeDosages )

Global.CalendarAgeInYearsAt(BirthDateTime DateTime, AsOf DateTime)

years between ToDate(BirthDateTime)and ToDate(AsOf)

Global.ToDate(Value DateTime)

DateTime(year from Value, month from Value, day from Value, 0, 0, 0, 0, timezoneoffset from Value)

More Than One of Same Medication Order(Medication List<"Medication, Order">)

"Medication" OrderMedication1 with "Medication" OrderMedication2 such that OrderMedication1.authorDatetime 1 day or more after OrderMedication2.authorDatetime and OrderMedication1.authorDatetime during "Measurement Period" and OrderMedication2.authorDatetime during "Measurement Period" return OrderMedication1 Terminology

• code "Birth date" ("LOINC Code (21112-8)") • code "Discharge to healthcare facility for hospice care (procedure)" ("SNOMEDCT Code (428371000124100)") • code "Discharge to home for hospice care (procedure)" ("SNOMEDCT Code (428361000124107)") • valueset "Amitriptyline Hydrochloride" (2.16.840.1.113883.3.464.1003.196.12.1373) • valueset "Amobarbital" (2.16.840.1.113883.3.464.1003.196.12.1512) • valueset "Amoxapine" (2.16.840.1.113883.3.464.1003.196.12.1273) • valueset "Annual Wellness Visit" (2.16.840.1.113883.3.526.3.1240) • valueset "Anti Infectives, other" (2.16.840.1.113883.3.464.1003.196.12.1481) • valueset "Atropine" (2.16.840.1.113883.3.464.1003.196.12.1274) • valueset "Benztropine" (2.16.840.1.113883.3.464.1003.196.12.1361) • valueset "Brompheniramine" (2.16.840.1.113883.3.464.1003.196.12.1427) • valueset "Butabarbital" (2.16.840.1.113883.3.464.1003.196.12.1402) • valueset "Butalbital" (2.16.840.1.113883.3.464.1003.196.12.1514) • valueset "Carbinoxamine" (2.16.840.1.113883.3.464.1003.196.12.1306) • valueset "Care Services in Long-Term Residential Facility" (2.16.840.1.113883.3.464.1003.101.12.1014) • valueset "Carisoprodol" (2.16.840.1.113883.3.464.1003.196.12.1369) • valueset "Chlorpheniramine" (2.16.840.1.113883.3.464.1003.196.12.1352) • valueset "Chlorpropamide" (2.16.840.1.113883.3.464.1003.196.12.1303) • valueset "Chlorzoxazone" (2.16.840.1.113883.3.464.1003.196.12.1362) • valueset "Clemastine" (2.16.840.1.113883.3.464.1003.196.12.1308) • valueset "Clomipramine" (2.16.840.1.113883.3.464.1003.196.12.1336) • valueset "Conjugated Estrogens" (2.16.840.1.113883.3.464.1003.196.12.1357) • valueset "Cyclobenzaprine Hydrochloride" (2.16.840.1.113883.3.464.1003.196.12.1372) • valueset "Cyproheptadine" (2.16.840.1.113883.3.464.1003.196.12.1277) • valueset "Desiccated Thyroid" (2.16.840.1.113883.3.464.1003.196.12.1354) • valueset "Desipramine" (2.16.840.1.113883.3.464.1003.196.12.1278) • valueset "Dexbrompheniramine" (2.16.840.1.113883.3.464.1003.196.12.1375) • valueset "Dexchlorpheniramine" (2.16.840.1.113883.3.464.1003.196.12.1300) • valueset "Dicyclomine" (2.16.840.1.113883.3.464.1003.196.12.1279) • valueset "Dimenhydrinate" (2.16.840.1.113883.3.464.1003.196.12.1500) • valueset "Diphenhydramine" (2.16.840.1.113883.3.464.1003.196.12.1293) • valueset "Diphenhydramine Hydrochloride" (2.16.840.1.113883.3.464.1003.196.12.1371) • valueset "Dipyridamole" (2.16.840.1.113883.3.464.1003.196.12.1349) • valueset "Discharge Services - Nursing Facility" (2.16.840.1.113883.3.464.1003.101.12.1013) • valueset "Disopyramide" (2.16.840.1.113883.3.464.1003.196.12.1311) • valueset "Doxylamine" (2.16.840.1.113883.3.464.1003.196.12.1515) • valueset "Encounter Inpatient" (2.16.840.1.113883.3.666.5.307) • valueset "Ergoloid Mesylates" (2.16.840.1.113883.3.464.1003.196.12.1516) • valueset "Esterified Estrogens" (2.16.840.1.113883.3.464.1003.196.12.1419) • valueset "Estradiol" (2.16.840.1.113883.3.464.1003.196.12.1365) • valueset "Estropipate" (2.16.840.1.113883.3.464.1003.196.12.1319) • valueset "Ethnicity" (2.16.840.1.114222.4.11.837) • valueset "Glyburide" (2.16.840.1.113883.3.464.1003.196.12.1368) • valueset "Guanfacine" (2.16.840.1.113883.3.464.1003.196.12.1341) • valueset "Home Healthcare Services" (2.16.840.1.113883.3.464.1003.101.12.1016) • valueset "Hospice care ambulatory" (2.16.840.1.113762.1.4.1108.15) • valueset "Hydroxyzine" (2.16.840.1.113883.3.464.1003.196.12.1374) • valueset "Hyoscyamine" (2.16.840.1.113883.3.464.1003.196.12.1501) • valueset "Imipramine" (2.16.840.1.113883.3.464.1003.196.12.1359) • valueset "Indomethacin" (2.16.840.1.113883.3.464.1003.196.12.1366) • valueset "Isoxsuprine" (2.16.840.1.113883.3.464.1003.196.12.1422) • valueset "Ketorolac Tromethamine" (2.16.840.1.113883.3.464.1003.196.12.1364) • valueset "List of Single RxNorm Code Concepts for High Risk Drugs for the Elderly" (2.16.840.1.113883.3.464.1003.196.12.1272) • valueset "Meclizine" (2.16.840.1.113883.3.464.1003.196.12.1506) • valueset "Megestrol" (2.16.840.1.113883.3.464.1003.196.12.1342) • valueset "Meperidine" (2.16.840.1.113883.3.464.1003.196.12.1351) • valueset "Meprobamate" (2.16.840.1.113883.3.464.1003.196.12.1284) • valueset "Metaxalone" (2.16.840.1.113883.3.464.1003.196.12.1358) • valueset "Methocarbamol" (2.16.840.1.113883.3.464.1003.196.12.1370) • valueset "Methyldopa" (2.16.840.1.113883.3.464.1003.196.12.1331) • valueset "Nifedipine" (2.16.840.1.113883.3.464.1003.196.12.1353) • valueset "Nonbenzodiazepine hypnotics" (2.16.840.1.113883.3.464.1003.196.12.1480) • valueset "Nortriptyline" (2.16.840.1.113883.3.464.1003.196.12.1507) • valueset "Nursing Facility Visit" (2.16.840.1.113883.3.464.1003.101.12.1012) • valueset "Office Visit" (2.16.840.1.113883.3.464.1003.101.12.1001) • valueset "ONC Administrative Sex" (2.16.840.1.113762.1.4.1) • valueset "Ophthalmologic Services" (2.16.840.1.113883.3.464.1003.101.11.1206) • valueset "Orphenadrine" (2.16.840.1.113883.3.464.1003.196.12.1302) • valueset "Paroxetine" (2.16.840.1.113883.3.464.1003.196.12.1508) • valueset "Payer" (2.16.840.1.114222.4.11.3591) • valueset "Pentobarbital" (2.16.840.1.113883.3.464.1003.196.12.1518) • valueset "Phenobarbital" (2.16.840.1.113883.3.464.1003.196.12.1348) • valueset "Preventive Care Services - Established Office Visit, 18 and Up" (2.16.840.1.113883.3.464.1003.101.12.1025) • valueset "Preventive Care Services-Initial Office Visit, 18 and Up" (2.16.840.1.113883.3.464.1003.101.12.1023) • valueset "Promethazine Hydrochloride" (2.16.840.1.113883.3.464.1003.196.12.1367) • valueset "Propantheline" (2.16.840.1.113883.3.464.1003.196.12.1519) • valueset "Protriptyline" (2.16.840.1.113883.3.464.1003.196.12.1509) • valueset "Race" (2.16.840.1.114222.4.11.836) • valueset "Scopolamine" (2.16.840.1.113883.3.464.1003.196.12.1520) • valueset "Secobarbital" (2.16.840.1.113883.3.464.1003.196.12.1521) • valueset "Trihexyphenidyl" (2.16.840.1.113883.3.464.1003.196.12.1334) • valueset "Trimipramine" (2.16.840.1.113883.3.464.1003.196.12.1285) • valueset "Triprolidine" (2.16.840.1.113883.3.464.1003.196.12.1408)

Data Criteria (QDM Data Elements)

• "Encounter, Performed: Annual Wellness Visit" using "Annual Wellness Visit (2.16.840.1.113883.3.526.3.1240)" • "Encounter, Performed: Care Services in Long-Term Residential Facility" using "Care Services in Long-Term Residential Facility (2.16.840.1.113883.3.464.1003.101.12.1014)" • "Encounter, Performed: Discharge Services - Nursing Facility" using "Discharge Services - Nursing Facility (2.16.840.1.113883.3.464.1003.101.12.1013)" • "Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient (2.16.840.1.113883.3.666.5.307)" • "Encounter, Performed: Home Healthcare Services" using "Home Healthcare Services (2.16.840.1.113883.3.464.1003.101.12.1016)" • "Encounter, Performed: Nursing Facility Visit" using "Nursing Facility Visit (2.16.840.1.113883.3.464.1003.101.12.1012)" • "Encounter, Performed: Office Visit" using "Office Visit (2.16.840.1.113883.3.464.1003.101.12.1001)" • "Encounter, Performed: Ophthalmologic Services" using "Ophthalmologic Services (2.16.840.1.113883.3.464.1003.101.11.1206)" • "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" using "Preventive Care Services - Established Office Visit, 18 and Up (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 (2.16.840.1.113883.3.464.1003.101.12.1023)" • "Intervention, Order: Hospice care ambulatory" using "Hospice care ambulatory (2.16.840.1.113762.1.4.1108.15)" • "Intervention, Performed: Hospice care ambulatory" using "Hospice care ambulatory (2.16.840.1.113762.1.4.1108.15)" • "Medication, Order: Amitriptyline Hydrochloride" using "Amitriptyline Hydrochloride (2.16.840.1.113883.3.464.1003.196.12.1373)" • "Medication, Order: Amobarbital" using "Amobarbital (2.16.840.1.113883.3.464.1003.196.12.1512)" • "Medication, Order: Amoxapine" using "Amoxapine (2.16.840.1.113883.3.464.1003.196.12.1273)" • "Medication, Order: Anti Infectives, other" using "Anti Infectives, other (2.16.840.1.113883.3.464.1003.196.12.1481)" • "Medication, Order: Atropine" using "Atropine (2.16.840.1.113883.3.464.1003.196.12.1274)" • "Medication, Order: Benztropine" using "Benztropine (2.16.840.1.113883.3.464.1003.196.12.1361)" • "Medication, Order: Brompheniramine" using "Brompheniramine (2.16.840.1.113883.3.464.1003.196.12.1427)" • "Medication, Order: Butabarbital" using "Butabarbital (2.16.840.1.113883.3.464.1003.196.12.1402)" • "Medication, Order: Butalbital" using "Butalbital (2.16.840.1.113883.3.464.1003.196.12.1514)" • "Medication, Order: Carbinoxamine" using "Carbinoxamine (2.16.840.1.113883.3.464.1003.196.12.1306)" • "Medication, Order: Carisoprodol" using "Carisoprodol (2.16.840.1.113883.3.464.1003.196.12.1369)" • "Medication, Order: Chlorpheniramine" using "Chlorpheniramine (2.16.840.1.113883.3.464.1003.196.12.1352)" • "Medication, Order: Chlorpropamide" using "Chlorpropamide (2.16.840.1.113883.3.464.1003.196.12.1303)" • "Medication, Order: Chlorzoxazone" using "Chlorzoxazone (2.16.840.1.113883.3.464.1003.196.12.1362)" • "Medication, Order: Clemastine" using "Clemastine (2.16.840.1.113883.3.464.1003.196.12.1308)" • "Medication, Order: Clomipramine" using "Clomipramine (2.16.840.1.113883.3.464.1003.196.12.1336)" • "Medication, Order: Conjugated Estrogens" using "Conjugated Estrogens (2.16.840.1.113883.3.464.1003.196.12.1357)" • "Medication, Order: Cyclobenzaprine Hydrochloride" using "Cyclobenzaprine Hydrochloride (2.16.840.1.113883.3.464.1003.196.12.1372)" • "Medication, Order: Cyproheptadine" using "Cyproheptadine (2.16.840.1.113883.3.464.1003.196.12.1277)" • "Medication, Order: Desiccated Thyroid" using "Desiccated Thyroid (2.16.840.1.113883.3.464.1003.196.12.1354)" • "Medication, Order: Desipramine" using "Desipramine (2.16.840.1.113883.3.464.1003.196.12.1278)" • "Medication, Order: Dexbrompheniramine" using "Dexbrompheniramine (2.16.840.1.113883.3.464.1003.196.12.1375)" • "Medication, Order: Dexchlorpheniramine" using "Dexchlorpheniramine (2.16.840.1.113883.3.464.1003.196.12.1300)" • "Medication, Order: Dicyclomine" using "Dicyclomine (2.16.840.1.113883.3.464.1003.196.12.1279)" • "Medication, Order: Dimenhydrinate" using "Dimenhydrinate (2.16.840.1.113883.3.464.1003.196.12.1500)" • "Medication, Order: Diphenhydramine" using "Diphenhydramine (2.16.840.1.113883.3.464.1003.196.12.1293)" • "Medication, Order: Diphenhydramine Hydrochloride" using "Diphenhydramine Hydrochloride (2.16.840.1.113883.3.464.1003.196.12.1371)" • "Medication, Order: Dipyridamole" using "Dipyridamole (2.16.840.1.113883.3.464.1003.196.12.1349)" • "Medication, Order: Disopyramide" using "Disopyramide (2.16.840.1.113883.3.464.1003.196.12.1311)" • "Medication, Order: Doxylamine" using "Doxylamine (2.16.840.1.113883.3.464.1003.196.12.1515)" • "Medication, Order: Ergoloid Mesylates" using "Ergoloid Mesylates (2.16.840.1.113883.3.464.1003.196.12.1516)" • "Medication, Order: Esterified Estrogens" using "Esterified Estrogens (2.16.840.1.113883.3.464.1003.196.12.1419)" • "Medication, Order: Estradiol" using "Estradiol (2.16.840.1.113883.3.464.1003.196.12.1365)" • "Medication, Order: Estropipate" using "Estropipate (2.16.840.1.113883.3.464.1003.196.12.1319)" • "Medication, Order: Glyburide" using "Glyburide (2.16.840.1.113883.3.464.1003.196.12.1368)" • "Medication, Order: Guanfacine" using "Guanfacine (2.16.840.1.113883.3.464.1003.196.12.1341)" • "Medication, Order: Hydroxyzine" using "Hydroxyzine (2.16.840.1.113883.3.464.1003.196.12.1374)" • "Medication, Order: Hyoscyamine" using "Hyoscyamine (2.16.840.1.113883.3.464.1003.196.12.1501)" • "Medication, Order: Imipramine" using "Imipramine (2.16.840.1.113883.3.464.1003.196.12.1359)" • "Medication, Order: Indomethacin" using "Indomethacin (2.16.840.1.113883.3.464.1003.196.12.1366)" • "Medication, Order: Isoxsuprine" using "Isoxsuprine (2.16.840.1.113883.3.464.1003.196.12.1422)" • "Medication, Order: Ketorolac Tromethamine" using "Ketorolac Tromethamine (2.16.840.1.113883.3.464.1003.196.12.1364)" • "Medication, Order: List of Single RxNorm Code Concepts for High Risk Drugs for the Elderly" using "List of Single RxNorm Code Concepts for High Risk Drugs for the Elderly (2.16.840.1.113883.3.464.1003.196.12.1272)" • "Medication, Order: Meclizine" using "Meclizine (2.16.840.1.113883.3.464.1003.196.12.1506)" • "Medication, Order: Megestrol" using "Megestrol (2.16.840.1.113883.3.464.1003.196.12.1342)" • "Medication, Order: Meperidine" using "Meperidine (2.16.840.1.113883.3.464.1003.196.12.1351)" • "Medication, Order: Meprobamate" using "Meprobamate (2.16.840.1.113883.3.464.1003.196.12.1284)" • "Medication, Order: Metaxalone" using "Metaxalone (2.16.840.1.113883.3.464.1003.196.12.1358)" • "Medication, Order: Methocarbamol" using "Methocarbamol (2.16.840.1.113883.3.464.1003.196.12.1370)" • "Medication, Order: Methyldopa" using "Methyldopa (2.16.840.1.113883.3.464.1003.196.12.1331)" • "Medication, Order: Nifedipine" using "Nifedipine (2.16.840.1.113883.3.464.1003.196.12.1353)" • "Medication, Order: Nonbenzodiazepine hypnotics" using "Nonbenzodiazepine hypnotics (2.16.840.1.113883.3.464.1003.196.12.1480)" • "Medication, Order: Nortriptyline" using "Nortriptyline (2.16.840.1.113883.3.464.1003.196.12.1507)" • "Medication, Order: Orphenadrine" using "Orphenadrine (2.16.840.1.113883.3.464.1003.196.12.1302)" • "Medication, Order: Paroxetine" using "Paroxetine (2.16.840.1.113883.3.464.1003.196.12.1508)" • "Medication, Order: Pentobarbital" using "Pentobarbital (2.16.840.1.113883.3.464.1003.196.12.1518)" • "Medication, Order: Phenobarbital" using "Phenobarbital (2.16.840.1.113883.3.464.1003.196.12.1348)" • "Medication, Order: Promethazine Hydrochloride" using "Promethazine Hydrochloride (2.16.840.1.113883.3.464.1003.196.12.1367)" • "Medication, Order: Propantheline" using "Propantheline (2.16.840.1.113883.3.464.1003.196.12.1519)" • "Medication, Order: Protriptyline" using "Protriptyline (2.16.840.1.113883.3.464.1003.196.12.1509)" • "Medication, Order: Scopolamine" using "Scopolamine (2.16.840.1.113883.3.464.1003.196.12.1520)" • "Medication, Order: Secobarbital" using "Secobarbital (2.16.840.1.113883.3.464.1003.196.12.1521)" • "Medication, Order: Trihexyphenidyl" using "Trihexyphenidyl (2.16.840.1.113883.3.464.1003.196.12.1334)" • "Medication, Order: Trimipramine" using "Trimipramine (2.16.840.1.113883.3.464.1003.196.12.1285)" • "Medication, Order: Triprolidine" using "Triprolidine (2.16.840.1.113883.3.464.1003.196.12.1408)" • "Patient Characteristic Birthdate: Birth date" using "Birth date (LOINC Code 21112-8)" • "Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity (2.16.840.1.114222.4.11.837)" • "Patient Characteristic Payer: Payer" using "Payer (2.16.840.1.114222.4.11.3591)" • "Patient Characteristic Race: Race" using "Race (2.16.840.1.114222.4.11.836)" • "Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex (2.16.840.1.113762.1.4.1)"

Supplemental Data Elements

SDE Ethnicity

["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

["Patient Characteristic Payer": "Payer"]

SDE Race

["Patient Characteristic Race": "Race"]

SDE Sex

["Patient Characteristic Sex": "ONC Administrative Sex"]

Risk Adjustment Variables

None

Measure Set None Quality ID #277: Sleep Apnea: Severity Assessment at Initial Diagnosis – National Quality Strategy Domain: Effective Clinical Care – Meaningful Measure Area: Management of Chronic Conditions

2021 COLLECTION TYPE: MIPS CLINICAL QUALITY MEASURES (CQMS)

MEASURE TYPE: Process

DESCRIPTION: Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) measured at the time of initial diagnosis

INSTRUCTIONS: This measure is to be submitted a minimum of once per performance period for patients with a diagnosis of sleep apnea seen during the performance period. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

NOTE: Patient encounters for this measure conducted via telehealth (e.g., encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable.

DENOMINATOR: All patients aged 18 years and older with an initial diagnosis of sleep apnea

DENOMINATOR NOTE: Denominator eligible encounters only include those where the initial diagnosis of sleep apnea is present in the medical documentation or it is the MIPS eligible clinician’s first encounter with a patient diagnosed with sleep apnea as represented in the coding below. Denominator Criteria (Eligible Cases): Patients aged ≥ 18 years on date of encounter AND Diagnosis for sleep apnea (ICD-10-CM): G47.30, G47.33 AND Patient encounter during the performance period (CPT): 99202, 99203, 99204, 99205, 99211, 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 AND Encounter corresponds to initial diagnosis of sleep apnea or first contact with sleep apnea diagnosed patient

NUMERATOR:

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 1 of 7 Patients who had an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) measured at the time of initial diagnosis

Definitions: Apnea-Hypopnea Index (AHI) - for polysomnography performed in a sleep lab is defined as (Total Apneas + Hypopneas per hour of sleep); Apnea-Hypopnea Index (AHI) for a home sleep study is defined as (Total Apneas + Hypopneas per hour of monitoring). Respiratory Disturbance Index (RDI) - is defined as (Total Apneas + Hypopneas + Respiratory Effort Related Arousals per hour of sleep).

NUMERATOR NOTE: The quality-data codes below should be used for assessment of a MIPS eligible clinician’s actions either at the time sleep apnea is initially diagnosed or at the initial encounter with a patient previously diagnosed with sleep apnea.

Numerator Options: Performance Met: Apnea hypopnea index (AHI) or respiratory disturbance index (RDI) measured at the time of initial diagnosis (G8842) OR Denominator Exception: Documentation of reason(s) for not measuring an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) at the time of initial diagnosis (e.g., psychiatric disease, dementia, patient declined, financial, insurance coverage, test ordered but not yet completed) (G8843) OR Performance Not Met: Apnea hypopnea index (AHI) or respiratory disturbance index (RDI) not measured at the time of initial diagnosis, reason not given (G8844)

RATIONALE: For patients with obstructive sleep apnea (OSA), the desired outcome of treatment includes the resolution of the clinical signs and symptoms of OSA and the normalization of the apnea hypopnea index (AHI) and oxyhemoglobin saturation. Physicians treating patients with OSA should calculate the patient’s level of severity, which informs risk for other co-morbid conditions and complications. Numerous Level 1 and Level 2 studies have shown that the risk of cardiovascular complications is established for patients with an AHI over 15 (Kushida et al, 2005). Patients with a respiratory disturbance index equal to or greater than 15 are considered to have moderate to severe OSA and should be treated with positive airway pressure therapy

CLINICAL RECOMMENDATION STATEMENTS: Moderate sleep apnea is defined as having an RDI of equal to or greater than 15, but less than 30 episodes per hour of sleep; severe sleep apnea is defined as having an RDI equal to or greater than 30 episodes per hour of sleep. These patients are at higher risk for severe cardiovascular diseases and other co-morbid conditions (Kushida et al, 2006). Polysomnography is indicated for positive airway pressure (PAP) titration in patients with sleep related breathing disorders (Level 1). PSG with CPAP titration is appropriate for patients with any of the following results: a) an RDI of at least 15 per hour, regardless of the patient’s symptoms; b) an RDI of at least 5 per hour in a patient with excessive daytime sleepiness. (Kushida et al, 2005)

COPYRIGHT: The Measure is not a clinical guideline, does not establish a standard of medical care, and has not been tested for all potential applications.

The Measure, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 2 of 7 sale, license, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain.

Neither the AASM, nor its members, shall be responsible for any use of the Measures outside of the AASM registry.

The PCPI’s and AMA’s significant past efforts and contributions to the development and updating of the Measures are acknowledged.

The AASM is solely responsible for the review and enhancement (“Maintenance”) of the Measure as of August 7, 2014.

The AASM encourages use of the Measure by other health care professionals, where appropriate.

THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.

Limited proprietary coding may be contained in the Measure specifications for convenience. A license agreement must be entered prior to a third party’s use of Current Procedural Terminology (CPT ®) or other proprietary code set contained in the Measures. Any other use of CPT or other coding by the third party is strictly prohibited. American Academy of Sleep Medicine and its members disclaim all liability for use or accuracy of any CPT or other coding contained in the specifications.

CPT® contained in the Measures specifications is copyright 2004-2020 American Medical Association. LOINC® copyright 2004-2020 Regenstrief Institute, Inc. SNOMED CLINICAL TERMS (SNOMED CT®) copyright 2004- 2020. The International Health Terminology Standards Development Organisation (IHTSDO). ICD-10 is copyright 2020 World Health Organization. All Rights Reserved.

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 3 of 7 2021 Clinical Quality Measure Flow for Quality ID #277: Sleep Apnea: Severity Assessment at Initial Diagnosis

Disclaimer: Refer to the measure specification for specific coding and instructions to submit this measure.

Denominator Numerator Start

Data Completeness Met + Apnea hypopnea index (AHI) or Performance Met respiratory disturbance index (RDI) Yes G8842 or equivalent measured at the time of initial diagnosis (50 patients) Patient aged a No ≥ 18 years on date of encounter

Yes No

Diagnosis for No sleep apnea as listed in Documentation Denominator* Data Completeness Met + of reason(s) for not measuring Denominator Exception an apnea hypopnea index (AHI) or a Yes G8843 or equivalent respiratory disturbance index (RDI) at the (10 patients) time of initial diagnosis b Not Included in Eligible Yes Population/Denominator

Patient encounter during No No performance period as listed in Denominator*

Yes Apnea hypopnea index (AHI) or Data Completeness Met + respiratory disturbance index (RDI) Performance Not Met Yes not measured at the time of initial G8844 or equivalent diagnosis, reason not given (10 patients) Encounter c corresponds to initial diagnosis of sleep apnea or No first contact with sleep apnea diagnosed patient No

Data Completeness Not Met Yes the Quality Data Code or equivalent was not submitted (10 patients) Include in Eligible Population/Denominator (80 patients) d

SAMPLE CALCULATIONS

Performance Rate= Performance Met (a=50 patients) = 50 patients = 83.33% Data Completeness Numerator (70 patients) – Denominator Exception (b=10 patients) = 60 patients

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 4 of 7 2021 Clinical Quality Measure Flow Narrative for Quality ID #277: Sleep Apnea: Severity Assessment at Initial Diagnosis Disclaimer: Refer to the measure specification for specific coding and instructions to submit this measure.

1. Start with Denominator

2. Check Patient aged greater than or equal to 18 years on date of encounter:

a. If Patient aged greater than or equal to 18 years on date of encounter equals No, do not include in Eligible Population/Denominator. Stop processing.

b. If Patient aged greater than or equal to 18 years on date of encounter equals Yes, proceed to check Diagnosis for sleep apnea as listed in Denominator*.

3. Check Diagnosis for sleep apnea as listed in Denominator*:

a. If Diagnosis for sleep apnea as listed in Denominator* equals No, do not include in Eligible Population/Denominator. Stop processing.

b. If Diagnosis for sleep apnea as listed in Denominator* equals Yes, proceed to check Patient encounter during performance period as listed in Denominator*.

4. Check Patient encounter during performance period as listed in Denominator*:

a. If Patient encounter during performance period as listed in Denominator* equals No, do not include in Eligible Population/Denominator. Stop processing.

b. If Patient encounter during performance period as listed in Denominator* equals Yes, proceed to check Encounter corresponds to initial diagnosis of sleep apnea or first contact with sleep apnea diagnosed patient.

5. Check Encounter corresponds to initial diagnosis of sleep apnea or first contact with sleep apnea diagnosed patient:

a. If Encounter corresponds to initial diagnosis of sleep apnea or first contact with sleep apnea diagnosed patient equals No, do not include in Eligible Population/Denominator. Stop processing.

b. If Encounter corresponds to initial diagnosis of sleep apnea or first contact with sleep apnea diagnosed patient equals Yes, include in Eligible Population/Denominator.

6. Denominator Population:

7. Start Numerator

8. Check Apnea hypopnea index (AHI) or respiratory disturbance index (RDI) measured at the time of initial diagnosis:

a. If Apnea hypopnea index (AHI) or respiratory disturbance index (RDI) measured at the time of initial diagnosis equals Yes, include in Data Completeness Met and Performance Met.

• Data Completeness Met and Performance Met letter is represented in the Data Completeness Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 5 of 7 and Performance Rate in the Sample Calculation listed at the end of this document. Letter a equals 50 patients in the Sample Calculation.

b. If Apnea hypopnea index (AHI) or respiratory disturbance index (RDI) measured at the time of initial diagnosis equals No, proceed to check Documentation of reason(s) for not measuring an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) at the time of initial diagnosis.

9. Check Documentation of reason(s) for not measuring an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) at the time of initial diagnosis:

a. If Documentation of reason(s) for not measuring an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) at the time of initial diagnosis equals Yes, include in Data Completeness Met and Denominator Exception.

b. If Documentation of reason(s) for not measuring an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) at the time of initial diagnosis equals No, proceed to check Apnea hypopnea index (AHI) or respiratory disturbance index (RDI) not measured at the time of initial diagnosis, reason not given.

10. Check Apnea hypopnea index (AHI) or respiratory disturbance index (RDI) not measured at the time of initial diagnosis, reason not given:

a. If Apnea hypopnea index (AHI) or respiratory disturbance index (RDI) not measured at the time of initial diagnosis, reason not given equals Yes, include in Data Completeness Met and Performance Not Met.

b. If Apnea hypopnea index (AHI) or respiratory disturbance index (RDI) not measured at the time of initial diagnosis, reason not given equals No, proceed to check Data Completeness Not Met.

11. Check Data Completeness Not Met:

a. If Data Completeness Not Met, the Quality Data Code or equivalent was not submitted. 10 patients have been subtracted from the Data Completeness Numerator in the Sample Calculation

Sample Calculations:

Data Completeness equals Performance Met (a equals 50 patients) plus Denominator Exception (b equals 10 patients) plus Performance Not Met (c equals 10 patients) divided by Eligible Population/Denominator (d equals 80 patients). All equals 70 patients divided by 80 patients. All equals 87.5 percent.

*See the posted measure specification for specific coding and instructions to submit this measure.

Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 7 of 7 eCQM Title Dementia: Cognitive Assessment eCQM Identifier 149 eCQM Version number 8.0.000 (Measure Authoring Tool)

NQF Number 2872e GUID 7c443b9b-1ad1-4467-b527-defc445701ff

Measurement January 1, 20XX through December 31, 20XX Period

Measure Steward PCPI(R) Foundation (PCPI[R])

Measure American Medical Association (AMA) Developer

Measure PCPI(R) Foundation (PCPI[R]) Developer

Endorsed By National Quality Forum

Description Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period

Disclaimer The Measure is not a clinical guideline, does not establish a standard of medical care, and has not been tested for all potential applications.

The Measure, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain.

Commercial uses of the Measure require a license agreement between the user and the PCPI(R) Foundation (PCPI[R]) or the American Medical Association (AMA). Neither the AMA, nor the former AMA-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI), nor PCPI, nor their members shall be responsible for any use of the Measure.

AMA and PCPI encourage use of the Measure by other health care professionals, where appropriate.

THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.

Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. The AMA, the PCPI and its members and former members of the AMA-PCPI disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT [R]) or other coding contained in the specifications.

CPT(R) contained in the Measure specifications is copyright 2004-2018 American Medical Association. LOINC(R) is copyright 2004-2018 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2018 International Health Terminology Standards Development Organisation. ICD-10 is copyright 2018 World Health Organization. All Rights Reserved.

Due to technical limitations, registered trademarks are indicated by (R) or [R].

Measure Scoring Proportion

Measure Type Process

Stratification None

Risk Adjustment None

Rate None Aggregation

Rationale Dementia is often characterized by the gradual onset and continuing cognitive decline in one or more domains including memory, executive function, language, judgment, and spatial abilities (American Psychiatric Association, 2007). Cognitive deterioration represents a major source of morbidity and mortality and poses a significant burden on affected individuals and their caregivers (National Institutes of Health, 2010). Although cognitive deterioration follows a different course depending on the type of dementia, significant rates of decline have been reported. For example, one study found that the annual rate of decline for Alzheimer's disease patients was more than four times that of older adults with no cognitive impairment (Wilson et al., 2010). Nevertheless, measurable cognitive abilities remain throughout the course of dementia (American Psychiatric Association, 2007). Initial and ongoing assessments of cognition are fundamental to the proper management of patients with dementia. These assessments serve as the basis for identifying treatment goals, developing a treatment plan, monitoring the effects of treatment, and modifying treatment as appropriate.

Clinical Ongoing assessment includes periodic monitoring of the development and evolution of cognitive and noncognitive Recommendation psychiatric symptoms and their response to intervention (Category I). Both cognitive and noncognitive Statement neuropsychiatric and behavioral symptoms of dementia tend to evolve over time, so regular monitoring allows detection of new symptoms and adaptation of treatment strategies to current needs... Cognitive symptoms that almost always require assessment include impairments in memory, executive function, language, judgment, and spatial abilities. It is often helpful to track cognitive status with a structured simple examination (American Psychiatric Association, 2007).

The American Psychiatric Association recommends that patients with dementia be assessed for the type, frequency, severity, pattern, and timing of symptoms (Category 1C). Quantitative measures provide a structured replicable way to document the patient's baseline symptoms and determine which symptoms (if any) should be the target of intervention based on factors such as frequency of occurrence, magnitude, potential for associated harm to the patient or others, and associated distress to the patient. The exact frequency at which measures are warranted will depend on clinical circumstances. However, use of quantitative measures as treatment proceeds allows more precise tracking of whether nonpharmacological and pharmacological treatments are having their intended effect or whether a shift in the treatment plan is needed (American Psychiatric Association, 2016).

Conduct and document an assessment and monitor changes in cognitive status using a reliable and valid instrument, e.g., MoCA (Montreal Cognitive Assessment), AD8 (Ascertian Dementia 8) or other tool. Cognitive status should be reassessed periodically to identify sudden changes, as well as to monitor the potential beneficial or harmful effects of environmental changes (including safety, care needs, and abuse and/or neglect), specific medications (both prescription and non-prescription, for appropriate use and contraindications), or other interventions. Proper assessment requires the use of a standardized, objective instrument that is relatively easy to use, reliable (with less variability between different assessors), and valid (results that would be similar to gold-standard evaluations) (California Department of Public Health, 2017).

Improvement Higher score indicates better quality Notation

Reference American Psychiatric Association. (2007, October). Practice guideline for the treatment of patients with Alzheimer’s disease and other dementias. Arlington, VA: American Psychiatric Association. Reference American Psychiatric Association. (2016). Practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia. Arlington, VA: American Psychiatric Association.

Reference California Department of Public Health. (2017). California guidelines for Alzheimer’s disease management, 2017. Retrieved from https://www.cdph.ca.gov/Programs/CCDPHP/DCDIC/CDCB/CDPH%20Document%20Library/Alzheimers'%20Disease% 20Program/ALZ-CareGuidelines.pdf

Reference National Institutes of Health. (2010). NIH State-of-the-Science Conference: Preventing Alzheimer’s disease and cognitive decline. Retrieved from http://consensus.nih.gov/2010/docs/alz/alz_stmt.pdf

Reference Wilson, R. S., Aggarwal, N. T., Barnes, L. L., et al. (2010, March 23). Cognitive decline in incident Alzheimer disease in a community population. Neurology, 74(12), 951-955.

Definition Cognition can be assessed by the clinician during the patient's clinical history. Cognition can also be assessed by direct examination of the patient using one of a number of instruments, including several originally developed and validated for screening purposes. This can also include, where appropriate, administration to a knowledgeable informant. Examples include, but are not limited to: -Blessed Orientation-Memory-Concentration Test (BOMC) -Montreal Cognitive Assessment (MoCA) -St. Louis University Mental Status Examination (SLUMS) -Mini-Mental State Examination (MMSE) [Note: The MMSE has not been well validated for non-Alzheimer's dementias] -Short Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) -Ascertain Dementia 8 (AD8) Questionnaire -Minimum Data Set (MDS) Brief Interview of Mental Status (BIMS) [Note: Validated for use with nursing home patients only] -Formal neuropsychological evaluation -Mini-Cog

Guidance Use of a standardized tool or instrument to assess cognition other than those listed will meet numerator performance. Standardized tools can be mapped to the concept "Intervention, Performed": "Cognitive Assessment" included in the numerator logic below.

The requirement of two or more visits is to establish that the eligible professional or eligible clinician has an existing relationship with the patient.

The DSM-5 has replaced the term dementia with major neurocognitive disorder and mild neurocognitive disorder. For the purposes of this measure, the terms are equivalent.

Transmission TBD Format

Initial All patients, regardless of age, with a diagnosis of dementia Population

Denominator Equals Initial Population

Denominator None Exclusions

Numerator Patients for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period

Numerator Not Applicable Exclusions

Denominator Documentation of patient reason(s) for not assessing cognition Exceptions

Supplemental For every patient evaluated by this measure also identify payer, race, ethnicity and sex Data Elements

Table of Contents

• Population Criteria • Definitions • Functions • Terminology • Data Criteria (QDM Data Elements) • Supplemental Data Elements • Risk Adjustment Variables

Population Criteria

Initial Population

exists "Dementia Encounter" and ( Count("Qualifying Encounter")>= 2 )

Denominator

"Initial Population"

Denominator Exclusions None Numerator

exists "Assessment of Cognition Using Standardized Tools" or exists "Cognitive Assessment Using Alternate Methods"

Numerator Exclusions None Denominator Exceptions

exists "Patient Reason for Not Performing Assessment of Cognition Using Standardized Tools" or exists "Patient Reason for Not Performing Cognitive Assessment Using Alternate Methods"

Stratification None

Definitions

Assessment of Cognition Using Standardized Tools ["Assessment, Performed": "Standardized Tools for Assessment of Cognition"] CognitiveAssessmentUsingTools with "Dementia Encounter" EncounterDementia such that CognitiveAssessmentUsingTools.authorDatetime 12 months or less on or before day of end of EncounterDementia.relevantPeriod where CognitiveAssessmentUsingTools.result is not null

Cognitive Assessment Using Alternate Methods

["Intervention, Performed": "Cognitive Assessment"] CognitiveAssessment with "Dementia Encounter" EncounterDementia such that CognitiveAssessment.relevantPeriod starts 12 months or less on or before day of end of EncounterDementia.relevantPeriod

Dementia Encounter

"Face to Face Encounter During Measurement Period" ValidFaceToFaceEncounter with ["Diagnosis": "Dementia & Mental Degenerations"] Dementia such that Dementia.prevalencePeriod overlaps ValidFaceToFaceEncounter.relevantPeriod

Denominator

"Initial Population"

Denominator Exceptions

exists "Patient Reason for Not Performing Assessment of Cognition Using Standardized Tools" or exists "Patient Reason for Not Performing Cognitive Assessment Using Alternate Methods"

Face to Face Encounter During Measurement Period

( ["Encounter, Performed": "Psych Visit - Diagnostic Evaluation"] union ["Encounter, Performed": "Nursing Facility Visit"] union ["Encounter, Performed": "Care Services in Long-Term Residential Facility"] union ["Encounter, Performed": "Home Healthcare Services"] union ["Encounter, Performed": "Psych Visit - Psychotherapy"] union ["Encounter, Performed": "Behavioral/Neuropsych Assessment"] union ["Encounter, Performed": "Occupational Therapy Evaluation"] union ["Encounter, Performed": "Office Visit"] union ["Encounter, Performed": "Outpatient Consultation"] ) FaceToFaceEncounter where FaceToFaceEncounter.relevantPeriod during "Measurement Period"

Initial Population

exists "Dementia Encounter" and ( Count("Qualifying Encounter")>= 2 )

Numerator

exists "Assessment of Cognition Using Standardized Tools" or exists "Cognitive Assessment Using Alternate Methods"

Patient Reason for Not Performing Assessment of Cognition Using Standardized Tools

["Assessment, Not Performed": "Standardized Tools for Assessment of Cognition"] NoCognitiveAssessmentUsingTools with "Dementia Encounter" EncounterDementia such that NoCognitiveAssessmentUsingTools.authorDatetime during EncounterDementia.relevantPeriod where NoCognitiveAssessmentUsingTools.negationRationale in "Patient Reason"

Patient Reason for Not Performing Cognitive Assessment Using Alternate Methods

["Intervention, Not Performed": "Cognitive Assessment"] NoCognitiveAssessmentUsingAlternateMethods with "Dementia Encounter" EncounterDementia such that NoCognitiveAssessmentUsingAlternateMethods.authorDatetime during EncounterDementia.relevantPeriod where NoCognitiveAssessmentUsingAlternateMethods.negationRationale in "Patient Reason"

Qualifying Encounter

( ["Encounter, Performed": "Psych Visit - Diagnostic Evaluation"] union ["Encounter, Performed": "Nursing Facility Visit"] union ["Encounter, Performed": "Care Services in Long-Term Residential Facility"] union ["Encounter, Performed": "Home Healthcare Services"] union ["Encounter, Performed": "Patient Provider Interaction"] union ["Encounter, Performed": "Psych Visit - Psychotherapy"] union ["Encounter, Performed": "Behavioral/Neuropsych Assessment"] union ["Encounter, Performed": "Occupational Therapy Evaluation"] union ["Encounter, Performed": "Office Visit"] union ["Encounter, Performed": "Outpatient Consultation"] ) ValidEncounter where ValidEncounter.relevantPeriod during "Measurement Period"

SDE Ethnicity

["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

["Patient Characteristic Payer": "Payer"]

SDE Race

["Patient Characteristic Race": "Race"]

SDE Sex

["Patient Characteristic Sex": "ONC Administrative Sex"]

Functions

None

Terminology

• valueset "Behavioral/Neuropsych Assessment" (2.16.840.1.113883.3.526.3.1023) • valueset "Care Services in Long-Term Residential Facility" (2.16.840.1.113883.3.464.1003.101.12.1014) • valueset "Cognitive Assessment" (2.16.840.1.113883.3.526.3.1332) • valueset "Dementia & Mental Degenerations" (2.16.840.1.113883.3.526.3.1005) • valueset "Ethnicity" (2.16.840.1.114222.4.11.837) • valueset "Home Healthcare Services" (2.16.840.1.113883.3.464.1003.101.12.1016) • valueset "Nursing Facility Visit" (2.16.840.1.113883.3.464.1003.101.12.1012) • valueset "Occupational Therapy Evaluation" (2.16.840.1.113883.3.526.3.1011) • valueset "Office Visit" (2.16.840.1.113883.3.464.1003.101.12.1001) • valueset "ONC Administrative Sex" (2.16.840.1.113762.1.4.1) • valueset "Outpatient Consultation" (2.16.840.1.113883.3.464.1003.101.12.1008) • valueset "Patient Provider Interaction" (2.16.840.1.113883.3.526.3.1012) • valueset "Patient Reason" (2.16.840.1.113883.3.526.3.1008) • valueset "Payer" (2.16.840.1.114222.4.11.3591) • valueset "Psych Visit - Diagnostic Evaluation" (2.16.840.1.113883.3.526.3.1492) • valueset "Psych Visit - Psychotherapy" (2.16.840.1.113883.3.526.3.1496) • valueset "Race" (2.16.840.1.114222.4.11.836) • valueset "Standardized Tools for Assessment of Cognition" (2.16.840.1.113883.3.526.3.1006)

Data Criteria (QDM Data Elements)

• "Assessment, Not Performed: Standardized Tools for Assessment of Cognition" using "Standardized Tools for Assessment of Cognition (2.16.840.1.113883.3.526.3.1006)" • "Assessment, Performed: Standardized Tools for Assessment of Cognition" using "Standardized Tools for Assessment of Cognition (2.16.840.1.113883.3.526.3.1006)" • "Diagnosis: Dementia & Mental Degenerations" using "Dementia & Mental Degenerations (2.16.840.1.113883.3.526.3.1005)" • "Encounter, Performed: Behavioral/Neuropsych Assessment" using "Behavioral/Neuropsych Assessment (2.16.840.1.113883.3.526.3.1023)" • "Encounter, Performed: Care Services in Long-Term Residential Facility" using "Care Services in Long-Term Residential Facility (2.16.840.1.113883.3.464.1003.101.12.1014)" • "Encounter, Performed: Home Healthcare Services" using "Home Healthcare Services (2.16.840.1.113883.3.464.1003.101.12.1016)" • "Encounter, Performed: Nursing Facility Visit" using "Nursing Facility Visit (2.16.840.1.113883.3.464.1003.101.12.1012)" • "Encounter, Performed: Occupational Therapy Evaluation" using "Occupational Therapy Evaluation (2.16.840.1.113883.3.526.3.1011)" • "Encounter, Performed: Office Visit" using "Office Visit (2.16.840.1.113883.3.464.1003.101.12.1001)" • "Encounter, Performed: Outpatient Consultation" using "Outpatient Consultation (2.16.840.1.113883.3.464.1003.101.12.1008)" • "Encounter, Performed: Patient Provider Interaction" using "Patient Provider Interaction (2.16.840.1.113883.3.526.3.1012)" • "Encounter, Performed: Psych Visit - Diagnostic Evaluation" using "Psych Visit - Diagnostic Evaluation (2.16.840.1.113883.3.526.3.1492)" • "Encounter, Performed: Psych Visit - Psychotherapy" using "Psych Visit - Psychotherapy (2.16.840.1.113883.3.526.3.1496)" • "Intervention, Not Performed: Cognitive Assessment" using "Cognitive Assessment (2.16.840.1.113883.3.526.3.1332)" • "Intervention, Performed: Cognitive Assessment" using "Cognitive Assessment (2.16.840.1.113883.3.526.3.1332)" • "Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity (2.16.840.1.114222.4.11.837)" • "Patient Characteristic Payer: Payer" using "Payer (2.16.840.1.114222.4.11.3591)" • "Patient Characteristic Race: Race" using "Race (2.16.840.1.114222.4.11.836)" • "Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex (2.16.840.1.113762.1.4.1)"

Supplemental Data Elements

SDE Ethnicity

["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

["Patient Characteristic Payer": "Payer"]

SDE Race

["Patient Characteristic Race": "Race"]

SDE Sex

["Patient Characteristic Sex": "ONC Administrative Sex"]

Risk Adjustment Variables

None

Measure Set None Measure Title Patient reported falls and plan of care Description Percentage of patients (or caregivers as appropriate) with an active diagnosis of a movement disorder, multiple sclerosis, a neuromuscular disorder, dementia, or stroke who reported a fall occurred and those that fell had a plan of care for falls documented at every visit Measurement January 1, 20xx to December 31, 20xx Period Eligible Eligible Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant (PA), Population Providers Advanced Practice Registered Nurse (APRN) Care Setting(s) Outpatient Ages All ages Event Office visit Diagnosis Movement disorder, MS, neuromuscular disorder, dementia, hemiplegic migraine, stroke Denominator Patients with an active^ diagnosis of a movement disorder, multiple sclerosis, a neuromuscular disorder, dementia, or stroke

^Active means the diagnosis has to be coded or billed for on the date of service, not just a diagnosis on the historical problem list.

NOTE: See coding table below for full list of conditions included Numerator A. Patients (or caregivers as appropriate) that reported a fall* occurred since the last visit

B. and those that fell had a plan of care^ for falls documented at every visit

*Fall: A sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, or the ground, other than as a consequence of sudden onset of paralysis, epileptic seizure, overwhelming external force, or overwhelming environmental hazards

^Plan of care must include  Balance, strength, or gait training OR  Referral to physical or occupational therapy OR  Home safety evaluation Required None Exclusions Allowable Patients diagnosed with any of the following disorders: Exclusions  Syncope  Vertigo and related disorders  Restless leg syndrome  Tourette syndrome/tic disorder  Back pain  Concussion/mTBI  Cervical dystonia  Epilepsy Exclusion Patients with syncope, concussion, or epilepsy may experience falls during the course of their Rationale disease. However, they have been excluded from this measure as patients with syncope or concussion may not experience falls. If they do, it is usually a limited time and the plan of care for would be different than balance, strength and gait training. The same is true for patients with epilepsy. A plan of care would include different components than what is recommended in this measure. RLS, Tourette syndrome/Tic disorder, primary headache, back pain, and cervical dystonia have been excluded as they are captured in the large buckets of disorders in the measure denominator but it may not always be appropriate to screen for falls and develop a plan of care for these specific patients. Measure Percentage Scoring Interpretation A. Lower score indicates better quality of Score B. Higher score indicates better quality Measure Type Patient reported outcome Level of Provider Measurement Risk TBD Adjustment For Process Measures Relationship to Desired Outcome Process Outcomes •Patients that have a plan of •Patients report a fall care documented occured

Opportunity to Many studies have been conducted on the rate of falls for common neurological conditions. All of Improve Gap them indicate that falls are an issue for neurology patients with symptomology that affects 1-21 in Care movement and balance . Falls and the fear of falling can impact quality of life and should be addressed for populations most at risk for falling.

In people age 65 years and older, falls are one of the leading causes of death22,23. However, patients with neurological conditions are often younger and are at an increased risk for falls due to disease symptomology. 127,456,106 non-fatal falls were recorded from 2001 to 201524. For those that were hospitalized due to the fall, the cost is approximately $39,000 per patient24.

The U.S. Preventive Services Task Force updated their recommendations for fall prevention in community-dwelling older adults. There are many intervention recommendations for patients 65 years and older.23 Harmonization There are many measures available to assess risk and future risk and create plans of care. The AAN with Existing has created this measure to combine separate measures that were developed for individual disease Measures states. This consolidated measure is meant to incorporate individuals that are younger and have rarer diseases that may never have a measure developed. References and 1. Hayes S, Galvin R, Kennedy C, et al. Interventions for preventing falls in people with Supporting multiple sclerosis. Cochrane Database of Systematic Reviews 2019; Issue 11. Evidence 2. Mackintosh SF, Hill KD, Dodd KJ, Goldie PA, Culham EG. Balance score and a history of falls in hospital predict recurrent falls in the 6 months following stroke rehabilitation. Arch Phys Med Rehabil. 2006;87:1583–9. 3. Kerse N, Parag V, Feigin VL, McNaughton H, Hackett ML, Bennett DA, Anderson CS. Falls after stroke: results from the Auckland regional community stroke (ARCOS) study, 2002 to 2003. Stroke. 2008;39:1890–3 4. Forster A, Young J. Incidence and consequences of falls due to stroke: a systematic inquiry. BMJ. 1995;311:83 5. Jørgensen L, Engstad T, Jacobsen BK. Higher incidence of falls in long-term stroke survivors than in population controls: depressive symptoms predict falls after stroke. Stroke. 2002;33:542–7. 6. Mackintosh SFH, Goldie P, Hill K. Falls incidence and factors associated with falling in older, community-dwelling, chronic stroke survivors (>1 year after stroke) and matched controls. Aging Clin Exp Res. 2005;17:74–81. 7. Kristensen J, Birn I, Mechlenburg I. Fractures after stroke – A Danish register-based study of 106,001 patients. Acta Neurol Scand 2020; 141:47-55. 8. Bloem, B.R.; Grimbergeb, Y.A.M.; Cramer, M.; Willemsen, M.; Zwinderman, A.H. Prospective assessment of falls in Parkinson’s disease. J. Neurol 2001; 248: 950–958. 9. Paul, S.S.; Sherrington, C.; Canning, C.G.; Fung, V.S.C.; Close, J.C.; Lord, S.R. The relative contribution of physical and cognitive fall risk factors in people with Parkinson’s disease: A large prospective cohort study. Neurorehabilit. Neural Repair 2014; 28: 282– 290. 10. Allen, N.E.; Schwarzel, A.K.; Canning, C.G. Recurrent falls in Parkinson’s disease: A systematic review. Parkinsons Dis. 2013; 2013: 906274. 11. Grimbergen YAM, Knol MJ, Bloem BR, et al. Falls and gait disturbances in Huntington’s disease. Mov Disord 2008; 23:970-976. 12. Hanewinckel R, Drenthen J, Verlinden VJA, et al. Polyneuropathy relates to impairment in daily activities, worse gait, and fall-related injuries. Neurology 2017; 89:76-83. 13. Schell WE, Mar VS, Da Silva CP. Correlation of falls in patients with Amyotrophic Lateral Sclerosis with objective measures of balance, strength, and spasticity. NeuroRehabilitation 2019; 44:85-93. 14. Hammaren E, Kjellby-Wendt G, Lindberg C. Muscle force, balance and falls in muscular impaired individuals with myotonic dystrophy type 1: a five-year prospective cohort study. Neuromuscul Disord 2015; 25: 141-8. 15. Matsuda PN, Verrall AM, Finlayson ML, Molton IR, Jensen MP. Falls among adults aging with disability. Arch Phys Med Rehabil 2015; 96:464-71. 16. Hiscock A, Dewar L, Parton M, Machado P, Hanna M, Ramdharry G. Frequency and circumstances of falls in people with inclusion body myositis: a questionnaire survey to explore falls management and physiotherapy provision. Physiotherapy 2014; 100:61-5. 17. Montes J, McIsaac TL, Dunaway S, et al. Falls and spinal muscular atrophy: exploring cause and prevention. Muscle Nerve 2013; 47:118-23. 18. Pieterse AJ, Luttikhold TB, de Laat K, Bloem BR, van Engelen BG, Munneke M. Falls in patients with neuromuscular disorders. J Neurol Sci 2006; 251:87-90. 19. Borges Sde M, Radanovic M, Forlenza OV. Fear of falling and falls in older adults with mild cognitive impairment and Alzheimer’s disease. Neuropsychol Dev Cogn B Aging Neuropsychol Cogn 2015; 22:312-21. 20. Ansai JH, Andrade LP, Nakagawa TH, Rebelatto JR. Performances on the timed up and go test and subtasks between fallers and non-fallers in older adults with cognitive impairment. Arq Neurosiquitr 2018; 76:381-386. 21. Carvalho GF, Almeida CS, Florencio LL, et al. Do patients with migraine experience an increased prevalence of falls and fear of falling? A cross-sectional study. Physiotherapy 2018; 104:424-429. 22. National Committee for Quality Assurance (NCQA) http://www.ncqa.org/report-cards/health-plans/state-of-health-care-quality/2016-table-of- contents/fall-risk 23. US Preventive Services Task Force. Interventions to Prevent Falls in Community-Dwelling Older Adults. JAMA 2018; 319:1696-1704. 24. Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. Available at: http://www.cdc.gov/ncipc/wisqars/

Movement disorders: Parkinson’s disease, ataxia, chorea, Huntington’s disease, multiple system atrophy, myoclonus, Progressive supranuclear palsy, tardive dyskinesia, Wilson’s disease, corticobasal degeneration syndrome, CP/spasticity Multiple sclerosis Neuromuscular: ALS, botulism, congenital myasthenic syndromes, congenital myopathies, inclusion body myositis, Lambert-Eaton syndrome, Motor neuron disease, mitochondrial myopathy, Muscular dystrophy, Myasthenia gravis, Peripheral neuropathy, Polymyositis Dementia: Alzheimer’s and mild cognitive impairment

Fatigue Screening and Follow-Up for Patients with Multiple Sclerosis (MS) Measure Title Fatigue Screening and Follow-Up for Patients with MS Description Percentage of patients 18 years and older with diagnosis of MS who were screened for fatigue in past 12 months, and if screening positive were provided appropriate follow-up.

Measurement January 1, 20xx to December 31, 20xx Period Eligible Eligible Providers Medical Doctor (MD), Doctor of Osteopathy (DO), Pharmacist (PharmD), Population Physician Assistant (PA), Advanced Practice Registered Nurse (APRN), Physical Therapy (PT), Occupational Therapy (OT) Care Setting(s) Outpatient Care Ages 18 and older Event Office or telehealth encounter Diagnosis Multiple Sclerosis Denominator Patients 18 years and older with a diagnosis of MS. Numerator Patients with MS who were screened* for fatigue in past 12 months, and if screening positive were provided appropriate follow-up.**

Definitions *Screened is defined as use of one of the following validated fatigue rating instruments: x the Fatigue Severity Scale (FSS)1-3 or x Modified Fatigue Impact Scale4 or x Shortened Modified Fatigue Impact Scale5 **Follow-up for this measure is defined as adjustment to the treatment plan, adjustment or initiation of appropriate medication, further testing, referral to PT/OT, exercise program, lifestyle modification program, or referral to an appropriate healthcare provider. Required None Exclusions Allowable x Patients unable to complete a fatigue screening on date of encounter Exclusions x Patient declines to complete a fatigue screening on date of encounter

Allowable Allowable exclusions can only help measure performance. If a patient has an allowable Exclusion exclusion but is found to meet the numerator that patient is included in the count to meet the Inclusion Logic measure. Exclusion x Fatigue is a subjective symptom that requires patient cooperation to assess. Rationale Measure Scoring Percentage Interpretation of Higher Score Indicates Better Quality Score Measure Type Process Level of Provider Measurement Risk Adjustment Not Applicable Opportunity to Fatigue occurs in about 80% of patients with MS reducing physical activity and level of daily Improve Gap in functioning.6 It is anticipated that by addressing fatigue, quality of life will improve as Care individuals have decreased fatigue and increased ability to function at work and home. For Process The desired outcome is to reduce or eliminate fatigue in MS patients. The measure will provide Measures an incentive for providers to identify and manage fatigue in MS patients. Relationship to Desired Outcome The following evidence statements are quoted verbatim from the referenced clinical guidelines:

x “Assess and offer treatment to people with MS who have fatigue for anxiety, depression, difficulty in sleeping, and any potential medical problems such as anaemia or thyroid disease.”7 x “Explain that MS-related fatigue may be precipitated by heat, overexertion and stress or may be related to the time of day.”7 x “Advise people that aerobic, balance and stretching exercises including yoga may be helpful in treating MS-related fatigue.”7

Intermediate Outcome Outcome Process Fatigue symptoms Reduction of fatigue Fatigue screening identified symptoms completed Treatment initiated for Improved quality of life fatigue symptoms

Harmonization There are currently no other comparable fatigue measures in national measurement programs or with Existing endorsed by the National Quality Forum. Measures References 1 Krupp LB, LaRocca NG, Nuir-Nash J, et al. The Fatigue Severity Scale: Application to Patients with Multiple Sclerosis and Systemic Lupus Erythematosus. Arch Neurol. 1989;46(10):1121-1123. 2 Christodoulou C, MacAllister WS, Krupp LB: Psychiatry for Neurologists: Fatigue 295-306 Philadelphia: Elsevier Science; 2003. 3 Schwartz JE, Jandorf L, Krupp LB. The measurement of fatigue: A new instrument. Journal of Psychosomatic Research 1993; 37(7):753-762. 4 Fisk JD, Pontefract A, Ritvo PG, Archibald CJ, Murray TJ. The impact of fatigue on patients with multiple sclerosis. Can J Neurol Sci 1994; 21: 9-14. 5 Ritvo PG, Fischer JS, Miller DM, et al. Multiple Sclerosis Quality of Life Inventory (MSQLI): A User’s Manual. New York: The Consortium of Multiple Sclerosis Centers Health Services Research Subcommittee, National Multiple Sclerosis Society, New York, 1997. 6 Meads DM, Doward LC, McKenna SP, et al. The development and validation of the Unidimensional Fatigue Impact Scale (U-FIS). Multiple Sclerosis 2009; 15(10):1228-1238. 7 National Clinical Guideline Centre (NICE) (UK). Multiple Sclerosis: Management of Multiple Sclerosis in Primary and Secondary Care. London: National Institute for Health and Care Excellence; 2014 Oct. 2019 update available at: https://www.nice.org.uk/guidance/cg186 Accessed on March 5, 2020.

Flow Chart Diagram: Fatigue Screening and Follow-Up for Patients with MS Did the patient have at least one new or established visit with an eligible provider No during the measurement period? Patient NOT Yes Included in Was patient 18 years or older on the date Eligible of the visit? No Population Yes Did patient have a MS diagnosis on the

date of the visit? No Yes

Patient INCLUDED in Eligible Population

On date of encounter, did patient decline Remove from or refuse fatigue screening? Yes denominator*

No *Do not remove/exclude if patient meets the On date of encounter, was patient unable numerator to complete fatigue screening? Yes

Patient INCLUDED in Was patient screened for fatigue in past 12 Denominator months, and if screening positive were provided appropriate follow-up?

Yes No

Patient did Patient met NOT meet numerator numerator criteria criteria

Bladder, Bowel, and Sexual Dysfunction Screening and Follow-Up for Patients with Multiple Sclerosis (MS) Measure Title Bladder, Bowel, and Sexual Dysfunction Screening and Follow-Up for Patients with MS Description Percentage of patients with MS who were screened for at least one of three symptoms: bladder, bowel, or sexual dysfunction in the past 12 months, and if screening positive for any one of these symptoms had appropriate follow-up care. Measurement January 1, 20xx to December 31, 20xx Period Eligible Eligible Providers Medical Doctor (MD), Doctor of Osteopathy (DO), Pharmacist (PharmD), Population Physician Assistant (PA), Advanced Practice Registered Nurse (APRN), Physical Therapy (PT), Occupational Therapy (OT) Care Setting(s) Outpatient Care Ages Any Event Office or telehealth encounter Diagnosis Multiple Sclerosis Denominator Patients with a diagnosis of MS.

Numerator Patients with MS who were screened* for at least one of three symptoms: bladder, bowel, or sexual dysfunction in the past 12 months, and if screening positive had appropriate follow-up** care.

Definitions: * Screened is defined as an assessment of symptoms. **Appropriate follow-up is defined as adjustment to the treatment plan, adjustment or initiation of appropriate medication, further testing, counseling on lifestyle changes, or referral to an appropriate healthcare provider. Required None Exclusions Allowable x Patient refuses or patient declines on date of encounter Exclusions Allowable Allowable exclusions can only help measure performance. If a patient has an allowable Exclusion exclusion but is found to meet the numerator that patient is included in the count to meet the Inclusion Logic measure. Exclusion x Patients need to be willing to complete the screening for the screening to be valid. Rationale Measure Scoring Percentage Interpretation of Higher Score Indicates Better Quality Score Measure Type Process Level of Provider Measurement Risk Adjustment Not Applicable Opportunity to 2010 North American Research Committee on Multiple Sclerosis (NARCOMS) Registry data Improve Gap in indicated that 91% of 9,341 patients with MS responding were mildly, moderately, or severely Care bothered by bladder, bowel, or sexual symptoms.1 Between 50 to 90% of men with MS and 40 to 80% of women with MS experience sexual dysfunction which is significantly more than in general population2. Sexual dysfunction symptoms are often overlooked in clinical evaluations of patients with MS.2 Schairer, et al., found that sexual dysfunction has a larger detrimental impact on the mental health of health-related quality of life for patients with MS than physical disability.3

For this first iteration of the measure a broad definition of screening was provided; clinicians may use a validated instrument. The work group notes these instruments are not widely used in practice. The measure may be updated in future reviews, to detail specific instruments as they become more widely used in practice. For Process By screening annually for bladder, bowel, and sexual dysfunction, clinicians will be able to Measures identify patients needing appropriate treatment to address these issues, leading to improved Relationship to outcomes and better quality of life. Desired Outcome Following evidence statements are quoted verbatim from the referenced clinical guidelines or :

x “Ensure all people with MS have a comprehensive review of all aspects of their care at least once a year.”4 x “Tailor the comprehensive review to the needs of the person with MS assessing: o …bladder, bowel, and sexual function…”4 x “Refer any issues identified during the comprehensive review of the person with MS to members of the MS multidisciplinary team and other appropriate teams so that they can be managed.”4 x “When assessing lower urinary tract dysfunction in a person with neurological disease, take a clinical history, including information about: o urinary tract symptoms o neurological symptoms and diagnosis (if known) o clinical course of the neurological disease o bowel symptoms o sexual function o comorbidities o use of prescription and other medication and therapies.”5 x “Refer people for urgent investigation if they have any of the following ‘red flag’ signs and symptoms: o haematuria o recurrent urinary tract infections (for example, three or more infections in the last 6 months) o loin pain o recurrent catheter blockages (for example, catheters blocking within 6 weeks of being changed) o hydronephrosis or kidney stones on imaging o biochemical evidence of renal deterioration.” 5 o “Be aware that unexplained changes in neurological symptoms (for example, confusion or worsening spasticity) can be caused by urinary tract disease, and consider further urinary tract investigation and treatment if this is suspected.” 4 x “Consider pelvic floor muscle training for people with: lower urinary tract dysfunction due to multiple sclerosis….”5

Fletcher, et al., state, “All MS patients should be specifically queried about sexual function.”6 Further, they noted, “A variety of factors, including MS related disease activity, MS symptoms, depression & effects of pharmacologic therapy can contribute to sexual dysfunction in patients with MS.”6

Intermediate Outcome Outcome Process Treatment of bladder, Improved quality of life bowel, or sexual Reduction or Screening completed dysfunction symptoms elimination of bladder, Reduction of secondary bowel, and sexual complications dysfunction symptoms

Harmonization No known similar measures with Existing Measures References 1. Wang G, Marrie RA, Fox RJ, et al. Treatment satisfaction and bothersome bladder, bowel, sexual symptoms in multiple sclerosis. Multiple Sclerosis and Related Disorders. 2018; 20: 16-21. 2. Pöttgen J, Rose A, van de Vis W, et al. Sexual dysfunctions in MS in relation to neuropsychiatric aspects and its psychological treatment: A scoping review. PLoS One. 2018;13(2):e0193381. 3. Schairer LC, Foley FW, Zemon V, et al. The impact of sexual dysfunction on health- related quality of life in people with multiple sclerosis. Multiple Sclerosis. 2014; 20(5):610-616. 4. National Clinical Guideline Centre (NICE) (UK). Multiple Sclerosis: Management of Multiple Sclerosis in Primary and Secondary Care. London: National Institute for Health and Care Excellence; 2014 Oct. 2019 update available at: https://www.nice.org.uk/guidance/cg186 Accessed on March 5, 2020. 5. National Clinical Guideline Centre (NICE) (UK). Urinary incontinence in neurological disease: assessment and management. London: National Institute for Health and Care Excellence; 2012 Aug. Available at: https:/www.nice.org.uk/guidance/cg148 Accessed on March 5, 2020. 6. Fletcher SG, Castro-Borrero W, Remington G, et al. Sexual dysfunction in patients with multiple sclerosis: a multidisciplinary approach to evaluation and management. Nature Clinical Practice Urology. 2009; 6: 96-107.

Flow Chart Diagram: Bladder, Bowel, and Sexual Dysfunction Screening and Follow-Up for Patients with MS

Did the patient have at least one new or established visit with an eligible provider Patient NOT during the measurement period? Included in No Eligible Yes Population

Did patient have a MS diagnosis on the date No of the visit?

Yes

Patient INCLUDED in Eligible Population

Remove from denominator* On date of encounter, did patient decline or refuse screening? *Do not remove/exclude Yes if patient meets the numerator No

Patient INCLUDED in Denominator

On date of the encounter, was patient screened for bladder, bowel, or sexual dysfunction, and if screen positive, had appropriate follow-up care?

Yes No

Patient did Patient met NOT meet numerator numerator criteria criteria

29 ©2020. American Academy of Neurology Institute. All Rights Reserved. CPT Copyright 2004-2020 American Medical Association. Measure Title Migraine preventive therapy management Description Percentage of patients aged 6 years and older with a diagnosis of migraine whose migraine frequency is > 6 days per month/4 attacks per month who were managed with an evidence-based preventive migraine therapy, including therapies prescribed by another clinician. Measurement January 1, 20xx to December 31, 20xx Period Eligible Eligible Providers Medical Doctor (MD), Doctor of Osteopathy (DO), Advanced Practice Population Provider (APP), Advanced Practice Registered Nurse (APRN) Care Setting(s) Outpatient Ages > 6 years of age Event Office visit Diagnosis Migraine Denominator Patients > 6 years of age diagnosed with migraine Numerator Patients whose migraine frequency is > 6 days per month/4 attacks per month who were managed with an evidence-based preventive migraine therapy^, including therapies prescribed by another clinician once during the measurement period

^Preventive migraine therapies can be at least one of the following: • Medication prescribed or recommended, or • Procedure ordered, performed, or referred, or • Device prescribed, or • Counseled on or referred to biobehavioral therapy, or • Counseled on the use of nutraceuticals, or • Counseled on evidence-based complementary and integrative strategies, or • Referral to neurology or headache specialist Required • Patient migraine frequency < 6 days per month or < 4 attacks per month Exclusions Allowable • Patient and/or caregiver decline therapies Exclusions For data collection via a clinical registry, we suggest using the following key phrases for capturing exclusions. These key phrases should be recorded on the encounter date: • “Patient declines therapies” • “Caregiver declines therapies” • “Patient and/or caregiver decline therapies” • “Migraine frequency < 6 days per month” • “Migraine frequency < 4 attacks per month” Exclusion Patients and their caregivers have the right to refuse a service. Patients with low frequency Rationale migraine should be excluded from this measure as it may not be appropriate for them to receive preventive therapies. Measure Scoring Percentage Interpretation of Higher score indicates better quality Score Measure Type Process Level of Provider Measurement Risk Adjustment Not applicable For Process It is anticipated that by prescribing preventive therapy there would be a reduction in frequency Measures and duration if therapy is successful for the patient. Relationship to Desired Outcome Process Intermediate Outcomes Outcomes •Preventive therapy •Patient adherence to •Reduction of migraine prescribed treatment plan frequency and duration •Improved quality of life

Opportunity to Epidemiologic studies suggest approximately 38% of people with headache need preventive Improve Gap in therapy, but only 3%–13% currently use it.1 Preventive therapies can decrease the occurrence of Care migraine attacks and reduce the severity and duration of migraine attacks that do occur. The American Migraine Prevalence and Prevention (AMPP) study found that approximately 12% of Americans have migraines and approximately 40% could benefit from preventative therapies.1

The Work Group discussed how to address use of diet and exercise changes prior to use of a preventive therapy. The Work Group agreed that patients that decline a preventive therapy in favor of diet and exercise changes would meet the allowable exclusion of “patient declines.” Use of the allowable exclusion will be monitored during future reviews to ensure there are no unintended consequences. A separate measure on lifestyle modifications can be found earlier in the measures document. Harmonization The Institute for Clinical Systems Improvement (ICSI) has a measure for the percentage of with Existing patients with primary headache syndrome who are prescribed prophylactic treatment when Measures appropriate (12 years and up). This measure focuses on patients aged 6 years and older and it also incorporates many different treatment modalities. References 1. Lipton RB, Bigal ME, Diamond M, et al. The American Migraine Prevalence and Prevention Advisory Group. Migraine Prevalence, disease burden, and the need for preventive therapy. Neurology 2017; 68:343-349.

Supporting evidence • Becker W, Findlay T, Moga C, et al. Guideline for primary care management of headache in adults. Canadian Family Physicians 2015; 61:670-679. • Pellegrino A, Davis-Martin R, Houle T, et al. Perceived triggers of primary headache disorders: A meta-analysis. Cephalalgia 2018; 38:1188-1198. • Silberstein SD, Holland S, Feitag F, et al. Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 2012; 78: 1337-1345. • Holland S, Silberstein SD, Feitag F, et al. Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 2012; 78:1346-1353. • Pringsheim T, Davenport W, Mackie G, et al. Candaian Headache Society guideline for migraine prophylaxis. Can J Neurol Sci 2012; 39:S1-59. • Carville S, Padhi S. Rason T, et al. Diagnosis and management of headaches in young people and adults: summary of NICE guidance. BMJ 2012; 345:e5765. • Loder E, Burch R, Rizzoli P. The 2012 AHS/AAN guidelines for prevention of episodic migraine: a summary and comparison with other recent clinical practice guidelines. Headache 2012; 52:930-45. • EFNS guideline on the treatment of migraine – revised report of an EFNS task force. Evers S, Afra J, Frese A, et al. Eur J Neurol 2009; 16:968-981. • Ramadan N, Silberstein S, Freitag F, et al. Evidence-based guidelines for migraine headache in the primary care setting: Pharmacological management for prevention of migraine. • Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of headache in adults Guideline 107. 2008. • NICE Headache: Diagnosis and management of headaches in young people and adults. National Clinical Guideline Centre on behalf of the National Institute for Health and Clinical Excellent (NICE). September 2012; NICE clinical guideline 150. • Harris P, Loveman E, Clegg A, et al. Systematic review of cognitive behavioral therapy for the management of headaches and migraines in adults. British Journal of Pain 2015; 9:213-224. • Hepp Z, Bloudek L, Varon S. Systematic review of migraine prophylaxis adherence and persistence. JMCP 2014; 20:22-33. • Oskoui M, Pringsheim T, Holler-Managan Y, et al. Practice guideline update summary: Acute treatment of migraine in children and adolescents: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 2019; Epub ahead of print. • Oskoui M, Pringsheim T, Billinghurst L, et al. Practice guideline update summary: Pharmacologic treatment for pediatric migraine prevention. Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 2019; Epub ahead of print. • Becker W, Findlay T, Moga C, et al. Guideline for primary care management of headache in adults. Canadian Family Physicians 2015; 61:670-679. • Robberstad L, Dyb G, Hagen K, Stovner LJ, Holmen TL, Zwart JA. An unfavorable lifestyle and recurrent headaches among adolescents: the HUNT study. Neurology 2010; 75. • Pellegrino A, Davis-Martin R, Houle T, et al. Perceived triggers of primary headache disorders: A meta-analysis. Cephalalgia 2018; 38:1188-1198. • Lipton RB, Diamond M, Freitag F, et al. Migraine prevention patterns in a community sample: results from the American migraine prevalence and prevention (AMPP) study. Headache 2005; 45:792-793.

Chart Diagram: Preventive Therapy Prescribed

Was patient 6 years or older during the measurement period? Patient NOT No Included in Yes Eligible Population

Did the patient have at least one new or established patient visit with an eligible No provider during the measurement period?

Yes

Did patient have a diagnosis of migraine during the measurement period? No

Yes

Patient INCLUDED in Eligible Population

On the date of the encounter, was patient migraine frequency <6 days per month or <4 attacks per month?

No or N/A Remove from denominator* On the date of the encounter, did patient and/or caregiver decline therapies? *Do not remove/exclude if Yes patient meets the numerator No or N/A

During the measurement period, was patient managed with an evidence-based preventive Patient migraine therapy, including therapies prescribed INCLUDED in by another clinician? Denominator Yes No

Patient did Patient met NOT meet numerator numerator criteria criteria Measure Title Acute treatment prescribed for cluster headache

**This is a paired measure. Recommend that this measure is used in conjunction with “Preventive Treatment Prescribed for Cluster Headache” on page 39** Description Percentage of patients > 18 years of age with a diagnosis of cluster headache (CH) who were prescribed an acute treatment, including treatments prescribed by a different clinician. Measurement January 1, 20xx to December 31, 20xx Period Eligible Eligible Providers Medical Doctor (MD), Doctor of Osteopathy (DO), Advanced Practice Population Provider (APP), Advanced Practice Registered Nurse (APRN) Care Setting(s) Outpatient Ages > 18 years of age Event Patient had an office visit or E/M services performed or supervised by an eligible provider. Diagnosis Cluster headache Denominator Patients > 18 years of age with a diagnosis of cluster headache Numerator Patients who were prescribed an acute treatment^, including treatments prescribed by a different clinician once during the measurement period

^Acute treatments include, but are not limited to, the following: oxygen 100%, sumatriptan SC, sumatriptan IN, zolmitriptan IN, DHE (IV, IM, SC, IN), external vagus nerve stimulation, Sphenopalatine ganglion (SPG) stimulation device*1,2,3

*Availability in U.S. may be limited

Note: The above list of medications/treatment names is based on clinical guidelines and other evidence and may not be all-inclusive or current. Physicians and other health care professionals should refer to the Food and Drug Administration’s (FDA) web site page entitled “Drug Safety Communications” for up-to-date drug recall and alert information when prescribing medications. Some treatments are not available in all care settings. Required None Exclusions Allowable • Guideline recommended treatment is medically contraindicated or ineffective for the Exclusions patient. (This allowable exclusion allows for documentation to occur any time in the patient record) • Patient reports no CH attacks within the past 12 months or is not in an active attack period. (This allowable exclusion must be documented in the measurement period) • CH are sufficiently controlled with over the counter [OTC] medications. (This allowable exclusion must be documented on the date of the encounter) • Patient and/or caregiver decline therapy. (This allowable exclusion must be documented on the date of the encounter) • Lack of insurance or insurance coverage for treatment prescribed. (This allowable exclusion must be documented in the measurement period) Exclusion A provider cannot prescribe an ineffective or contraindicated treatment. A patient may not need Rationale treatment if they have not had any CH attacks in the past 12 months. A patient and/or caregiver reserve the right to decline a prescription. Some of these treatments are costly to be paid out of pocket for a patient who does not have health insurance. Measure Scoring Percentage Interpretation of Higher score indicates better quality. Score Measure Type Process Level of Provider Measurement Risk Adjustment Not applicable For Process Measures Relationship to Desired Outcome Process Intermediate Outcomes Outcomes •Acute treatment prescribed •Medication adherence •Reliable reflief for symptom attacks •Minimal or no side effects

Opportunity to Cluster headache is underdiagnosed and undertreated due to difficult symptomology and poor Improve Gap in recognition.1,2 Although cluster headache has a much lower prevalence than many other types of 3 Care headache , it is often considered the most severe headache pain. Suicidal ideations in one study were as high as 55% of the study population.4

Appropriate acute and preventive treatment for patients diagnosed with cluster headache leads to reliable symptom relief for attacks and reduction of attack frequency and severity. Cluster headache leads to major socioeconomic effects on patients as well as society due to direct healthcare costs and indirect costs caused by loss of working capacity.5 Approximately 20% of CH patients have lost a job secondary to CH, while another 8% are out of work or on disability secondary to their headaches.4

According to a 2016 study by Lademan et al, “guideline-adherent treatment in cluster headache is about 70% for acute treatment and about 35% for prophylactic treatment.”6 The efficacy rate for treatments for both groups is above 90%.6 This evidence presents a wide gap in care for patients with cluster headache. Harmonization No similar measures known. with Existing Measures References 1. Klapper JA, Klapper A and Voss T. The misdiagnosis of cluster headache: a nonclinical, population-based, Internet survey. Headache. 2000 Oct; 40(9):730-5. 2. Robbins M, Starling A, Pringsheim T, et al. Treatment of Cluster Headache: The American Headache Society Evidence-Based Guidelines. Headache 2016; 56:1093-1106. 3. Fischera M, Marziniak M, Gralow I, Evers S The incidence and prevalence of cluster headache: a meta-analysis of population-based studies. Cephalalgia. 2008 Jun;28(6):614-8 4. Rozen RD, Fishman RS Cluster headache in the United States of America: Demographics, Clinical Characteristics, Triggers, Suicidality, and Personal Burden. 2012 Headache doi: 10.1111/j.1526-4610.2011.02028.x 5. Gaul C, Finken J, Biermann J, et al. Treatment costs and indirect costs of cluster headache: A health economics analysis. Cephalgia 2011; 31 (16): 1664-1672. 6. Lademann v, Jasen JP, Evers S, Frese A. Evaluation of guideline-adherent treatment in cluster headache. Cephalalgia 2016; 36:760-764.

Supporting evidence • EFNS Evers S, Afra J, Frese A, et al. Cluster headache and other trigemino-autonomic cephalgias. European handbook of neurological management. 2nd ed. Vol 1. Oxford (UK): Wiley-Blackwell; 2001; pg. 179-190. • Francis GJ, Becker WJ, Pringsheim TM. Acute and Preventive Pharmacologic Treatment of Cluster Headache Neurology 2010; 75;463 • EFNS guidelines on the treatment of cluster headache and other trigeminal-autonomic cephalalgias. European Journal of Neurology 2006; 13:1066-77. • Bennett MH, French C, Schnabel A, et al. Normobaric and hyperbaric oxygen therapy for the treatment and prevention of migraine and cluster headache (Review). Cochrane Library 2015.

Flow Chart Diagram

Was patient 18 years or older during the measurement period? Patient NOT No Included in Yes Eligible Population

Did the patient have at least one new or established patient visit with an eligible No provider during the measurement period?

Yes

Did patient have a diagnosis of cluster No headache during the measurement period?

Yes

Patient INCLUDED in Eligible Population

On the date of the encounter, were guideline recommended treatments medically contraindicated or ineffective?

No or N/A Yes

On the date of the encounter, did the patient report no CH attacks within the past Remove from 12 months or is not in an active attack denominator* period? No or N/A Yes *Do not remove/exclude if patient meets the numerator On the date of the encounter, did the patient report CH are sufficiently controlled with OTC meds? Yes

No or N/A

On the date of the encounter, did the patient and/or caregiver decline therapy? Yes

No or N/A On the date of the encounter, did the patient lack insurance for treatment Yes prescribed?

No or N/A

During the measurement period, was the patient Patient prescribed an acute treatment^, including INCLUDED in treatments prescribed by a different clinician Denominator Yes No

Patient did Patient met NOT meet numerator numerator criteria criteria

Code System Code Code Description ICD-10 G44.001 Cluster headache syndrome, unspecified, intractable ICD-10 G44.009 Cluster headache syndrome, unspecified, not intractable ICD-10 G44.011 Episodic cluster headache, intractable ICD-10 G44.019 Episodic cluster headache, not intractable ICD-10 G44.021 Chronic cluster headache, intractable ICD-10 G44.029 Chronic cluster headache, not intractable CPT 99201-99205 Office or other outpatient visit 10, 20, 30, 45, or 60 minutes for the evaluation and management of a new patient CPT 99211-99215 Office or other outpatient visit 5, 10, 15, 25, or 40 minutes for the evaluation and management of an established patient

Measure Title Preventive treatment prescribed for cluster headache.

**This is a paired measure. Recommend that this measure is used in conjunction with “Acute Treatment Prescribed for Cluster Headache” on page 34** Description Percentage of patients > 18 years of age with a diagnosis of cluster headache (CH) who were prescribed short-term and/or long-term preventive treatment, including treatments prescribed by a different clinician. Measurement January 1, 20xx to December 31, 20xx Period Eligible Eligible Providers Medical Doctor (MD), Doctor of Osteopathy (DO), Population Advanced Practice Provider (APP), Advanced Practice Registered Nurse (APRN) Care Setting(s) Outpatient Ages > 18 years of age Event Patient had an office visit or E/M services performed or supervised by an eligible provider. Diagnosis Cluster headache Denominator Patients > 18 years of age with a diagnosis of cluster headache. Numerator Patients who were prescribed short-term^ and/or long-term* preventive treatment, including treatments prescribed by a different clinician once during the measurement period

^Short term preventive treatments include, but are not limited to, the following: Occipital nerve injection with steroid, oral steroid.

*Long term preventive treatments include, but are not limited to, the following: verapamil, lithium, sphenopalatine ganglion (SPG) stimulation device**, galcanezumab.

**Availability may be limited in U.S. Required None Exclusions Allowable • Guideline recommended treatment is medically contraindicated or ineffective for Exclusions the patient. (This allowable exclusion allows for documentation to occur at any time in the patient record) • Patient reports no CH attacks within the past 12 months or is not in an active attack period. (This allowable exclusion must be documented in the measurement period) • Provider determined attack frequency does not warrant preventive treatment (This allowable exclusion must be documented on the date of the encounter) • CH are sufficiently controlled with over the counter [OTC] medications. (This allowable exclusion must be documented on the date of the encounter) • Patient and/or caregiver decline. (This allowable exclusion must be documented on the date of the encounter) • Lack of insurance or insurance coverage for treatment prescribed. (This allowable exclusion must be documented in the measurement period) Exclusion A provider cannot prescribe an ineffective or contraindicated treatment. A patient may Rationale not need treatment if they have not had any CH attacks in the past 12 months. A patient and/or caregiver reserve the right to decline a prescription. Some of these treatments are costly to be paid out of pocket for a patient who does not have health insurance. Measure Percentage Scoring Interpretation Higher score indicates better quality. of Score Measure Type Process Level of Provider Measurement Risk Not applicable Adjustment For Process Measures Relationship to Desired Outcome Process Intermediate Outcomes Outcomes •Preventive treatment •Medication adherence •Reduction of attack prescribed frequency and severity •Minimal or no side effects

Opportunity to Cluster headache is underdiagnosed and undertreated due to difficult symptomology and Improve Gap poor recognition.1,2 Although cluster headache has a much lower prevalence than many 3 in Care other types of headache , it is often considered the most severe headache pain. Suicidality ideations in one study were as high as 55% of the study population.4

Appropriate acute and preventive treatment for patients diagnosed with cluster headache lead to reliable symptom relief for attacks and reduction of attack frequency and severity. Cluster headache leads to major socioeconomic impacts on patients as well as society due to direct healthcare costs and indirect costs caused by loss of working capacity.5 Approximately 20% of CH patients have lost a job secondary to CH, while another 8% are out of work or on disability secondary to their headaches.4

According to a 2016 study by Lademan et al, “guideline-adherent treatment in cluster headache is about 70% for acute treatment and about 35% for prophylactic treatment.”6 The efficacy rate for treatments for both groups is above 90%.6 This evidence presents a wide gap in care for patients with cluster headache. Harmonization No similar measures known. with Existing Measures References 1. Klapper JA, Klapper A and Voss T. The misdiagnosis of cluster headache: a nonclinical, population-based, Internet survey. Headache. 2000 Oct; 40(9):730-5. 2. Robbins M, Starling A, Pringsheim T, et al. Treatment of Cluster Headache: The American Headache Society Evidence-Based Guidelines. Headache 2016; 56:1093- 1106. 3. Fischera M, Marziniak M, Gralow I, Evers S The incidence and prevalence of cluster headache: a meta-analysis of population-based studies. Cephalalgia. 2008 Jun;28(6):614-8 4. Rozen RD, Fishman RS Cluster headache in the United States of America: Demographics, Clinical Characteristics, Triggers, Suicidality, and Personal Burden. 2012 Headache doi: 10.1111/j.1526-4610.2011.02028.x 5. Gaul C, Finken J, Biermann J, et al. Treatment costs and indirect costs of cluster headache: A health economics analysis. Cephalgia 2011; 31 (16): 1664-1672. 6. Lademann v, Jasen JP, Evers S, Frese A. Evaluation of guideline-adherent treatment in cluster headache. Cephalalgia 2016; 36:760-764.

Supporting evidence • EFNS Evers S, Afra J, Frese A, et al. Cluster headache and other trigemino- autonomic cephalgias. European handbook of neurological management. 2nd ed. Vol 1. Oxford (UK): Wiley-Blackwell; 2001; pg. 179-190. • Francis GJ, Becker WJ, Pringsheim TM. Acute and Preventive Pharmacologic Treatment of Cluster Headache Neurology 2010; 75;463 • EFNS guidelines on the treatment of cluster headache and other trigeminal- autonomic cephalalgias. European Journal of Neurology 2006; 13:1066-77. • Bennett MH, French C, Schnabel A, et al. Normobaric and hyperbaric oxygen therapy for the treatment and prevention of migraine and cluster headache (Review). Cochrane Library 2015.

Flow Chart Diagram

Was patient 18 years or older during the measurement period? Patient NOT No Included in Yes Eligible Population

Did the patient have at least one new or established patient visit with an eligible No provider during the measurement period?

Yes

Did patient have a diagnosis of cluster No headache during the measurement period?

Yes

Patient INCLUDED in Eligible Population

On the date of the encounter, were guideline recommended treatments medically contraindicated or ineffective?

No or N/A Yes

On the date of the encounter, did the patient report no CH attacks within the past Remove from 12 months or is not in an active attack denominator* period? No or N/A Yes *Do not remove/exclude if patient meets the numerator On the date of the encounter, did the provider determine the attack frequency did not warrant preventive treatment? Yes

No or N/A

On the date of the encounter, did the patient report CH are sufficiently controlled with OTC meds? Yes

No or N/A On the date of the encounter, did the patient and/or caregiver decline therapy? Remove from denominator* Yes *Do not remove/exclude No or N/A if patient meets the numerator On the date of the encounter, did the patient lack insurance for treatment Yes prescribed?

No or N/A

During the measurement period, was patient Patient prescribed short-term and/or long-term preventive treatment, including treatments INCLUDED in prescribed by a different clinician? Denominator

Yes No

Patient did Patient met NOT meet numerator numerator criteria criteria

Quality ID #279: Sleep Apnea: Assessment of Adherence to Positive Airway Pressure Therapy – National Quality Strategy Domain: Effective Clinical Care – Meaningful Measure Area: Management of Chronic Conditions

2021 COLLECTION TYPE: MIPS CLINICAL QUALITY MEASURES (CQMS)

MEASURE TYPE: Process

DESCRIPTION: Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea who were prescribed positive airway pressure therapy who had documentation that adherence to positive airway pressure therapy was objectively measured

INSTRUCTIONS: This measure is to be submitted a minimum of once per performance period for patients with sleep apnea seen during the performance period. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

NOTE: Patient encounters for this measure conducted via telehealth (e.g., encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable.

Measure Submission: Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality-data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

DENOMINATOR: All patients aged 18 years and older with a diagnosis of sleep apnea

Denominator Criteria (Eligible Cases): Patients aged ≥ 18 years on date of encounter AND Diagnosis for sleep apnea (ICD-10-CM): G47.30, G47.33 AND Patient encounter during the performance period (CPT): 99202, 99203, 99204, 99205, 99211, 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 AND Positive airway pressure therapy was prescribed: G8852

NUMERATOR: Patient visits with documentation that adherence to positive airway pressure therapy was objectively measured

Definition: Objectively Measured - is defined as positive airway pressure machine-generated measurement of hours of use. Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 1 of 6 Numerator Options: Performance Met: Objective measurement of adherence to positive airway pressure therapy, documented (G8851) OR Denominator Exception: Documentation of reason(s) for not objectively measuring adherence to positive airway pressure therapy (e.g., patient didn’t bring data from continuous positive airway pressure [CPAP], therapy not yet initiated, not available on machine) (G8854) OR Performance Not Met: Objective measurement of adherence to positive airway pressure therapy not performed, reason not given (G8855)

RATIONALE: This recommendation is based on overwhelming evidence at all levels indicating patients with obstructive sleep apnea (OSA) overestimate their positive airway pressure use time. Level I and Level II studies indicate that objectively-measured nightly continuous positive airway pressure (CPAP) "time on" ranges from 3.5 hours/night in minimally symptomatic new patients to 7.1 hours/night in established users (Kushida et al, 2006). The success of any positive airway pressure device therapy depends primarily on patient adherence, which can be enhanced by education, proper mask/interface fit, frequent follow-up by the clinician and durable medical equipment provider, and finally, A.W.A.K.E. (Alert Well And Keeping Energetic) meetings (ICSI, 2007). When objective adherence is assessed and an intervention is employed –ether in the clinic or via the telephone, use is increased. Meter reads (on the machines) or card reads provide a longitudinal assessment of use and prevent the potential for overuse of stimulant therapy and daytime testing of sleepiness with multiple sleep latency tests.

Numerous studies have shown that patient adherence to CPAP is low or over-estimated by patients. A 2006 study assessed OSA severity, continuous positive airway pressure adherence, and factors associated with CPAP adherence among a group of patients with OSA receiving care at a publicly-funded county hospital. The findings indicated that CPAP adherence was low, with women having a higher likelihood of non-adherence than men. When individuals without follow-up were assumed to be non-adherent, the overall compliance rate was 30.4%, and women were 1.72 (95% CI, 1.03-2.88) times more likely to be noncompliant than men, adjusting for race, marital status, and age (Joo et al, 2007). Another study by Kribbs et al (Level I) found that subjective and covertly monitored objective CPAP adherence were discordant and that OSA patients in the aggregate overestimate subjective CPAP adherence compared with objective adherence measurements obtained by microprocessor. Adherence was arbitrarily defined as ≥ 4 hours of CPAP usage for ≥ 70% of the nights monitored. Although 60% of patients subjectively reported nightly use of CPAP for a mean of 106.9 days, only 16 of 35 (46%) were objectively using CPAP at least 4 hours per night on 70% of the nights. Patients over-estimated actual CPAP use by 69 ± 110 min. (Gay et al, 2005)

OSA is a chronic disease that rarely resolves except with substantial weight loss or successful corrective surgery. As with other chronic diseases, periodic follow-up by a qualified clinician (eg, physician or advanced practice provider) is necessary to confirm adequate treatment, assess symptom resolution, and promote continued adherence to treatment. Initial treatment of OSA requires close monitoring and early identification of difficulties with PAP use, as adherence over the first few days to weeks has been shown to predict long-term adherence. Objective monitoring of PAP therapy should be performed to complement patient reporting of difficulties with PAP use, as patients often overestimate their use of PAP treatment. (Patil, et al, 2019)

CLINICAL RECOMMENDATION STATEMENTS: CPAP usage should be objectively monitored to help assure utilization (Level 1). Close follow-up for PAP usage and problems in patients with obstructive sleep apnea (OSA) by appropriately trained health care providers is indicated to establish effective utilization patterns and remediate problems, if needed. This recommendation is based on 61 studies that examined management paradigms and collected acceptance, utilization, and adverse events; 17 of these Version 5.0 CPT only copyright 2020 American Medical Association. All rights reserved. November 2020 Page 2 of 6 studies qualified as Level I. This is especially important during the first few weeks of PAP use and can prove to be beneficial for the longitudinal care of the patient. (Kushida et al, 2006)

Adequate follow-up, including troubleshooting and monitoring of objective efficacy and usage data to ensure adequate treatment and adherence, should occur following PAP therapy initiation and during treatment of OSA. (Patil et al, 2019)