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pdf2010 Physician Quality Reporting Initiative
Measure Specifications Manual for Claims and Registry
Reporting of Individual Measures
The measure specifications for the 175 measures contained in this manual are intended for claims-based and
registry reporting of individual measures for the 2010 Physician Quality Reporting Initiative (PQRI). Each
measure is assigned a unique number. Measure numbers for 2010 PQRI represent a continuation in numbering
from the 2009 PQRI measures 1 through 186. Gaps in measure numbering reflect those PQRI measures that
are not included for implementation in 2010 PQRI. For the 2009 PQRI measures which are continuing for 2010
PQRI, measure specifications have been updated prior to the beginning of the 2010 PQRI program. In addition
to the measure specifications manual, please refer to the “2010 PQRI Implementation Guide” for additional
information essential in helping eligible professionals (EPs) understand and submit measures. This document
can be found at: http://www.cms.hhs.gov/PQRI/15_MeasuresCodes.asp#TopOfPage. Measure specifications
for measures groups reporting are included in a separate manual, “2010 PQRI Measures Groups Specifications
Manual,” which can be found at: http://www.cms.hhs.gov/PQRI/15_MeasuresCodes.asp#TopOfPage.
Eligible Professionals
EPs submitting billable services on Part B claims for allowable Medicare Physician Fee Schedule (PFS) charges
may report the quality action for selected PQRI quality measure(s). Providers not defined as EPs in the Tax
Relief and Health Care Act of 2006 or the Medicare Improvements for Patients and Providers Act of 2008 are
not eligible to participate in PQRI. A list of EPs can be found on the PQRI website at:
http://www.cms.hhs.gov/PQRI/10_EligibleProfessionals.asp#TopOfPage.
Frequency and Performance Timeframes
The measure instructions limit the frequency of reporting necessary in certain circumstances, such as for
patients with chronic illness for whom a particular process of care is provided only periodically. Each individual
EP participating in 2010 PQRI should report according to the frequency and timeframe listed within each
measure specification.
Denominator Codes (Eligible Cases) and Numerator Quality-Data Codes (QDCs)
Quality measures consist of a numerator and a denominator that permit the calculation of the percentage of a
defined patient population that receive a particular process of care or achieve a particular outcome. The
denominator population is defined by certain ICD-9-CM diagnosis, CPT Category I, and HCPCS codes specified
in the measure that are submitted by individual EPs as part of a claim for covered services under the PFS. If the
specified denominator codes for a measure are not included on the patient’s claim (for the same date of service)
as submitted by the individual EP, then the patient does not fall into the denominator population, and the PQRI
measure does not apply to the patient. Some measure specifications are adapted as needed for implementation
in PQRI in agreement with the measure developer. For example, CPT codes for non-covered services such as
preventive visits are not included in the denominator. Also, the denominators for measures groups have been
modified to provide common denominator codes for all measures within the group.
PQRI measure specifications include specific instructions regarding CPT Category I modifiers, place of service
codes, and other detailed information. Each EP should carefully review the measure’s denominator coding to
determine whether codes submitted on a given claim meet denominator inclusion.
If the patient does fall into the denominator population, the applicable QDC(s) (CPT Category II codes or Gcodes) that defines the numerator should be submitted to satisfactorily report quality data for a measure under
the PQRI program. Where a patient falls into the denominator but the measure specifications define
circumstances in which a patient may be excluded, CPT Category II code modifiers such as 1P, 2P, 3P, and 8P
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are available to describe medical, patient, system, or other reasons for performance exclusion. Where the
performance exclusion does not apply, a measure-specific CPT Category II reporting modifier 8P or HCPCS
G-code may be used to indicate that the process of care was not provided for a reason not otherwise specified.
Instructions specific to each measure provide additional reporting information.
Measure Specification Format
Measure title
Reporting option available for each measure (claims-based or registry)
Measure description
Instructions on reporting including frequency, timeframes, and applicability
Numerator coding
Definitions of terms
Coding instructions
Use of CPT Category II exclusion modifiers, where applicable
Denominator coding
Rationale statement for measure
Clinical recommendations or evidence forming the basis or supporting criteria for the measure
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Reporting of Individual Measures
Table of Contents
Page
Introduction
Table of 2010 PQRI Measure Numbers, Measure Titles, Reporting Options, and Page Numbers
List of Retired PQRI Measure Specifications
2010 PQRI Measure Specifications for Claims and Registry
Symbol and Copyright Information
1
4
10
12
517
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Measure
Number
1
2
3
5
6
7
8
9
10
12
14
18
19
20
21
22
23
24
28
30
31
32
33
35
36
Measure Title
Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus
Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus
Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus
Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin
Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients
with CAD
Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with
Prior Myocardial Infarction (MI)
Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction
(LVSD)
Major Depressive Disorder (MDD): Antidepressant Medication During Acute
Phase for Patients with MDD
Stroke and Stroke Rehabilitation: Computed Tomography (CT) or Magnetic
Resonance Imaging (MRI) Reports
Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation
Age-Related Macular Degeneration (AMD): Dilated Macular Examination
Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema
and Level of Severity of Retinopathy
Diabetic Retinopathy: Communication with the Physician Managing On-going
Diabetes Care
Perioperative Care: Timing of Antibiotic Prophylaxis – Ordering Physician
Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second
Generation Cephalosporin
Perioperative Care: Discontinuation of Prophylactic Antibiotics (Non-Cardiac
Procedures)
Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When
Indicated in ALL Patients)
Osteoporosis: Communication with the Physician Managing On-going Care PostFracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and
Older
Aspirin at Arrival for Acute Myocardial Infarction (AMI)
Perioperative Care: Timely Administration of Prophylactic Parenteral Antibiotics
Stroke and Stroke Rehabilitation: Deep Vein Thrombosis Prophylaxis (DVT) for
Ischemic Stroke or Intracranial Hemorrhage
Stroke and Stroke Rehabilitation: Discharged on Antiplatelet Therapy
Stroke and Stroke Rehabilitation: Anticoagulant Therapy Prescribed for Atrial
Fibrillation at Discharge
Stroke and Stroke Rehabilitation: Screening for Dysphagia
Stroke and Stroke Rehabilitation: Consideration of Rehabilitation Services
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Measure
Measure Title
Number
39
Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older
40
Osteoporosis: Management Following Fracture of Hip, Spine or Distal Radius for
Men and Women Aged 50 Years and Older
41
Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years and
Older
43
Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in
Patients with Isolated CABG Surgery
44
Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients
with Isolated CABG Surgery
45
Perioperative Care: Discontinuation of Prophylactic Antibiotics (Cardiac
Procedures)
46
Medication Reconciliation: Reconciliation After Discharge from an Inpatient
Facility
47
Advance Care Plan
48
Urinary Incontinence: Assessment of Presence or Absence of Urinary
Incontinence in Women Aged 65 Years and Older
49
Urinary Incontinence: Characterization of Urinary Incontinence in Women Aged
65 Years and Older
50
Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65
Years and Older
51
Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation
52
Chronic Obstructive Pulmonary Disease (COPD): Bronchodilator Therapy
53
Asthma: Pharmacologic Therapy
54
12-Lead Electrocardiogram (ECG) Performed for Non-Traumatic Chest Pain
55
12-Lead Electrocardiogram (ECG) Performed for Syncope
56
Community-Acquired Pneumonia (CAP): Vital Signs
57
Community-Acquired Pneumonia (CAP): Assessment of Oxygen Saturation
58
Community-Acquired Pneumonia (CAP): Assessment of Mental Status
59
Community-Acquired Pneumonia (CAP): Empiric Antibiotic
64
Asthma: Asthma Assessment
65
Treatment for Children with Upper Respiratory Infection (URI): Avoidance of
Inappropriate Use
66
Appropriate Testing for Children with Pharyngitis
67
Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic
Testing Performed on Bone Marrow
68
Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients
Receiving Erythropoietin Therapy
69
Multiple Myeloma: Treatment with Bisphosphonates
70
Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry
71
Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/
Progesterone Receptor (ER/PR) Positive Breast Cancer
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Measure
Reporting
Measure Title
Number
Options
72
Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients
C, R
76
Prevention of Catheter-Related Bloodstream Infections (CRBSI): Central Venous
C, R
Catheter (CVC) Insertion Protocol
79
End Stage Renal Disease (ESRD): Influenza Immunization in Patients with ESRD
C, R
81
82
83
84
85
86
87
89
90
91
92
93
94
99
100
102
104
105
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107
108
109
110
111
112
End Stage Renal Disease (ESRD): Plan of Care for Inadequate Hemodialysis in
ESRD Patients
End Stage Renal Disease (ESRD): Plan of Care for Inadequate Peritoneal
Dialysis
Hepatitis C: Testing for Chronic Hepatitis C – Confirmation of Hepatitis C Viremia
Hepatitis C: Ribonucleic Acid (RNA) Testing Before Initiating Treatment
Hepatitis C: HCV Genotype Testing Prior to Treatment
Hepatitis C: Antiviral Treatment Prescribed
Hepatitis C: HCV Ribonucleic Acid (RNA) Testing at Week 12 of Treatment
Hepatitis C: Counseling Regarding Risk of Alcohol Consumption
Hepatitis C: Counseling Regarding Use of Contraception Prior to Antiviral
Therapy
Acute Otitis Externa (AOE): Topical Therapy
Acute Otitis Externa (AOE): Pain Assessment
Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of
Inappropriate Use
Otitis Media with Effusion (OME): Diagnostic Evaluation – Assessment of
Tympanic Membrane Mobility
Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and
pN Category (Regional Lymph Nodes) with Histologic Grade
Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor)
and pN Category (Regional Lymph Nodes) with Histologic Grade
Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low-Risk
Prostate Cancer Patients
Prostate Cancer: Adjuvant Hormonal Therapy for High-Risk Prostate Cancer
Patients
Prostate Cancer: Three-Dimensional (3D) Radiotherapy
Major Depressive Disorder (MDD): Diagnostic Evaluation
Major Depressive Disorder (MDD): Suicide Risk Assessment
Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug
(DMARD)Therapy
Osteoarthritis (OA): Function and Pain Assessment
Preventive Care and Screening: Influenza Immunization for Patients ≥ 50 Years
Old
Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years
and Older
Preventive Care and Screening: Screening Mammography
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Measure
Number
113
114
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116
117
118
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121
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Measure Title
Preventive Care and Screening: Colorectal Cancer Screening
Preventive Care and Screening: Inquiry Regarding Tobacco Use
Preventive Care and Screening: Advising Smokers and Tobacco Users to Quit
Antibiotic Treatment for Adults with Acute Bronchitis: Avoidance of Inappropriate
Use
Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient
Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor
or Angiotensin Receptor Blocker (ARB) Therapy for Patients with CAD and
Diabetes and/or Left Ventricular Systolic Dysfunction (LVSD)
Diabetes Mellitus: Urine Screening for Microalbumin or Medical Attention for
Nephropathy in Diabetic Patients
Chronic Kidney Disease (CKD): Laboratory Testing (Calcium, Phosphorus, Intact
Parathyroid Hormone (iPTH) and Lipid Profile)
Chronic Kidney Disease (CKD): Blood Pressure Management
Chronic Kidney Disease (CKD): Plan of Care – Elevated Hemoglobin for Patients
Receiving Erythropoiesis-Stimulating Agents (ESA)
Health Information Technology (HIT): Adoption/Use of Electronic Health Records
(EHR)
Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy Neurological Evaluation
Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of
Footwear
Preventive Care and Screening: Body Mass Index (BMI) Screening and FollowUp
Documentation and Verification of Current Medications in the Medical Record
Pain Assessment Prior to Initiation of Patient Therapy and Follow-Up
Screening for Clinical Depression and Follow-Up Plan
Chronic Kidney Disease (CKD): Influenza Immunization
Melanoma: Follow-Up Aspects of Care
Melanoma: Continuity of Care – Recall System
Melanoma: Coordination of Care
Cataracts: Comprehensive Preoperative Assessment for Cataract Surgery with
Intraocular Lens (IOL) Placement
Age-Related Macular Degeneration (AMD): Counseling on Antioxidant
Supplement
Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP)
by 15% OR Documentation of a Plan of Care
Osteoarthritis (OA): Assessment for Use of Anti-Inflammatory or Analgesic Overthe-Counter (OTC) Medications
Oncology: Medical and Radiation – Pain Intensity Quantified
Oncology: Medical and Radiation – Plan of Care for Pain
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Measure
Measure Title
Number
145
Radiology: Exposure Time Reported for Procedures Using Fluoroscopy
Radiology: Inappropriate Use of “Probably Benign” Assessment Category in
146
Mammography Screening
Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients
147
Undergoing Bone Scintigraphy
153
Chronic Kidney Disease (CKD): Referral for Arteriovenous (AV) Fistula
154
Falls: Risk Assessment
155
Falls: Plan of Care
156
Oncology: Radiation Dose Limits to Normal Tissues
Thoracic Surgery: Recording of Clinical Stage for Lung Cancer and Esophageal
157
Cancer Resection
Carotid Endarterectomy: Use of Patch During Conventional Carotid
158
Endarterectomy
159
HIV/AIDS: CD4+ Cell Count or CD4+ Percentage
160
HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis
HIV/AIDS: Adolescent and Adult Patients with HIV/AIDS Who Are Prescribed
161
Potent Antiretroviral Therapy
162
HIV/AIDS: HIV RNA Control After Six Months of Potent Antiretroviral Therapy
163
Diabetes Mellitus: Foot Exam
164
Coronary Artery Bypass Graft (CABG): Prolonged Intubation (Ventilation)
165
Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate
166
Coronary Artery Bypass Graft (CABG): Stroke/Cerebrovascular Accident (CVA)
167
Coronary Artery Bypass Graft (CABG): Postoperative Renal Insufficiency
168
Coronary Artery Bypass Graft (CABG): Surgical Re-exploration
169
Coronary Artery Bypass Graft (CABG): Antiplatelet Medications at Discharge
170
Coronary Artery Bypass Graft (CABG): Beta-Blockers Administered at Discharge
171
Coronary Artery Bypass Graft (CABG): Lipid Management and Counseling
Hemodialysis Vascular Access Decision-Making by Surgeon to Maximize
172
Placement of Autogenous Arterial Venous (AV) Fistula
173
Preventive Care and Screening: Unhealthy Alcohol Use – Screening
Pediatric End Stage Renal Disease (ESRD): Plan of Care for Inadequate
174
Hemodialysis
175
Pediatric End Stage Renal Disease (ESRD): Influenza Immunization
176
Rheumatoid Arthritis (RA): Tuberculosis Screening
177
Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity
178
Rheumatoid Arthritis (RA): Functional Status Assessment
179
Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis
180
Rheumatoid Arthritis (RA): Glucocorticoid Management
181
Elder Maltreatment Screen and Follow-Up Plan
182
Functional Outcome Assessment in Chiropractic Care
183
Hepatitis C: Hepatitis A Vaccination in Patients with HCV
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Measure
Measure Title
Number
184
Hepatitis C: Hepatitis B Vaccination in Patients with HCV
Endoscopy & Polyp Surveillance: Colonoscopy Interval for Patients with a History
185
of Adenomatous Polyps – Avoidance of Inappropriate Use
186
Wound Care: Use of Compression System in Patients with Venous Ulcers
187
Stroke and Stroke Rehabilitation: Thrombolytic Therapy
Referral for Otologic Evaluation for Patients with Congenital or Traumatic
188
Deformity of the Ear
Referral for Otologic Evaluation for Patients with History of Active Drainage from
189
the Ear within the Previous 90 Days
Referral for Otologic Evaluation for Patients with a History of Sudden or Rapidly
190
Progressive Hearing Loss
Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract
191
Surgery
Cataracts: Complications within 30 days Following Cataract Surgery Requiring
192
Additional Surgical Procedures
193
Perioperative Temperature Management
194
Oncology: Cancer Stage Documented
195
Stenosis Measurement in Carotid Imaging Studies
196
Coronary Artery Disease (CAD): Symptom and Activity Assessment
197
Coronary Artery Disease (CAD): Drug Therapy for Lowering LDL-Cholesterol
198
Heart Failure: Left Ventricular Function (LVF) Assessment
199
Heart Failure: Patient Education
200
Heart Failure: Warfarin Therapy for Patients with Atrial Fibrillation
201
Ischemic Vascular Disease (IVD): Blood Pressure Management Control
202
Ischemic Vascular Disease (IVD): Complete Lipid Profile
203
Ischemic Vascular Disease (IVD): Low Density Lipoprotein (LDL-C) Control
204
Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic
HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia and
205
Gonorrhea
206
HIV/AIDS: Screening for High Risk Sexual Behaviors
207
HIV/AIDS: Screening for Injection Drug Use
208
HIV/AIDS: Sexually Transmitted Disease Screening for Syphilis
209
Functional Communication Measure – Spoken Language Comprehension
210
Functional Communication Measure – Attention
211
Functional Communication Measure – Memory
212
Functional Communication Measure – Motor Speech
213
Functional Communication Measure – Reading
214
Functional Communication Measure – Spoken Language Expression
215
Functional Communication Measure – Writing
216
Functional Communication Measure – Swallowing
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List of Retired PQRI Measure Specifications
Measure #
Measure Title
Retirement
Effective Date
4
Screening for Future Fall Risk
January 1, 2009
11
Stroke and Stroke Rehabilitation: Carotid Imaging Reports
Age-Related Macular Degeneration: Age-Related Eye Disease
Study (AREDS) Prescribed/Recommended
January 1, 2010
15
Cataracts: Assessment of Visual Functional Status
January 1, 2008
16
Cataracts: Documentation of Pre-Surgical Axial Length, Corneal
Power Measurement and Method of Intraocular Lens Power
Calculation
January 1, 2008
17
Cataracts: Pre-Surgical Dilated Fundus Evaluation
January 1, 2008
25
Melanoma: Patient Medical History
January 1, 2008
26
Melanoma: Complete Physical Skin Examination
January 1, 2008
27
Melanoma: Counseling on Self-Examination
January 1, 2008
13
29
34
Beta-Blocker at Time of Arrival for Acute Myocardial Infarction
(AMI)
Stroke and Stroke Rehabilitation: Tissue Plasminogen Activator (tPA) Considered
January 1, 2008
January 1, 2008
January 1, 2010
37
Dialysis Dose in End Stage Renal Disease (ESRD) Patients
January 1, 2008
38
Hematocrit Level in End Stage Renal Disease (ESRD) Patients
Osteoporosis: Counseling for Vitamin D, Calcium Intake, and
Exercise
Gastroesophageal Reflux Disease (GERD): Assessment for Alarm
Symptoms
Gastroesophageal Reflux Disease (GERD): Upper Endoscopy for
Patients with Alarm Symptoms
Gastroesophageal Reflux Disease (GERD): Biopsy for Barrett’s
Esophagus
Gastroesophageal Reflux Disease (GERD): Barium SwallowInappropriate Use
Plan for Chemotherapy Documented Before Chemotherapy
Administered
Radiation Therapy Recommended for Invasive Breast Cancer
January 1, 2008
42
60
61
62
63
73
74
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List of Retired PQRI Measure Specifications
Measure #
Measure Title
Patients who Have undergone Breast Conserving Surgery
Retirement
Effective Date
75
Prevention of Ventilator-Associated Pneumonia – Head Elevation
January 1, 2009
77
Assessment of GERD Symptoms in Patients Receiving Chronic
Medication for GERD
January 1, 2009
78
Vascular Access for Patients Undergoing Hemodialysis
January 1, 2009
80
End Stage Renal Disease (ESRD): Plan of Care for ESRD
Patients with Anemia
January 1, 2009
88
Hepatitis C: Hepatitis A and B Vaccination in Patients with HCV
January 1, 2009
95
Otitis Media with Effusion (OME): Hearing Testing
January 1, 2010
96
97
98
101
103
120
125
Otitis Media with Effusion (OME): Antihistamines or
Decongestants – Avoidance of Inappropriate Use
Otitis Media with Effusion (OME): Systemic Antimicrobials –
Avoidance of Inappropriate Use
Otitis Media with Effusion (OME): Systemic Corticosteroids –
Avoidance of Inappropriate Use
Appropriate Initial Evaluation of Patients with Prostate Cancer
Prostate Cancer: Review of Treatment Options in Patients with
Clinically Localized Prostate Cancer
Chronic Kidney Disease (CKD): Angiotensin-Converting Enzyme
(ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy
Health Information Technology (HIT): Adoption/Use of Medication
Electronic Prescribing (e-Rx)
January 1, 2009
January 1, 2009
January 1, 2009
January 1, 2009
January 1, 2009
January 1, 2009
January 1, 2009
Refer to new Electronic Prescribing (e-Rx) incentive program
129
Universal Influenza Vaccine Screening and Counseling
January 1, 2009
132
Patient Co-Development of Treatment Plan/Plan of Care
January 1, 2009
133
Screening for Cognitive Impairment
January 1, 2009
152
Coronary Artery Disease (CAD): Lipid Profile in Patients with CAD
January 1, 2010
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Measure #1: Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent
hemoglobin A1c greater than 9.0%
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with diabetes
mellitus seen during the reporting period. The performance period for this measure is 12 months.
The most recent quality-data code submitted will be used for performance calculation. This
measure may be reported by clinicians who perform the quality actions described in the measure
based on the services provided and the measure-specific denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, G-codes, and patient demographics are used to
identify patients who are included in the measure’s denominator. CPT Category II codes are used
to report the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
G-codes, and the appropriate CPT Category II code OR the CPT Category II code with the
modifier. The reporting modifier allowed for this measure is: 8P- reason not otherwise specified.
There are no allowable performance exclusions for this measure. All measure-specific coding
should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, G-codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. The numerator options as described in
the quality-data codes are used to report the numerator of the measure. The quality-data codes
listed do not need to be submitted for registry-based submissions; however, these codes may be
submitted for those registries that utilize claims data. There are no allowable performance
exclusions for this measure.
NUMERATOR:
Patients with most recent hemoglobin A1c level > 9.0%
Numerator Instructions: For performance, a lower rate indicates better
performance/control.
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Most Recent Hemoglobin A1c Level > 9.0%
CPT II 3046F: Most recent hemoglobin A1c level > 9.0%
OR
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OR
Hemoglobin A1c not Performed
Append a reporting modifier (8P) to CPT Category II code 3046F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3046F with 8P: Hemoglobin A1c level was not performed during the performance period
(12 months)
Most Recent Hemoglobin A1c Level ≤ 9.0%
CPT II 3044F: Most recent hemoglobin A1c (HbA1c) level < 7.0%
OR
CPT II 3045F: Most recent hemoglobin A1c (HbA1c) level 7.0 to 9.0%
DENOMINATOR:
Patients aged 18 through 75 years with the diagnosis of diabetes
Denominator Criteria (Eligible Cases):
Patients aged 18 through 75 years on date of encounter
AND
Diagnosis for diabetes (line-item ICD-9-CM): 250.00, 250.01, 250.02, 250.03, 250.10,
250.11, 250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33,
250.40, 250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62,
250.63, 250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91,
250.92, 250.93, 357.2, 362.01, 362.02, 362.03, 362.04, 362.05, 362.06, 362.07, 366.41,
648.00, 648.01, 648.02, 648.03, 648.04
AND
Patient encounter during reporting period (CPT or HCPCS): 97802, 97803, 97804,
99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306,
99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336,
99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0270, G0271
RATIONALE:
Intensive therapy of glycosylated hemoglobin (A1c) reduces the risk of microvascular
complications.
CLINICAL RECOMMENDATION STATEMENTS:
A glycosylated hemoglobin should be performed during an initial assessment and during follow-up
assessments, which should occur at no longer than three-month intervals. (AACE/ACE)
The A1c should be universally adopted as the primary method of assessment of glycemic control.
On the basis of data from multiple interventional trials, the target for attainment of glycemic control
should be A1c values ≤6.5%. (AACE/ACE)
Obtain a glycosylated hemoglobin during an initial assessment and then routinely as part of
continuing care. In the absence of well-controlled studies that suggest a definite testing protocol,
expert opinion recommends glycosylated hemoglobin be obtained at least twice a year in patients
who are meeting treatment goals and who have stable glycemic control and more frequently
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(quarterly assessment) in patients whose therapy was changed or who are not meeting glycemic
goals. (Level of Evidence: E) (ADA)
Because different assays can give varying glycated hemoglobin values, the ADA recommends that
laboratories only use assay methods that are certified as traceable to the Diabetes Control and
Complications Trial A1c reference method. The ADA’s goal for glycemic control is A1c <7%. (Level
of Evidence: B) (ADA)
Monitor and treat hyperglycemia, with a target A1c of 7%, but less stringent goals for therapy may
be appropriate once patient preferences, diabetes severity, life expectancy and functional status
have been considered. (AGS)
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Measure #2: Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes
Mellitus
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent LDLC level in control (less than 100 mg/dl)
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with diabetes
mellitus seen during the reporting period. The performance period for this measure is 12 months.
The most recent quality code submitted will be used for performance calculation. This measure
may be reported by clinicians who perform the quality actions described in the measure based on
the services provided and the measure-specific denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, G-codes, and patient demographics are used to
identify patients who are included in the measure’s denominator. CPT Category II codes are used
to report the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
G-codes, and the appropriate CPT Category II code OR the CPT Category II code with the
modifier. The reporting modifier allowed for this measure is: 8P- reason not otherwise specified.
There are no allowable performance exclusions for this measure. All measure-specific coding
should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, G-codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. The numerator options as described in
the quality-data codes are used to report the numerator of the measure. The quality-data codes
listed do not need to be submitted for registry-based submissions; however, these codes may be
submitted for those registries that utilize claims data. There are no allowable performance
exclusions for this measure.
NUMERATOR:
Patients with most recent LDL-C < 100 mg/dL
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Most Recent LDL-C Level < 100 mg/dL
CPT II 3048F: Most recent LDL-C < 100 mg/dL
Most Recent LDL-C Level ≥ 100 mg/dL
CPT II 3049F: Most recent LDL-C 100-129 mg/dL
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OR
CPT II 3050F: Most recent LDL-C ≥ 130 mg/dL
OR
LDL-C Level not Performed
Append a reporting modifier (8P) to CPT Category II code 3048F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3048F with 8P: LDL-C was not performed during the performance period (12 months)
Note: If unable to calculate LDL-C due to high triglycerides, CPT Category II code 3048F8P should be reported
DENOMINATOR:
Patients aged 18 through 75 years with the diagnosis of diabetes
Denominator Criteria (Eligible Cases):
Patients aged 18 through 75 years on date of encounter
AND
Diagnosis for diabetes (line-item ICD-9-CM): 250.00, 250.01, 250.02, 250.03, 250.10,
250.11, 250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33,
250.40, 250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62,
250.63, 250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91,
250.92, 250.93, 357.2, 362.01, 362.02, 362.03, 362.04, 362.05, 362.06, 362.07, 366.41,
648.00, 648.01, 648.02, 648.03, 648.04
AND
Patient encounter during reporting period (CPT or HCPCS): 97802, 97803, 97804,
99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306,
99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336,
99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0270, G0271
RATIONALE:
Persons with diabetes are at increased risk for coronary heart disease (CHD). Lowering serum
cholesterol levels can reduce the risk for CHD events.
CLINICAL RECOMMENDATION STATEMENTS:
A fasting lipid profile should be obtained during an initial assessment, each follow-up assessment,
and annually as part of the cardiac-cerebrovascular-peripheral vascular module. (AACE/ACE)
A fasting lipid profile should be obtained as part of an initial assessment. Adult patients with
diabetes should be tested annually for lipid disorders with fasting serum cholesterol, triglycerides,
HDL cholesterol, and calculated LDL cholesterol measurements. If values fall in lower-risk levels,
assessments may be repeated every two years. (Level of Evidence: E) (ADA)
Patients who do not achieve lipid goals with lifestyle modifications require pharmacological therapy.
Lowering LDL cholesterol with a statin is associated with a reduction in cardiovascular events.
(Level of Evidence: A)
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Lipid-lowering therapy should be used for secondary prevention of cardiovascular mortality and
morbidity for all patients with known coronary artery disease and type 2 diabetes. (ACP)
Statins should be used for primary prevention against macrovascular complications in patients with
type 2 diabetes and other cardiovascular risk factors.
Once lipid-lowering therapy is initiated, patients with type 2 diabetes mellitus should be taking at
least moderate doses of a statin.
Older persons with diabetes are likely to benefit greatly from cardiovascular risk reduction,
therefore monitor and treat hypertension and dyslipidemias. (AGS)
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Measure #3: Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent blood
pressure in control (less than 140/80 mmHg)
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with diabetes
mellitus seen during the reporting period. The performance period for this measure is 12 months.
The most recent quality code submitted will be used for performance calculation. This measure
may be reported by clinicians who perform the quality actions described in the measure based on
the services provided and the measure-specific denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, G-codes, and patient demographics are used to
identify patients who are included in the measure’s denominator. CPT Category II codes are used
to report the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
G-codes, and the appropriate CPT Category II codes OR the CPT Category II code with the
modifier. The reporting modifier allowed for this measure is: 8P- reason not otherwise specified.
There are no allowable performance exclusions for this measure. All measure-specific coding
should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, G-codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. The numerator options as described in
the quality-data codes are used to report the numerator of the measure. The quality-data codes
listed do not need to be submitted for registry-based submissions; however, these codes may be
submitted for those registries that utilize claims data. There are no allowable performance
exclusions for this measure.
NUMERATOR:
Patients whose most recent blood pressure < 140/80 mmHg
Numerator Instructions: To describe both systolic and diastolic blood pressure values,
two CPT II codes must be reported – 1) One to describe the systolic value; AND
2) One to describe the diastolic value. If there are multiple blood pressures on the same
date of service, use the lowest systolic and lowest diastolic blood pressure on that date as
the representative blood pressure.
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OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Most Recent Blood Pressure Measurement Performed
Systolic codes (Select one (1) code from this section):
CPT II 3074F: Most recent systolic blood pressure < 130 mmHg
OR
CPT II 3075F: Most recent systolic blood pressure 130 - 139 mmHg
OR
CPT II 3077F: Most recent systolic blood pressure ≥ 140 mmHg
AND
Diastolic code (Select one (1) code from this section):
CPT II 3078F: Most recent diastolic blood pressure < 80 mmHg
OR
CPT II 3079F: Most recent diastolic blood pressure 80 - 89 mmHg
OR
CPT II 3080F: Most recent diastolic blood pressure ≥ 90 mmHg
Blood Pressure Measurement not Performed
Append a reporting modifier (8P) to CPT Category II code 2000F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
2000F with 8P: No documentation of blood pressure measurement
DENOMINATOR:
Patients aged 18 through 75 years with the diagnosis of diabetes
Denominator Criteria (Eligible Cases):
Patients aged 18 through 75 years on date of encounter
AND
Diagnosis for diabetes (line-item ICD-9-CM): 250.00, 250.01, 250.02, 250.03, 250.10,
250.11, 250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33,
250.40, 250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62,
250.63, 250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91,
250.92, 250.93, 357.2, 362.01, 362.02, 362.03, 362.04, 362.05, 362.06, 362.07, 366.41,
648.00, 648.01, 648.02, 648.03, 648.04
AND
Patient encounter during reporting period (CPT or HCPCS): 97802, 97803, 97804,
99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306,
99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336,
99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0270, G0271
RATIONALE:
Intensive control of blood pressure in patients with diabetes reduces diabetes complications,
diabetes-related deaths, strokes, heart failure, and microvascular complications.
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CLINICAL RECOMMENDATION STATEMENTS:
Recommends that a blood pressure determination during the initial evaluation, including orthostatic
evaluation, be included in the initial and every interim physical examination. (AACE/ACE)
Blood pressure control must be a priority in the management of persons with hypertension and
type 2 diabetes. (ACP)
Blood pressure should be measured at every routine diabetes visit. Patients found to have systolic
blood pressure >130 mmHg or diastolic >80 mmHg should have blood pressure confirmed on a
separate day. Orthostatic measurement of blood pressure should be performed to assess for the
presence of autonomic neuropathy. (Level of Evidence: E) (ADA)
Older persons with diabetes are likely to benefit greatly from cardiovascular risk reduction,
therefore monitor and treat hypertension and dyslipidemias. (AGS)
Measurement of blood pressure in the standing position is indicated periodically, especially in
those at risk for postural hypotension. At least two measurements should be made and the average
recorded. After BP is at goal and stable, follow-up visits can usually be at 3- to 6-month intervals.
Comorbidities such as heart failure, associated diseases such as diabetes, and the need for
laboratory tests influence the frequency of visits. (JNC)
All individuals should be evaluated during health encounters to determine whether they are at
increased risk of having or of developing chronic kidney disease. This evaluation of risk factors
should include blood pressure measurement. (NKF)
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Measure #5: Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or
Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction
(LVSD)
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of heart failure and LVSD (LVEF
< 40%) who were prescribed ACE inhibitor or ARB therapy
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all heart failure patients
seen during the reporting period. This measure is intended to reflect the quality of services
provided for patients with heart failure and decreased left ventricular systolic function. The left
ventricular systolic dysfunction may be determined by quantitative or qualitative assessment, which
may be current or historical. Examples of a quantitative or qualitative assessment may include an
echocardiogram: 1) that provides a numerical value of left ventricular systolic dysfunction or 2) that
uses descriptive terms such as moderately or severely depressed left ventricular systolic function.
Any current or prior ejection fraction study documenting LVSD can be used to identify patients.
This measure may be reported by clinicians who perform the quality actions described in the
measure based on the services provided and the measure-specific denominator coding.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The listed numerator options are used to report
the numerator of the measure. The quality-data codes have been provided for registry only
measures for use by registries that utilize claims data. It is not necessary to submit these codes for
registry-based submissions. Do not report this measure via claims.
NUMERATOR:
Patients who were prescribed ACE inhibitor or ARB therapy
Definition:
Prescribed – May include prescription given to the patient for ACE inhibitor or ARB
therapy at one or more visits in the 12-month period OR patient already taking ACE
inhibitor or ARB therapy as documented in current medication list.
OR
Numerator Options:
Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB)
therapy prescribed (4009F)
AND
Left ventricular ejection fraction (LVEF) <40% or documentation of moderately or severely
depressed left ventricular systolic function (3021F)
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Documentation of medical reason(s) for not prescribing angiotensin converting enzyme
(ACE) inhibitor or angiotensin receptor blocker (ARB) therapy (4009F with 1P)
OR
Documentation of patient reason(s) for not prescribing angiotensin converting enzyme
(ACE) inhibitor or angiotensin receptor blocker (ARB) therapy (4009F with 2P)
OR
Documentation of system reason(s) for not prescribing angiotensin converting enzyme
(ACE) inhibitor or angiotensin receptor blocker (ARB) therapy (4009F with 3P)
AND
Left ventricular ejection fraction (LVEF) < 40% or documentation of moderately or severely
depressed left ventricular systolic function (3021F)
OR
OR
Left ventricular ejection fraction (LVEF) ≥ 40% or documentation as normal or mildly
depressed left ventricular systolic function (3022F)
OR
Left ventricular ejection fraction (LVEF) was not performed or documented (3021F with 8P)
Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB)
therapy was not prescribed, reason not otherwise specified (4009F with 8P)
AND
Left ventricular ejection fraction < 40% or documentation of moderately or severely
depressed left ventricular systolic function (3021F)
DENOMINATOR:
Heart failure patients aged 18 years and older with LVEF < 40% or with moderately or severely
depressed left ventricular systolic function
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for heart failure (ICD-9-CM): 398.91, 402.01, 402.11, 402.91, 404.01, 404.03,
404.11, 404.13, 404.91, 404.93, 425.0, 425.1, 425.2, 425.3, 425.4, 425.5, 425.7, 425.8,
425.9, 428.0, 428.1, 428.20, 428.21, 428.22, 428.23, 428.30, 428.31, 428.32, 428.33,
428.40, 428.41, 428.42, 428.43, 428.9
AND
Patient encounter during reporting period (CPT): 99201, 99202, 99203, 99204, 99205,
99212, 99213, 99214, 99215, 99238, 99239, 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
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RATIONALE:
In the absence of contraindications, ACE Inhibitors or ARBs are recommended for all patients with
symptoms of heart failure and reduced left ventricular systolic function, as measured by left
ventricular ejection fraction (LVEF). Both drugs have been shown to decrease mortality and
hospitalizations.
CLINICAL RECOMMENDATION STATEMENTS:
Angiotensin converting enzyme inhibitors are recommended for all patients with current or prior
symptoms of HF and reduced LVEF, unless contraindicated. (Class I Recommendation, Level of
Evidence: A)(ACC/AHA)
Angiotensin II receptor blockers approved for the treatment of HF are recommended in patients
with current or prior symptoms of HF and reduced LVEF who are ACEI-intolerant. (Class I
Recommendation, Level of Evidence: A) (ACC/AHA)
Angiotensin II receptor blockers are reasonable to use as alternatives to ACEIs as first-line therapy
for patients with mild to moderate HF and reduced LVEF, especially for patients already taking
ARBs for other indications. (Class IIa Recommendation, Level of Evidence: A) (ACC/AHA)
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Measure #6: Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for
Patients with CAD
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of CAD who were prescribed oral
antiplatelet therapy
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with coronary
artery disease seen during the reporting period. This measure may be reported by clinicians who
perform the quality actions described in the measure based on the services provided and the
measure-specific denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 3P- system
reasons, 8P- reason not otherwise specified. All measure-specific coding should be reported ON
THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients who were prescribed oral antiplatelet therapy
Numerator Instructions: Oral antiplatelet therapy consists of aspirin, clopidogrel or
combination of aspirin and extended release dipyridamole.
Definition:
Prescribed - May include prescription given to the patient for aspirin or clopidogrel at one
or more visits in the 12 month period OR patient already taking aspirin or clopidogrel as
documented in current medication list.
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OR
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Oral Antiplatelet Therapy Prescribed
CPT II 4011F: Oral antiplatelet therapy prescribed
Oral Antiplatelet Therapy not Prescribed for Medical, Patient, or System Reasons
Append a modifier (1P, 2P or 3P) to Category II code 4011F to report documented
circumstances that appropriately exclude patients from the denominator.
4011F with 1P: Documentation of medical reason(s) for not prescribing oral antiplatelet
therapy
4011F with 2P: Documentation of patient reason(s) for not prescribing oral antiplatelet
therapy
4011F with 3P: Documentation of system reason(s) for not prescribing oral antiplatelet
therapy
Oral Antiplatelet Therapy not Prescribed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4011F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4011F with 8P: Oral antiplatelet therapy was not prescribed, reason not otherwise
specified
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of coronary artery disease
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for CAD (line-item ICD-9-CM): 410.00, 410.01, 410.02, 410.10, 410.11,
410.12, 410.20, 410.21, 410.22, 410.30, 410.31, 410.32, 410.40, 410.41, 410.42, 410.50,
410.51, 410.52, 410.60, 410.61, 410.62, 410.70, 410.71, 410.72, 410.80, 410.81, 410.82,
410.90, 410.91, 410.92, 411.0, 411.1, 411.81, 411.89, 412, 413.0, 413.1, 413.9, 414.00,
414.01, 414.02, 414.03, 414.04, 414.05, 414.06, 414.07, 414.8, 414.9, V45.81, V45.82
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99238, 99239, 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
RATIONALE:
Oral antiplatelet therapy, preferably aspirin unless contraindicated, is recommended for all patients
with coronary artery disease. By limiting the ability of clots to form in the arteries, antiplatelet
agents have proven benefits in reducing the risk of non-fatal myocardial infarction, non-fatal stroke
and death.
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CLINICAL RECOMMENDATION STATEMENTS:
Chronic Stable Angina: Class I – Aspirin 75-325 mg daily should be used routinely in all patients
with acute and chronic ischemic heart disease with or without manifest symptoms in the absence of
contraindications. Class IIa – Clopidogrel is recommended when aspirin is absolutely
contraindicated. Class III – Dipyridamole. Because even the usual oral doses of dipyridamole can
enhance exercise-induced myocardial ischemia in patients with stable angina, it should not be
used as an antiplatelet agent. (ACC/AHA/ACP-ASIM)
Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction: Class I – Aspirin 75 to 325
mg/dl in the absence of contraindications. Class I – Clopidogrel 75 qd for patients with a
contraindication to ASA. (ACC/AHA)
Acute Myocardial Infarction (AMI): Class I – A dose of aspirin, 160 to 325 mg, should be given on
day one of AMI and continued indefinitely on a daily basis thereafter. Trials suggest long-term use
of aspirin in the postinfarction patient in a dose as low as 75 mg per day can be effective, with the
likelihood that side effects can be reduced. Class IIb – Other antiplatelet agents such as
dipyridamole, ticlopidine or clopidogrel may be substituted if true aspirin allergy is present or if the
patient is unresponsive to aspirin. (ACC/AHA)
Coronary Artery Bypass Graft Surgery: Aspirin is the drug of choice for prophylaxis against early
saphenous graft thrombotic closure and should be considered a standard of care for the first
postoperative year. In general, patients are continued on aspirin indefinitely, given its benefit in the
secondary prevention of AMI. Ticlopidine is efficacious but offers no advantage over aspirin except
as an alternative in the truly aspirin-allergic patient. Clopidogrel offers the potential of fewer side
effects compared with ticlopidine as an alternative to aspirin for platelet inhibition. Indobufen
appears to be as effective as aspirin for saphenous graft patency over the first postoperative year
but with fewer gastrointestinal side effects. Current evidence suggests that dipyridamole adds
nothing to the aspirin effect for saphenous graft patency. (ACC/AHA)
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Measure #7: Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients
with Prior Myocardial Infarction (MI)
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of CAD and prior MI who were
prescribed beta-blocker therapy
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with prior
myocardial infarction (MI) seen during the reporting period. This measure may be reported by
clinicians who perform the quality actions described in the measure based on the services provided
and the measure-specific denominator coding.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The listed numerator options are used to report
the numerator of the measure. The quality-data codes have been provided for registry only
measures for use by registries that utilize claims data. It is not necessary to submit these codes for
registry-based submissions. Do not report this measure via claims.
NUMERATOR:
Patients who were prescribed beta-blocker therapy
Definition:
Prescribed – May include prescription given to the patient for beta-blocker therapy at one
or more visits in the 12-month period OR patient already taking beta-blocker therapy as
documented in current medication list.
OR
OR
Numerator Options:
Beta-blocker therapy prescribed (4006F)
Beta-blocker therapy not prescribed for medical reason (4006F with 1P)
OR
Beta-blocker therapy not prescribed for patient reason (4006F with 2P)
OR
Beta-blocker therapy not prescribed for system reason (4006F with 3P)
Beta-blocker therapy not prescribed, reason not specified (4006F with 8P)
DENOMINATOR:
Patients aged 18 years and older with a diagnosis of coronary artery disease who also have prior
myocardial infarction (MI) at any time
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Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for CAD* (ICD-9-CM): 410.00*, 410.01*, 410.02*, 410.10*, 410.11*, 410.12*,
410.20*, 410.21*, 410.22*, 410.30*, 410.31*, 410.32*, 410.40*, 410.41*, 410.42*, 410.50*,
410.51*, 410.52*, 410.60*, 410.61*, 410.62*, 410.70*, 410.71*, 410.72*, 410.80*, 410.81*,
410.82*, 410.90*, 410.91*, 410.92*, 411.0, 411.1, 411.81, 411.89, 412*, 413.0, 413.1,
413.9, 414.00, 414.01, 414.02, 414.03, 414.04, 414.05, 414.06, 414.07, 414.8, 414.9,
V45.81, V45.82
AND
Diagnosis for MI – includes patient that had a prior MI at any time: (ICD-9-CM):
410.00, 410.01, 410.02, 410.10, 410.11, 410.12, 410.20, 410.21, 410.22, 410.30, 410.31,
410.32, 410.40, 410.41, 410.42, 410.50, 410.51, 410.52, 410.60, 410.61, 410.62, 410.70,
410.71, 410.72, 410.80, 410.81, 410.82, 410.90, 410.91, 410.92, 412
AND
Patient encounter during reporting period (CPT): 99201, 99202, 99203, 99204, 99205,
99212, 99213, 99214, 99215, 99238, 99239, 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
*Denominator inclusion for this measure requires the presence of a prior MI
diagnosis AND at least one E/M code during the measurement period. Diagnosis
codes for Coronary Artery Disease (which include MI diagnosis codes) may also
accompany the MI diagnosis code, but are not required for inclusion in the measure.
RATIONALE:
In the absence of contraindications, beta-blocker therapy has been shown to reduce the risk of a
recurrent MI and decrease mortality for those patients with a prior MI.
CLINICAL RECOMMENDATION STATEMENTS:
Chronic Stable Angina: Class I – Beta-blockers as initial therapy in the absence of
contraindications in patients with prior MI. Class I – Beta-blockers as initial therapy in the absence
of contraindications in patients without prior MI. (ACC/AHA/ACP-ASIM)
Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction: Class I – Drugs required in
the hospital to control ischemia should be continued after hospital discharge in patients who do not
undergo coronary revascularization, patients with unsuccessful revascularization, or patients with
recurrent symptoms after revascularization. Upward or downward titration of the doses may be
required. Class I – Beta-blockers in the absence of contraindications. (ACC/AHA)
Acute Myocardial Infarction: Class I – All but low-risk patients without a clear contraindication to ßadrenoceptor blocker therapy. Treatment should begin within a few days of the event (if not
initiated acutely) and continue indefinitely. Class IIa – Low-risk patients without a clear
contraindication to ß-adrenoceptor blocker therapy. Survivors of non-ST-elevation MI. Class IIb –
Patients with moderate or severe LV failure or other relative contraindications to ß-adrenoceptor
blocker therapy, provided they can be monitored closely. (ACC/AHA)
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Although no study has determined if long-term ß-adrenoceptor blocker therapy should be
administered to survivors of MI who subsequently have satisfactorily undergone revascularization,
there is no reason to believe that these agents act differently in coronary patients who have
undergone revascularization. (ACC/AHA)
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Measure #8: Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic
Dysfunction (LVSD)
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of heart failure who also have
LVSD (LVEF < 40%) and who were prescribed beta-blocker therapy
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all heart failure patients
seen during the reporting period. This measure is intended to reflect the quality of services
provided for patients with heart failure and decreased left ventricular systolic function. The left
ventricular systolic dysfunction may be determined by quantitative or qualitative assessment, which
may be current or historical. Examples of a quantitative or qualitative assessment may include an
echocardiogram: 1) that provides a numerical value of left ventricular systolic dysfunction or 2) that
uses descriptive terms such as moderately or severely depressed left ventricular systolic function.
Any current or prior ejection fraction study documenting LVSD can be used to identify patients.
This measure may be reported by clinicians who perform the quality actions described in the
measure based on the services provided and the measure-specific denominator coding.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The listed numerator options are used to report
the numerator of the measure. The quality-data codes have been provided for registry only
measures for use by registries that utilize claims data. It is not necessary to submit these codes for
registry-based submissions. Do not report this measure via claims.
NUMERATOR:
Patients who were prescribed beta-blocker therapy
Definition:
Prescribed – May include prescription given to the patient for beta-blocker therapy at one
or more visits in the 12-month period OR patient already taking beta-blocker therapy as
documented in current medication list.
Numerator Options:
Beta-blocker therapy prescribed for patients with left ventricular ejection fraction (LVEF)
<40% or documentation as moderately or severely depressed left ventricular systolic
function (G8450)
OR
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Clinician documented patient with left ventricular ejection fraction (LVEF) <40% or
documentation as moderately or severely depressed left ventricular systolic function was
not eligible candidate for beta-blocker therapy (G8451)
OR
OR
Left ventricular ejection fraction (LVEF) ≥ 40% or documentation as normal or mildly
depressed left ventricular systolic function (G8395)
OR
Left ventricular ejection fraction (LVEF) not performed or documented (G8396)
Beta-blocker therapy not prescribed for patients with left ventricular ejection fraction
(LVEF) <40% or documentation as moderately or severely depressed left ventricular
systolic function (G8452)
DENOMINATOR:
Patients aged 18 years and older with a diagnosis of heart failure with left ventricular ejection
fraction (LVEF) < 40% or with moderately or severely depressed left ventricular systolic function
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for heart failure (ICD-9-CM): 398.91, 402.01, 402.11, 402.91, 404.01, 404.03,
404.11, 404.13, 404.91, 404.93, 425.0, 425.1, 425.2, 425.3, 425.4, 425.5, 425.7, 425.8,
425.9, 428.0, 428.1, 428.20, 428.21, 428.22, 428.23, 428.30, 428.31, 428.32, 428.33,
428.40, 428.41, 428.42, 428.43, 428.9
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310,
99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343,
99344, 99345, 99347, 99348, 99349, 99350
RATIONALE:
Beta-blockers are recommended for all patients with symptoms of heart failure and left ventricular
systolic dysfunction, unless contraindicated. Treatment with beta-blockers has been shown to
provide multiple benefits to the patient, including reducing the symptoms of heart failure, improving
the clinical status of patients, and decreasing the risk of mortality and hospitalizations.
CLINICAL RECOMMENDATION STATEMENTS:
Beta-blockers (using 1 of the 3 proven to reduce mortality, i.e., bisoprolol, carvedilol, and sustained
release metoprolol succinate) are recommended for all stable patients with current or prior
symptoms of HF and reduced LVEF, unless contraindicated. (Class I Recommendation, Level of
Evidence: A) (ACC/AHA)
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Measure #9: Major Depressive Disorder (MDD): Antidepressant Medication During Acute
Phase for Patients with MDD
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older diagnosed with new episode of MDD and
documented as treated with antidepressant medication during the entire 84-day (12-week) acute
treatment phase
INSTRUCTIONS:
This measure is to be reported for each occurrence of MDD during the reporting period. This
measure may be reported by clinicians who perform the quality actions described in the measure
based on the services provided and the measure-specific denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. G-codes are used to report the numerator
of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate numerator G-code. All measure-specific coding should be reported ON THE
SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients with an 84-day (12-week) acute treatment of antidepressant medication
Numerator Instructions: Report G8126: 1) For all patients with a diagnosis of Major
Depression, New Episode who were prescribed a full 12-week course of antidepressant
medication OR 2) At the completion of a 12-week course of antidepressant medication.
Definition:
New Episode – Patient with major depression who has not been seen or treated for major
depression by any practitioner in the prior 4 months. A new episode can either be a
recurrence for a patient with prior major depression or a patient with a new onset of major
depression.
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OR
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Acute Treatment with Antidepressant Medication
G8126: Patient with new episode of MDD documented as being treated with
antidepressant medication during the entire 12 week acute treatment phase
Acute Treatment with Antidepressant Medication not Completed for Documented
Reasons
G8128: Clinician documented that patient with a new episode of MDD was not an eligible
candidate for antidepressant medication treatment or patient did not have a new episode
of MDD
Acute Treatment with Antidepressant Medication not Completed
G8127: Patient with new episode of MDD not documented as being treated with
antidepressant medication during the entire 12 week acute treatment phase
DENOMINATOR:
Patients 18 years and older diagnosed with a New Episode of MDD (major depression) and treated
with antidepressant medication
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for MDD (line-item ICD-9-CM): 296.20, 296.21, 296.22, 296.23, 296.24,
296.25, 296.30, 296.31, 296.32, 296.33, 296.34, 296.35, 298.0, 300.4, 309.0, 309.1, 311
AND
Patient encounter during the reporting period (CPT): 90801, 90802, 90804, 90805,
90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90821, 90822,
90823, 90824, 90829, 90845, 90849, 90853, 90857, 90862, 99078, 99201, 99202, 99203,
99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347,
99348, 99349, 99350
RATIONALE:
The consequences of untreated, or inadequately treated, depression are significant; therefore,
adherence to antidepressant medication is very important. Clinical guidelines for depression stress
the importance of effective clinical management in increasing patients’ medication compliance,
monitoring treatment effectiveness, and identifying and managing side effects. If pharmacological
treatment is initiated, appropriate dosing and continuation of therapy through the acute and
continuation phases decreases recurrence of depression. Thus, evaluation of length of treatment
serves as an important indicator of success in promoting patient compliance with the establishment
and maintenance of an effective medication regimen.
CLINICAL RECOMMENDATION STATEMENTS:
Successful treatment of patients with major depressive disorder is promoted by a thorough
assessment of the patient and close adherence to treatment plans. Treatment consists of an acute
phase, during which remission is induced; a continuation phase, during which remission is
preserved; and a maintenance phase, during which the susceptible patient is protected against the
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recurrence of a subsequent major depressive episode. Patients who have been treated with
antidepressant medications in the acute phase should be maintained on these agents to prevent
relapse. American Psychiatric Association (APA) Practice Guideline for the Treatment of Patients
with Major Depressive Disorder, 2000
Antidepressants should be continued for at least 6 months after remission of an episode of
depression, because this greatly reduces the risk of relapse. (A: At least one randomized controlled
trial as part of a body of literature of overall good quality and consistency addressing the specific
recommendation (evidence level-I) without extrapolation) National Institute for Clinical Excellence
(UK), Management of Depression in Primary and Secondary Care, 2004
In recent years, major depression has come to be considered a chronic and/or recurrent, rather
than an acute illness. This reevaluation of the disorder has inherent treatment implications because
patients with major depression tend to exhibit episodic recurrence and/or chronic residual
symptoms. Considering this, the management of depression can be divided into the acute phase
(suppression of symptoms to achieve clinical remission), lasting 8 to 12 weeks, and the
maintenance phase (prevention of relapse/recurrence), lasting 6 months or longer. Clinical
management is an important component of pharmacotherapy; and includes a brief session of
psychoeducation and supportive strategies. During the maintenance phase after remission of acute
symptoms, all patients should continue the antidepressant dose that induced remission for at least
6 months. The relapse rate is 35% to 60% if antidepressants are discontinued in the first 6 months,
compared with 10% to 25% in patients who continue medications. The risk of relapse is particularly
high if drug discontinuation occurs in the first few months of response/remission. Canadian
Psychiatric Association, 2001
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Measure #10: Stroke and Stroke Rehabilitation: Computed Tomography (CT) or Magnetic
Resonance Imaging (MRI) Reports
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of final reports for CT or MRI studies of the brain performed either:
• In the hospital within 24 hours of arrival, OR
• In an outpatient imaging center to confirm initial diagnosis of stroke, TIA or intracranial
hemorrhage.
For patients aged 18 years and older with either a diagnosis of ischemic stroke or TIA or
intracranial hemorrhage OR at least one documented symptom consistent with ischemic stroke or
TIA or intracranial hemorrhage that includes documentation of the presence or absence of each of
the following: hemorrhage and mass lesion and acute infarction
INSTRUCTIONS:
This measure is to be reported each time a CT or MRI study of the brain is performed in a hospital
or outpatient setting during the reporting period for patients with a diagnosis or symptom of
ischemic stroke, TIA, or intracranial hemorrhage. The “within 24 hours of arrival” requirement does
not apply to CT or MRI studies performed in an outpatient imaging center because it is the intent of
the measure to include these outpatient studies regardless of whether the patient is subsequently
referred to the hospital. It is anticipated that clinicians who provide the physician component of
diagnostic imaging studies for patients with stroke, TIA, or intracranial hemorrhage in the hospital
or outpatient setting will submit this measure. Note: Use of symptom codes is limited to those
specified in the denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis (includes symptom codes), CPT codes, and patient demographics
are used to identify patients who are included in the measure’s denominator. CPT Category II
codes are used to report the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis (including symptom
codes), CPT codes, and the appropriate CPT Category II code(s) OR the CPT Category II code(s)
with the modifier. The reporting modifier allowed for this measure is: 8P- reason not otherwise
specified. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes (includes symptom codes), CPT codes, and patient demographics are
used to identify patients who are included in the measure’s denominator. The numerator options as
described in the quality-data codes are used to report the numerator of the measure. The qualitydata codes listed do not need to be submitted for registry-based submissions; however, these
codes may be submitted for those registries that utilize claims data.
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NUMERATOR:
Final reports of the initial CT or MRI that include documentation of the presence or absence of
each of the following: hemorrhage and mass lesion and acute infarction
Definition: Equivalent terms or synonyms for hemorrhage, mass lesion, or infarction, if
documented in the CT or MRI report, would meet the measure
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
OR
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Presence/Absence of Hemorrhage, Mass Lesion, and Acute Infarction Documented
(Two CPT II codes [3110F & 3111F] are required on the claim form to submit this
numerator option)
CPT II 3110F: Documentation in the final CT or MRI report of presence or absence of
hemorrhage and mass lesion and acute infarction
AND
CPT II 3111F: CT or MRI of the brain performed in the hospital within 24 hours of arrival
OR performed in an outpatient imaging center to confirm initial diagnosis of stroke, TIA or
intracranial hemorrhage.
If patient is not eligible for this measure because CT or MRI of the brain was
performed in the hospital greater than 24 hours after arrival or performed in an
outpatient imaging center for the purpose other than confirmation of initial
diagnosis, report:
(One CPT II code [3112F] is required on the claim form to submit this numerator option)
CPT II 3112F: CT or MRI of the brain performed in the hospital greater than 24 hours after
arrival OR performed in an outpatient imaging center for purpose other than confirmation
of initial diagnosis of stroke, TIA or intracranial hemorrhage.
Presence/Absence of Hemorrhage, Mass Lesion, and Acute Infarction not
Documented, Reason not Specified
(Two CPT II codes [3110F-8P & 3111F] are required on the claim form to submit this
numerator option)
Append a reporting modifier (8P) to CPT Category II code 3110F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3110F with 8P: No documentation in final CT or MRI report of presence or absence of
hemorrhage and mass lesion and acute infarction, reason not otherwise
specified
AND
CPT II 3111F: CT or MRI of the brain performed in the hospital within 24 hours of arrival
OR performed in an outpatient imaging center to confirm initial diagnosis of stroke, TIA or
intracranial hemorrhage.
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DENOMINATOR:
All final reports for CT or MRI studies of the brain performed either:
• In the hospital within 24 hours of arrival OR
• In an outpatient imaging center to confirm initial diagnosis of stroke, TIA or intracranial
hemorrhage.*
For patients aged 18 years and older with either a diagnosis of ischemic stroke or TIA or
intracranial hemorrhage OR at least one documented symptom consistent with ischemic stroke
or TIA or intracranial hemorrhage
* Final reports for outpatient imaging studies of the brain performed to confirm initial diagnosis
are eligible for this measure whether or not patient is subsequently referred to the hospital.
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
For purposes of this measure, the listed symptoms will be considered “documented
symptoms consistent” with ischemic stroke or TIA or intracranial hemorrhage. Each of the
listed symptoms corresponds to a specific ICD-9-CM code in the code table below.
Note: Use of symptom codes is limited to the following:
•
•
•
•
•
•
Transient visual loss (368.12)
Diplopia (double vision) (368.2)
Vertigo of central origin (386.2)
Transient global amnesia (437.7)
Transient alteration of awareness (780.02)
Lack of coordination (781.3)
•
•
•
•
•
Transient paralysis of limb (781.4)
Facial weakness (781.94)
Disturbance of skin sensation (782.0)
Aphasia (784.3)
Slurred speech (784.51, 784.59)
Diagnosis for ischemic stroke or TIA or intracranial hemorrhage – including
symptom codes (line-item ICD-9-CM): 368.12, 368.2, 386.2, 431, 433.01, 433.11,
433.21, 433.31, 433.81, 433.91, 434.01, 434.11, 434.91, 435.0, 435.1, 435.2, 435.3,
435.8, 435.9, 437.7, 780.02, 781.3, 781.4, 781.94, 782.0, 784.3, 784.51, 784.59
AND
Patient encounter during the reporting period (CPT): 0042T, 70450, 70460, 70470,
70551, 70552, 70553
RATIONALE:
The CT and MRI findings are critical to initiating care for the patient with stroke. All CT and MRI
reports should address the presence or absence of these three important findings. This
documentation is particularly vital in the report of the first imaging study performed after arrival at
the hospital (whether or not the patient is admitted), on which initial treatment decisions will be
based. The denominator language and specifications also allow for inclusion of CT or MRI studies
performed in an outpatient imaging center to confirm initial diagnosis of stroke, TIA or intracranial
hemorrhage (i.e., not including follow-up studies performed after acute treatment for these
diagnoses), regardless of whether the patient is subsequently referred to the hospital.
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CLINICAL RECOMMENDATION STATEMENTS:
Brain imaging is required to guide acute intervention. (Grade A) There is a uniform agreement that
CT accurately identifies most cases of intracranial hemorrhage and helps discriminate nonvascular
causes of neurological symptoms, e.g., brain tumor. (Grade B) With the advent of rtPA treatment,
interest has grown in using CT to identify subtle, early signs of ischemic brain injury (early infarct
signs) or arterial occlusion that might affect decisions about treatment. The presence of these signs
is associated with poor outcomes. (Adams, ASA, 2003) (Class A)
A technically adequate head CT scan is required prior to administration of thrombolytic therapy to
exclude brain hemorrhage and nonischemic diagnoses. The baseline CT scan is also sensitive for
detection of early signs of cerebral infarction. Subtle or limited signs of early infarction on the CT
scan are common even within the first 3 h of stroke evolution.
Preliminary data suggest that specific MRI profiles may identify patients who are particularly likely
to benefit from thrombolytic therapy. New MRI techniques including perfusion-weighted and
diffusion-weighted may detect ischemic injury in the first hour and may reveal the extent of
reversible and irreversible injury. In addition, MRI appears to be highly sensitive for identification of
acute brain hemorrhage. (Albers, ACCP, 2004)
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Measure #12: Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of POAG who have an optic nerve
head evaluation during one or more office visits within 12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. It is anticipated that clinicians who provide the primary management of patients
with primary open-angle glaucoma (in either one or both eyes) will submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 8P- reason not otherwise specified.
All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients who have an optic nerve head evaluation during one or more office visits within 12 months
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Optic Nerve Head Evaluation Performed
CPT II 2027F: Optic nerve head evaluation performed
Optic Nerve Head Evaluation not Performed for Medical Reasons
Append a modifier (1P) to CPT Category II code 2027F to report documented
circumstances that appropriately exclude patients from the denominator.
2027F with 1P: Documentation of medical reason(s) for not performing an optic nerve
head evaluation
OR
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Optic Nerve Head Evaluation not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 2027F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
2027F with 8P: Optic nerve head evaluation was not performed, reason not otherwise
specified
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of primary open-angle glaucoma
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for primary open-angle glaucoma (line-item ICD-9-CM): 365.10, 365.11,
365.12, 365.15
AND
Patient encounter during the reporting period (CPT): 92002, 92004, 92012, 92014,
99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306,
99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336,
99337
RATIONALE:
Changes in the optic nerve are one of two characteristics which currently define progression and
thus worsening of glaucoma disease status (the other characteristic is visual field). There is a
significant gap in documentation patterns of the optic nerve for both initial and follow-up care
(Fremont, 2003), even among specialists (Lee, 2006). Examination of the optic nerve head and
retinal nerve fiber layer provides valuable structural information about glaucomatous optic nerve
damage. Visible structural alterations of the optic nerve head or retinal nerve fiber layer and
development of peripapillary choroidal atrophy frequently occur before visual field defects can be
detected. Careful study of the optic disc neural rim for small hemorrhages is important, since these
hemorrhages can precede visual field loss and further optic nerve damage.
CLINICAL RECOMMENDATION STATEMENTS:
The physical exam focuses on nine elements: visual acuity, pupils, slit-lamp biomicroscopy of the
anterior segment, measurement of intraocular pressure (IOP), determination of central corneal
thickness, gonioscopy, evaluation of optic nerve head and retinal nerve fiber layer, documentation
of optic nerve head appearance, evaluation of fundus (through dilated pupil), and evaluation of the
visual field. (Level A: II Recommendation for optic nerve head evaluation) (AAO, 2005)
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Measure #14: Age-Related Macular Degeneration (AMD): Dilated Macular Examination
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 50 years and older with a diagnosis of AMD who had a dilated
macular examination performed which included documentation of the presence or absence of
macular thickening or hemorrhage AND the level of macular degeneration severity during one or
more office visits within 12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. It is anticipated that clinicians who provide the primary management of patients
with age-related macular degeneration (in either one or both eyes) will submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 8P- reason not
otherwise specified. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients who had a dilated macular examination performed which included documentation of the
presence or absence of macular thickening or hemorrhage AND the level of macular degeneration
severity during one or more office visits within 12 months
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Dilated Macular Examination Performed
CPT II 2019F: Dilated macular exam performed, including documentation of the presence
or absence of macular thickening or hemorrhage AND the level of macular degeneration
severity
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OR
Dilated Macular Examination not Performed for Medical or Patient Reasons
Append a modifier (1P or 2P) to CPT Category II code 2019F to report documented
circumstances that appropriately exclude patients from the denominator.
2019F with 1P: Documentation of medical reason(s) for not performing a dilated macular
examination
2019F with 2P: Documentation of patient reason(s) for not performing a dilated macular
examination
Dilated Macular Examination not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 2019F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
2019F with 8P: Dilated macular exam was not performed, reason not otherwise specified
DENOMINATOR:
All patients aged 50 years and older with a diagnosis of age-related macular degeneration
Denominator Criteria (Eligible Cases):
Patients aged ≥ 50 years on date of encounter
AND
Diagnosis for age-related macular degeneration (line-item ICD-9-CM): 362.50, 362.51,
362.52
AND
Patient encounter during the reporting period (CPT): 92002, 92004, 92012, 92014,
99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306,
99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336,
99337
RATIONALE:
A documented complete macular examination is a necessary prerequisite to determine the
presence and severity of AMD, so that a decision can be made as to the benefits of prescribing
antioxidant vitamins. Further, periodic assessment is necessary to determine whether there is
progression of the disease and to plan the on-going treatment of the disease, since several
therapies exist that reduce vision loss once the advanced “wet” form of AMD occurs. While no data
exist on the frequency or absence of regular examinations of the macula for patients with AMD,
parallel data for key structural assessments for glaucoma, cataract and diabetic retinopathy
suggest that significant gaps are likely.
CLINICAL RECOMMENDATION STATEMENTS:
According to the American Academy of Ophthalmology, a stereo biomicroscopic examination of the
macula should be completed. Binocular slit-lamp biomicroscopy of the ocular fundus is often
necessary to detect subtle clinical clues of CNV. These include small areas of hemorrhage, hard
exudates, subretinal fluid, or pigment epithelial elevation. (Level A: III Recommendation) (AAO,
2005)
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Measure #18: Diabetic Retinopathy: Documentation of Presence or Absence of Macular
Edema and Level of Severity of Retinopathy
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a
dilated macular or fundus exam performed which included documentation of the level of severity of
retinopathy and the presence or absence of macular edema during one or more office visits within
12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. It is anticipated that clinicians who provide the primary management of patients
with diabetic retinopathy (in either one or both eyes) will submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 8P- reason not
otherwise specified. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients who had a dilated macular or fundus exam performed which included documentation of
the level of severity of retinopathy AND the presence or absence of macular edema during one or
more office visits within 12 months
Definition:
Medical Record – Must include: Documentation of the level of severity of retinopathy
(e.g., background diabetic retinopathy, proliferative diabetic retinopathy, non-proliferative
diabetic retinopathy) AND documentation of whether macular edema was present or
absent
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OR
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Macular or Fundus Exam Performed
CPT II 2021F: Dilated macular or fundus exam performed, including documentation of the
presence or absence of macular edema AND level of severity of retinopathy
Macular or Fundus Exam not Performed for Medical or Patient Reasons
Append a modifier (1P or 2P) to CPT Category II code 2021F to report documented
circumstances that appropriately exclude patients from the denominator.
2021F with 1P: Documentation of medical reason(s) for not performing a dilated macular
or fundus examination
2021F with 2P: Documentation of patient reason(s) for not performing a dilated macular or
fundus examination
Macular or Fundus Exam not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 2021F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
2021F with 8P: Dilated macular or fundus exam was not performed reason not otherwise
specified
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of diabetic retinopathy
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for diabetic retinopathy (line-item ICD-9-CM): 362.01, 362.02, 362.03,
362.04, 362.05, 362.06
AND
Patient encounter during the reporting period (CPT): 92002, 92004, 92012, 92014,
99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306,
99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336,
99337
RATIONALE:
Several level 1 RCT studies demonstrate the ability of timely treatment to reduce the rate and
severity of vision loss from diabetes (Diabetic Retinopathy Study – DRS, Early Treatment Diabetic
Retinopathy Study – ETDRS). Necessary examination prerequisites to applying the study results
are that the presence and severity of both peripheral diabetic retinopathy and macular edema be
accurately documented. In the RAND chronic disease quality project, while administrative data
indicated that roughly half of the patients had an eye exam in the recommended time period, chart
review data indicated that only 19% had documented evidence of a dilated examination. (McGlynn,
2003). Thus, ensuring timely treatment that could prevent 95% of the blindness due to diabetes
requires the performance and documentation of key examination parameters. The documented
level of severity of retinopathy and the documented presence or absence of macular edema assists
with the on-going plan of care for the patient with diabetic retinopathy.
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CLINICAL RECOMMENDATION STATEMENTS:
Since treatment is effective in reducing the risk of visual loss, detailed examination is indicated to
assess for the following features that often lead to visual impairment: presence of macular edema,
optic nerve neovascularization and/or neovascularization elsewhere, signs of severe NPDR and
vitreous or preretinal hemorrhage. (Level A:III Recommendation) (AAO, 2003)
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Measure #19: Diabetic Retinopathy: Communication with the Physician Managing
On-going Diabetes Care
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a
dilated macular or fundus exam performed with documented communication to the physician who
manages the on-going care of the patient with diabetes mellitus regarding the findings of the
macular or fundus exam at least once within 12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all patients with diabetic
retinopathy seen during the reporting period. It is anticipated that clinicians who provide the primary
management of patients with diabetic retinopathy (in either one or both eyes) will submit this
measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II and/or G-codes are used
to report the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code AND/OR G-code OR the CPT Category II code with the
modifier AND G-code. The modifiers allowed for this measure are: 2P- patient reasons, 8P- reason
not otherwise specified. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients with documentation, at least once within 12 months, of the findings of the dilated macular
or fundus exam via communication to the physician who manages the patient’s diabetic care
Definition:
Communication – May include documentation in the medical record indicating that the
results of the dilated macular or fundus exam were communicated (e.g., verbally, by letter)
with the clinician managing the patient’s diabetic care OR a copy of a letter in the medical
record to the clinician managing the patient’s diabetic care outlining the findings of the
dilated macular or fundus exam.
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NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Dilated Macular or Fundus Exam Findings Communicated
(One CPT II code & one G-code [5010F & G8397] are required on the claim form to submit
this numerator option)
CPT II 5010F: Findings of dilated macular or fundus exam communicated to the physician
managing the diabetes care
AND
G8397: Dilated macular or fundus exam performed, including documentation of the
presence or absence of macular edema AND level of severity of retinopathy
Dilated Macular or Fundus Exam Findings not Communicated for Patient Reasons
(One CPT II code & one G-code [5010F-2P & G8397] are required on the claim form to
submit this numerator option)
Append a modifier (2P) to CPT Category II code 5010F to report documented
circumstances that appropriately exclude patients from the denominator.
5010F with 2P: Documentation of patient reason(s) for not communicating the findings of
the dilated macular or fundus exam to the physician who manages the
on-going care of the patient with diabetes
AND
G8397: Dilated macular or fundus exam performed, including documentation of the
presence or absence of macular edema AND level of severity of retinopathy
OR
OR
If patient is not eligible for this measure because patient did not have dilated
macular or fundus exam performed, report:
(One G-code [G8398] is required on the claim form to submit this numerator option)
G8398: Dilated macular or fundus exam not performed
Dilated Macular or Fundus Exam Findings not Communicated, Reason not Specified
(One CPT II code & one G-code [5010F-8P & G8397] are required on the claim form to
submit this numerator option)
Append a reporting modifier (8P) to CPT Category II code 5010F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
5010F with 8P: Findings of dilated macular or fundus exam was not communicated to the
physician managing the diabetes care, reason not otherwise specified
AND
G8397: Dilated macular or fundus exam performed, including documentation of the
presence or absence of macular edema AND level of severity of retinopathy
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DENOMINATOR:
All patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated
macular or fundus exam performed
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for diabetic retinopathy (line-item ICD-9-CM): 362.01, 362.02, 362.03,
362.04, 362.05, 362.06
AND
Patient encounter during the reporting period (CPT): 92002, 92004, 92012, 92014,
99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306,
99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336,
99337
RATIONALE:
The physician that manages the on-going care of the patient with diabetes should be aware of the
patient’s dilated eye examination and severity of retinopathy to manage the on-going diabetes
care. Such communication is important in assisting the physician to better manage the diabetes.
Several studies have shown that better management of diabetes is directly related to lower rates of
development of diabetic eye disease. (Diabetes Control and Complications Trial – DCCT, UK
Prospective Diabetes Study – UKPDS)
CLINICAL RECOMMENDATION STATEMENTS:
While it is clearly the responsibility of the ophthalmologist to manage eye disease, it is also the
ophthalmologist’s responsibility to ensure that patients with diabetes are referred for appropriate
management of their systemic condition. It is the realm of the patient’s family physician, internist or
endocrinologist to manage the systemic diabetes. The ophthalmologist should communicate with
the attending physician. (Level A: III Recommendation) (AAO, 2003)
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Measure #20: Perioperative Care: Timing of Antibiotic Prophylaxis – Ordering Physician
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of surgical patients aged 18 years and older undergoing procedures with the
indications for prophylactic parenteral antibiotics, who have an order for prophylactic parenteral
antibiotic to be given within one hour (if fluoroquinolone or vancomycin, two hours), prior to the
surgical incision (or start of procedure when no incision is required)
INSTRUCTIONS:
This measure is to be reported each time a procedure is performed during the reporting period for
patients who undergo surgical procedures with the indications for prophylactic parenteral
antibiotics. There is no diagnosis associated with this measure. It is anticipated that clinicians who
perform the listed surgical procedures as specified in the denominator coding will submit this
measure.
Measure Reporting via Claims:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. CPT Category II codes are used to report the numerator of the measure. If
multiple surgical procedures were performed on the same date of service and submitted on the
same claim form, it is not necessary for the same clinician to submit the CPT Category II code with
each procedure. However, if multiple NPIs are reporting this measure on the same claim, each NPI
should report the quality-data code.
When reporting the measure via claims, submit the listed CPT codes, and the appropriate CPT
Category II code OR the CPT Category II code with the modifier. The modifiers allowed for this
measure are: 1P- medical reasons, 8P- reason not otherwise specified. All measure-specific
coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. The numerator options as described in the quality-data codes are used to
report the numerator of the measure. The quality-data codes listed do not need to be submitted for
registry-based submissions; however, these codes may be submitted for those registries that utilize
claims data.
NUMERATOR:
Surgical patients who have an order for prophylactic parenteral antibiotic to be given within one
hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical incision (or start of
procedure when no incision is required)
Numerator Instructions: There must be documentation of order (written order, verbal
order, or standing order/protocol) specifying that prophylactic parenteral antibiotic is to be
given within one hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical
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incision (or start of procedure when no incision is required) OR documentation that
prophylactic parenteral antibiotic has been given within one hour (if fluoroquinolone or
vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision
is required).
Note: In the event surgery is delayed, as long as the patient is redosed (if clinically
appropriate) the numerator coding should be applied.
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Table 1A: The antimicrobial drugs listed below are considered prophylactic parenteral
antibiotics for the purposes of this measure. 4047F-8P should be reported when antibiotics
from this table were not ordered.
• Ampicillin/sulbactam
• Cefuroxime
• Gentamicin
• Aztreonam
• Ciprofloxacin
• Levofloxacin
• Cefazolin
• Clindamycin
• Metronidazole
• Cefmetazole
• Ertapenem
• Moxifloxacin
• Cefotetan
• Erythromycin base
• Neomycin
• Cefoxitin
• Gatifloxacin
• Vancomycin
OR
OR
Documentation of Order for Prophylactic Parenteral Antibiotic (written order, verbal
order, or standing order/protocol)
CPT II 4047F: Documentation of order for prophylactic parenteral antibiotics to be given
within one hour (if fluoroquinolone or vancomycin, two hours) prior to surgical incision (or
start of procedure when no incision is required)
OR
Documentation that Prophylactic Parenteral Antibiotic has been Given within One
Hour Prior to the Surgical Incision (or start of procedure when no incision is
required)
CPT II 4048F: Documentation that administration of prophylactic parenteral antibiotic was
initiated within one hour (if fluoroquinolone or vancomycin, two hours) prior to surgical
incision (or start of procedure when no incision is required), as ordered.
Order for Prophylactic Parenteral Antibiotic not Given for Medical Reasons
Append a modifier (1P) to CPT Category II code 4047F to report documented
circumstances that appropriately exclude patients from the denominator.
4047F with 1P: Documentation of medical reason(s) for not ordering prophylactic
parenteral antibiotics to be given within one hour (if fluoroquinolone or
vancomycin, two hours) prior to the surgical incision (or start of procedure
when no incision is required)
Order for Administration of Prophylactic Parenteral Antibiotic not Given, Reason not
Specified
Append a reporting modifier (8P) to CPT Category II code 4047F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
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4047F with 8P: Prophylactic parenteral antibiotics were not ordered to be given or given
within one hour (if fluoroquinolone or vancomycin, two hours) prior to the
surgical incision (or start of procedure when no incision is required),
reason not otherwise specified
DENOMINATOR:
All surgical patients aged 18 years and older undergoing procedures with the indications for
prophylactic parenteral antibiotics
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Patient encounter during the reporting period (CPT): Listed below are surgical
procedures for which prophylactic parenteral antibiotics are indicated.
SURGICAL PROCEDURE
Integumentary
Le Fort Fractures
Mandibular Fracture
Spine
Hip Reconstruction
Trauma (Fractures)
Knee Reconstruction
Laryngectomy
Vascular
Spleen and Lymph Nodes
Glossectomy
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CPT CODE
15734, 15738, 19260, 19271, 19272, 19301, 19302,
19303, 19304, 19305, 19306, 19307, 19361, 19364,
19366, 19367, 19368, 19369
21346, 21347, 21348, 21422, 21423, 21432, 21433,
21435, 21436
21454, 21461, 21462, 21465, 21470
22325, 22612, 22630, 22800, 22802, 22804, 63030,
63042
27125, 27130, 27132, 27134, 27137, 27138
27235, 27236, 27244, 27245, 27269, 27758, 27759,
27766, 27769, 27792, 27814
27440, 27441, 27442, 27443, 27445, 27446, 27447
31360, 31365, 31367, 31368, 31370, 31375, 31380,
31382, 31390, 31395
33877, 33880, 33881, 33883, 33886, 33891, 34800,
34802, 34803, 34804, 34805, 34825, 34830, 34831,
34832, 34900, 35081, 35091, 35102, 35131, 35141,
35151, 35601, 35606, 35612, 35616, 35621, 35623,
35626, 35631, 35632, 35633, 35634, 35636, 35637,
35638, 35642, 35645, 35646, 35647, 35650, 35651,
35654, 35656, 35661, 35663, 35665, 35666, 35671,
36830
38115
41130, 41135, 41140, 41145, 41150, 41153, 41155
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SURGICAL PROCEDURE
Esophagus
Stomach
Small Intestine
Colon and Rectum
Anus and Rectum
Hepatic Surgery
Biliary Surgery
Pancreas
Abdomen, Peritoneum, & Omentum
Renal Transplant
Gynecologic Surgery
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CPT CODE
43045, 43100, 43101, 43107, 43108, 43112, 43113,
43116, 43117, 43118, 43121, 43122, 43123, 43124,
43130, 43135, 43300, 43305, 43310, 43312, 43313,
43320, 43324, 43325, 43326, 43330, 43331, 43340,
43341, 43350, 43351, 43352, 43360, 43361, 43400,
43401, 43405, 43410, 43415, 43420, 43425, 43496
43500, 43501, 43502, 43510, 43520, 43605, 43610,
43611, 43620, 43621, 43622, 43631, 43632, 43633,
43634, 43640, 43641, 43653, 43800, 43810, 43820,
43825, 43830, 43831, 43832, 43840, 43843, 43845,
43846, 43847, 43848, 43850, 43855, 43860, 43865,
43870
44005, 44010, 44020, 44021, 44050, 44055, 44100,
44120, 44125, 44126, 44127, 44130, 44132, 44133,
44135, 44136
43880, 44025, 44110, 44111, 44140, 44141, 44143,
44144, 44145, 44146, 44147, 44150, 44151, 44155,
44156, 44157, 44158, 44160, 44202, 44204, 44205,
44206, 44207, 44208, 44210, 44211, 44212, 44300,
44310, 44312, 44314, 44316, 44320, 44322, 44340,
44345, 44346, 44602, 44603, 44604, 44605, 44615,
44620, 44625, 44626, 44640, 44650, 44660, 44661,
44700, 44950, 51597
45108, 45110, 45111, 45112, 45113, 45114, 45116,
45119, 45120, 45121, 45123, 45126, 45130, 45135,
45136, 45150, 45160, 45171, 45172, 45190, 45500,
45505, 45520, 45540, 45541, 45550, 45560, 45562,
45563, 45800, 45805, 45820, 45825
47135, 47136, 47140, 47141, 47142
47420, 47425, 47460, 47480, 47560, 47561, 47570,
47600, 47605, 47610, 47612, 47620, 47700, 47701,
47711, 47712, 47715, 47720, 47721, 47740, 47741,
47760, 47765, 47780, 47785, 47800, 47802, 47900
48020, 48100, 48120, 48140, 48145, 48146, 48148,
48150, 48152, 48153, 48154, 48155, 48500, 48510,
48511, 48520, 48540, 48545, 48547, 48548, 48554,
48556
49215, 49568
50320, 50340, 50360, 50365, 50370, 50380
58150, 58152, 58180, 58200, 58210, 58260, 58262,
58263, 58267, 58270, 58275, 58280, 58285, 58290,
58291, 58292, 58293, 58294
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SURGICAL PROCEDURE
Acoustic Neuroma
Cochlear Implants
Neurological Surgery
Cardiothoracic Surgery
Cardiothoracic (Pacemaker)
Genitourinary Surgery
General Thoracic Surgery
Foot & Ankle
Version 4.0
Version 4.0
CPT CODE
61520, 61526, 61530, 61591, 61595, 61596, 61598,
61606, 61616, 61618, 61619, 69720, 69955, 69960,
69970
69930
22524, 22554, 22558, 22600, 22612, 22630, 35301,
61154, 61312, 61313, 61315, 61510, 61512, 61518,
61548, 61697, 61700, 61750, 61751, 61867, 62223,
62230, 63015, 63020, 63030, 63042, 63045, 63047,
63056, 63075, 63081, 63267, 63276
33120, 33130, 33140, 33141, 33202, 33250, 33251,
33256, 33261, 33305, 33315, 33321, 33322, 33332,
33335, 33400, 33401, 33403, 33404, 33405, 33406,
33410, 33411, 33413, 33416, 33422, 33425, 33426,
33427, 33430, 33460, 33463, 33464, 33465, 33475,
33496, 33510, 33511, 33512, 33513, 33514, 33516,
33517, 33518, 33519, 33521, 33522, 33523, 33530,
33533, 33534, 33535, 33536, 33542, 33545, 33548,
33572, 35211, 35241, 35271
33203, 33206, 33207, 33208, 33212, 33213, 33214,
33215, 33216, 33217, 33218, 33220, 33222, 33223,
33224, 33225, 33226, 33233, 33234, 33235, 33236,
33237, 33238, 33240, 33241, 33243, 33244, 33249,
33254, 33255
51550, 51555, 51565, 51570, 51575, 51580, 51585,
51590, 51595, 51596, 51920, 51925, 52450, 52601,
52630, 52647, 52648, 52649, 54401, 54405, 54406,
54408, 54410, 54415, 54416, 55801, 55810, 55812,
55815, 55821, 55831, 55840, 55842, 55845
19272, 21627, 21632, 21740, 21750, 21805, 21825,
31760, 31766, 31770, 31775, 31786, 31805, 32095,
32100, 32110, 32120, 32124, 32140, 32141, 32150,
32215, 32220, 32225, 32310, 32320, 32402, 32440,
32442, 32445, 32480, 32482, 32484, 32486, 32488,
32491, 32500, 32501, 32800, 32810, 32815, 32900,
32905, 32906, 32940, 33020, 33025, 33030, 33031,
33050, 33300, 33310, 33320, 34051, 35021, 35216,
35246, 35276, 35311, 35481, 35526, 37616, 38381,
38746, 39000, 39010, 39200, 39220, 39545, 39561,
60521, 60522, 64746
27702, 27703, 27704, 28192, 28193, 28293, 28415,
28420, 28445, 28465, 28485, 28505, 28525, 28531,
28555, 28585, 28615, 28645, 28675, 28705, 28715,
28725, 28730, 28735, 28737
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RATIONALE:
The appropriate timing of administration of prophylactic parenteral antibiotics has been
demonstrated to reduce the incidence of surgical wound infections. Specifying the time of
administration in the order is critical as available evidence suggests that the drug should be
received within one hour before incision for maximum antimicrobial effect.
CLINICAL RECOMMENDATION STATEMENTS:
The anti-infective drug should ideally be given within 30 minutes to 1 hour before the initial incision
to ensure its presence in an adequate concentration in the targeted tissues. For most procedures,
scheduling administration at the time of induction of anesthesia ensures adequate concentrations
during the period of potential contamination. Exceptions: cesarean procedures (after cross
clamping of the umbilical cord); colonic procedures (starting 19 hours before the scheduled time of
surgery). (ASHP)
Infusion of the first antimicrobial dose should begin within 60 minutes before incision. However,
when a fluoroquinolone or vancomycin is indicated, the infusion should begin within 120 minutes
before incision to prevent antibiotic-associated reactions. Although research has demonstrated that
administration of the antimicrobial at the time of anesthesia induction is safe and results in adequate
serum and tissue drug levels at the time of incision, there was no consensus that the infusion must
be completed before incision. (SIPGWW)
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Measure #21: Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second
Generation Cephalosporin
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of surgical patients aged 18 years and older undergoing procedures with the
indications for a first OR second generation cephalosporin prophylactic antibiotic, who had an order
for cefazolin OR cefuroxime for antimicrobial prophylaxis
INSTRUCTIONS:
This measure is to be reported each time a procedure is performed during the reporting period for
patients who undergo surgical procedures with the indications for a first or second generation
cephalosporin prophylactic antibiotic. There is no diagnosis associated with this measure. It is
anticipated that clinicians who perform the listed surgical procedures as specified in the
denominator coding will submit this measure.
Measure Reporting via Claims:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. CPT Category II codes are used to report the numerator of the measure. If
multiple surgical procedures were performed on the same date of service and submitted on the
same claim form, it is not necessary for the same clinician to submit the CPT Category II code with
each procedure. However, if multiple NPIs are reporting this measure on the same claim, each NPI
should report the quality-data code.
When reporting the measure via claims, submit the listed CPT codes, and the appropriate CPT
Category II code OR the CPT Category II code with the modifier. The modifiers allowed for this
measure are: 1P- medical reasons, 8P- reason not otherwise specified. All measure-specific
coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. The numerator options as described in the quality-data codes are used to
report the numerator of the measure. The quality-data codes listed do not need to be submitted for
registry-based submissions; however, these codes may be submitted for those registries that utilize
claims data.
NUMERATOR:
Surgical patients who had an order for cefazolin OR cefuroxime for antimicrobial prophylaxis
Numerator Instructions: There must be documentation of order (written order, verbal
order, or standing order/protocol) for cefazolin or cefuroxime for antimicrobial prophylaxis
OR documentation that cefazolin or cefuroxime was given.
Note: In the event surgery is delayed, as long as the patient is redosed (if clinically
appropriate) the numerator coding should be applied.
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Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Acceptable First and Second Generation Cephalosporin Prophylactic Antibiotics
First generation cephalosporin: cefazolin
Second generation cephalosporin: cefuroxime
OR
OR
Documentation of order for cefazolin OR cefuroxime for antimicrobial prophylaxis
(written order, verbal order, or standing order/protocol)
CPT II 4041F: Documentation of order for cefazolin OR cefuroxime for antimicrobial
prophylaxis
Note: CPT Category II code 4041F is provided for antibiotic ordered or antibiotic given.
Report CPT Category II code 4041F if cefazolin OR cefuroxime was given for antimicrobial
prophylaxis.
Order for First or Second Generation Cephalosporin not Ordered for Medical
Reasons
Append a modifier (1P) to CPT Category II code 4041F to report documented
circumstances that appropriately exclude patients from the denominator.
4041F with 1P: Documentation of medical reason(s) for not ordering cefazolin OR
cefuroxime for antimicrobial prophylaxis
Order for First or Second Generation Cephalosporin not Ordered, Reason not
Specified
Append a reporting modifier (8P) to CPT Category II code 4041F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4041F with 8P: Order for cefazolin OR cefuroxime for antimicrobial prophylaxis was not
documented, reason not otherwise specified
DENOMINATOR:
All surgical patients aged 18 years and older undergoing procedures with the indications for a first
or second generation cephalosporin prophylactic antibiotic
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Patient encounter during the reporting period (CPT): Listed below are surgical
procedures with indications for first or second generation cephalosporin prophylactic
antibiotic.
SURGICAL PROCEDURE
Integumentary
Spine
Hip Reconstruction
Version 4.0
Version 4.0
CPT CODE
15734, 15738, 19260, 19271, 19272, 19301, 19302,
19303, 19304, 19305, 19306, 19307, 19361, 19364,
19366, 19367, 19368, 19369
22325, 22612, 22630, 22800, 22802, 22804, 63030,
63042
27125, 27130, 27132, 27134, 27137, 27138
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SURGICAL PROCEDURE
Trauma (Fractures)
Knee Reconstruction
Vascular
Spleen and Lymph Nodes
Esophagus
Stomach
Small Intestine
Biliary Surgery
Pancreas
Abdomen, Peritoneum &
Omentum
Renal Transplant
Neurological Surgery
Version 4.0
Version 4.0
CPT CODE
27235, 27236, 27244, 27245, 27269, 27758, 27759,
27766, 27769, 27792, 27814
27440, 27441, 27442, 27443, 27445, 27446, 27447
33877, 33880, 33881, 33883, 33886, 33891, 34800,
34802, 34803, 34804, 34805, 34825, 34830, 34831,
34832, 34900, 35081, 35091, 35102, 35131, 35141,
35151, 35601, 35606, 35612, 35616, 35621, 35623,
35626, 35631, 35632, 35633, 35634, 35636, 35637,
35638, 35642, 35645, 35646, 35647, 35650, 35651,
35654, 35656, 35661, 35663, 35665, 35666, 35671,
36830
38115
43045, 43100, 43101, 43107, 43108, 43112, 43113,
43116, 43117, 43118, 43121, 43122, 43123, 43124,
43130, 43135, 43300, 43305, 43310, 43312, 43313,
43320, 43324, 43325, 43326, 43330, 43331, 43340,
43341, 43350, 43351, 43352, 43360, 43361, 43400,
43401, 43405, 43410, 43415, 43420, 43425, 43496
43500, 43501, 43502, 43510, 43520, 43605, 43610,
43611, 43620, 43621, 43622, 43631, 43632, 43633,
43634, 43640, 43641, 43653, 43800, 43810, 43820,
43825, 43830, 43831, 43832, 43840, 43843, 43845,
43846, 43847, 43848, 43850, 43855, 43860, 43865,
43870
44005, 44010, 44020, 44021, 44050, 44055, 44100,
44120, 44125, 44126, 44127, 44130, 44132, 44133,
44135, 44136
47420, 47425, 47460, 47480, 47560, 47561, 47570,
47600, 47605, 47610, 47612, 47620, 47700, 47701,
47711, 47712, 47715, 47720, 47721, 47740, 47741,
47760, 47765, 47780, 47785, 47800, 47802, 47900
48020, 48100, 48120, 48140, 48145, 48146, 48148,
48150, 48152, 48153, 48154, 48155, 48500, 48510,
48511, 48520, 48540, 48545, 48547, 48548, 48554,
48556
49215, 49568
50320, 50340, 50360, 50365, 50370, 50380
22524, 22554, 22558, 22600, 22612, 22630, 35301,
61154, 61312, 61313, 61315, 61510, 61512, 61518,
61548, 61697, 61700, 61750, 61751, 61867, 62223,
62230, 63015, 63020, 63030, 63042, 63045, 63047,
63056, 63075, 63081, 63267, 63276
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SURGICAL PROCEDURE
Cardiothoracic Surgery
General Thoracic Surgery
Foot & Ankle
CPT CODE
33120, 33130, 33140, 33141, 33202, 33250, 33251,
33256, 33261, 33305, 33315, 33321, 33322, 33332,
33335, 33400, 33401, 33403, 33404, 33405, 33406,
33410, 33411, 33413, 33416, 33422, 33425, 33426,
33427, 33430, 33460, 33463, 33464, 33465, 33475,
33496, 33510, 33511, 33512, 33513, 33514, 33516,
33517, 33518, 33519, 33521, 33522, 33523, 33530,
33533, 33534, 33535, 33536, 33542, 33545, 33548,
33572, 35211, 35241, 35271
19272, 21627, 21632, 21740, 21750, 21805, 21825,
31760, 31766, 31770, 31775, 31786, 31805, 32095,
32100, 32110, 32120, 32124, 32140, 32141, 32150,
32215, 32220, 32225, 32310, 32320, 32402, 32440,
32442, 32445, 32480, 32482, 32484, 32486, 32488,
32491, 32500, 32501, 32800, 32810, 32815, 32900,
32905, 32906, 32940, 33020, 33025, 33030, 33031,
33050, 33300, 33310, 33320, 34051, 35021, 35216,
35246, 35276, 35311, 35481, 35526, 37616, 38381,
38746, 39000, 39010, 39200, 39220, 39545, 39561,
60521, 60522, 64746
27702, 27703, 27704, 28192, 28193, 28293, 28415,
28420, 28445, 28465, 28485, 28505, 28525, 28531,
28555, 28585, 28615, 28645, 28675, 28705, 28715,
28725, 28730, 28735, 28737
RATIONALE:
Current published evidence supports the use of either cefazolin, a first generation cephalosporin,
or cefuroxime, a second generation cephalosporin, for many surgical procedures, in the absence of
β-lactam allergy. An alternative antimicrobial regimen may be appropriate depending on the
antimicrobial susceptibility pattern in an individual institution (potentially a medical reason for
excluding patients treated at that institution from this measure.)
CLINICAL RECOMMENDATION STATEMENTS:
For most procedures, cefazolin should be the agent of choice because of its relatively long duration
of action, its effectiveness against the organisms most commonly encountered in surgery, and its
relatively low cost. (ASHP)
In operations for which cephalosporins represent appropriate prophylaxis, alternative antimicrobials
should be provided to those with a high likelihood of serious adverse reaction or allergy on the
basis of patient history or diagnostic tests such as skin testing.
The preferred antimicrobials for prophylaxis in patients undergoing hip or knee arthroplasty are
cefazolin and cefuroxime. Vancomycin or clindamycin may be used in patients with serious allergy
or adverse reactions to β-lactams.
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The recommended antimicrobials for cardiothoracic and vascular operations include cefazolin or
cefuroxime. For patients with serious allergy or adverse reaction to β-lactams, vancomycin is
appropriate, and clindamycin may be an acceptable alternative. (SIPGWW)
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Measure #22: Perioperative Care: Discontinuation of Prophylactic Antibiotics (NonCardiac Procedures)
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of non-cardiac surgical patients aged 18 years and older undergoing procedures with
the indications for prophylactic parenteral antibiotics AND who received a prophylactic parenteral
antibiotic, who have an order for discontinuation of prophylactic parenteral antibiotics within 24
hours of surgical end time
INSTRUCTIONS:
This measure is to be reported each time a procedure is performed during the reporting period for
patients who undergo non-cardiac surgical procedures with the indications for prophylactic
parenteral antibiotics. There is no diagnosis associated with this measure. It is anticipated that
clinicians who perform the listed surgical procedures as specified in the denominator coding will
submit this measure.
Measure Reporting via Claims:
CPT codes and patient demographics are used to identify patients who are included in the
denominator. CPT Category II codes are used to report the numerator of the measure. If multiple
surgical procedures were performed on the same date of service and submitted on the same claim
form, it is not necessary for the same clinician to submit the CPT Category II code with each
procedure. However, if multiple NPIs are reporting this measure on the same claim, each NPI
should report the quality-data code.
When reporting the measure via claims, submit the listed CPT codes, and the appropriate CPT
Category II code(s) OR the CPT Category II code(s) with the modifier. The modifiers allowed for
this measure are: 1P- medical reasons, 8P- reason not otherwise specified. All measure-specific
coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. The numerator options as described in the quality-data codes are used to
report the numerator of the measure. The quality-data codes listed do not need to be submitted for
registry-based submissions; however, these codes may be submitted for those registries that utilize
claims data.
NUMERATOR:
Non-cardiac surgical patients who have an order for discontinuation of prophylactic parenteral
antibiotics within 24 hours of surgical end time
Numerator Instructions: There must be documentation of order (written order, verbal
order, or standing order/protocol) specifying that prophylactic parenteral antibiotic is to be
discontinued within 24 hours of surgical end time OR specifying a course of antibiotic
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administration limited to that 24-hour period (e.g., “to be given every 8 hours for three
doses” or for “one time” IV dose orders) OR documentation that prophylactic parenteral
antibiotic was discontinued within 24 hours of surgical end time.
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Documentation of Order for Discontinuation of Prophylactic Parenteral Antibiotics
(written order, verbal order, or standing order/protocol) Within 24 Hours of Surgical
End Time
(Two CPT II codes [4049F & 4046F] are required on the claim form to submit this
numerator option)
CPT II 4049F: Documentation that order was given to discontinue prophylactic antibiotics
within 24 hours of surgical end time, non-cardiac procedure
Note: CPT Category II code 4049F is provided for documentation that antibiotic
discontinuation was ordered or that antibiotic discontinuation was accomplished. Report
CPT Category II code 4049F if antibiotics were discontinued within 24 hours.
AND
CPT II 4046F: Documentation that prophylactic antibiotics were given within 4 hours prior
to surgical incision or given intraoperatively
Prophylactic Parenteral Antibiotics not Discontinued for Medical Reasons
(Two CPT II codes [4049F-1P & 4046F] are required on the claim form to submit this
numerator option)
Append a modifier (1P) to CPT Category II code 4049F to report documented
circumstances that appropriately exclude patients from the denominator.
4049F with 1P: Documentation of medical reason(s) for not discontinuing prophylactic
antibiotics within 24 hours of surgical end time
AND
CPT II 4046F: Documentation that prophylactic antibiotics were given within 4 hours prior
to surgical incision or given intraoperatively
OR
OR
If patient is not eligible for this measure because patient did not receive
prophylactic parenteral antibiotics within specified timeframe, report:
(One CPT II code [4042F] is required on the claim form to submit this numerator option)
CPT II 4042F: Documentation that prophylactic antibiotics were neither given within 4
hours prior to surgical incision nor given intraoperatively
Prophylactic Parenteral Antibiotics not Discontinued, Reason not Specified
(Two CPT II codes [4049F-8P & 4046F] are required on the claim form to submit this
numerator option)
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Append a reporting modifier (8P) to CPT Category II code 4049F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4049F with 8P: Order was not given to discontinue prophylactic antibiotics within 24 hours
of surgical end time, non-cardiac procedure, reason not otherwise
specified
AND
CPT II 4046F: Documentation that prophylactic antibiotics were given within 4 hours prior
to surgical incision or given intraoperatively
DENOMINATOR:
All non-cardiac surgical patients aged 18 years and older undergoing procedures with the
indications for prophylactic parenteral antibiotics AND who received a prophylactic parenteral
antibiotic.
Denominator Instructions: For the purpose of this measure of antibiotic discontinuation,
patients may be counted as having “received a prophylactic parenteral antibiotic” if the
antibiotic was received within 4 hours prior to the surgical incision (or start of procedure
when no incision is required) or intraoperatively.
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Patient encounter during the reporting period (CPT): Listed below are non-cardiac
surgical procedures for which prophylactic parenteral antibiotics are indicated.
SURGICAL PROCEDURE
Integumentary
Le Fort Fractures
Mandibular Fracture
Spine
Hip Reconstruction
Trauma (Fractures)
Knee Reconstruction
Laryngectomy
Version 4.0
Version 4.0
CPT CODE
15734, 15738, 19260, 19271, 19272, 19301, 19302,
19303, 19304, 19305, 19306, 19307, 19361, 19364,
19366, 19367, 19368, 19369
21346, 21347, 21348, 21422, 21423, 21432, 21433,
21435, 21436
21454, 21461, 21462, 21465, 21470
22325, 22612, 22630, 22800, 22802, 22804, 63030,
63042
27125, 27130, 27132, 27134, 27137, 27138
27235, 27236, 27244, 27245, 27269, 27758, 27759,
27766, 27769, 27792, 27814
27440, 27441, 27442, 27443, 27445, 27446, 27447
31360, 31365, 31367, 31368, 31370, 31375, 31380,
31382, 31390, 31395
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SURGICAL PROCEDURE
Vascular
Glossectomy
Esophagus
Stomach
Small Intestine
Colon and Rectum
Anus and Rectum
Biliary Surgery
Pancreas
Version 4.0
Version 4.0
CPT CODE
33877, 33880, 33881, 33883, 33886, 33891, 34800,
34802, 34803, 34804, 34805, 34825, 34830, 34831,
34832, 34900, 35081, 35091, 35102, 35131, 35141,
35151, 35601, 35606, 35612, 35616, 35621, 35623,
35626, 35631, 35632, 35633, 35634, 35636, 35637,
35638, 35642, 35645, 35646, 35647, 35650, 35651,
35654, 35656, 35661, 35663, 35665, 35666, 35671,
36830
41130, 41135, 41140, 41145, 41150, 41153, 41155
43045, 43100, 43101, 43107, 43108, 43112, 43113,
43116, 43117, 43118, 43121, 43122, 43123, 43124,
43130, 43135, 43300, 43305, 43310, 43312, 43313,
43320, 43324, 43325, 43326, 43330, 43331, 43340,
43341, 43350, 43351, 43352, 43360, 43361, 43400,
43401, 43405, 43410, 43415, 43420, 43425, 43496
43500, 43501, 43502, 43510, 43520, 43605, 43610,
43611, 43620, 43621, 43622, 43631, 43632, 43633,
43634, 43640, 43641, 43653, 43800, 43810, 43820,
43825, 43830, 43831, 43832, 43840, 43843, 43845,
43846, 43847, 43848, 43850, 43855, 43860, 43865,
43870
44005, 44010, 44020, 44021, 44050, 44055, 44100,
44120, 44125, 44126, 44127, 44130, 44132, 44133,
44135, 44136
43880, 44025, 44110, 44111, 44140, 44141, 44143,
44144, 44145, 44146, 44147, 44150, 44151, 44155,
44156, 44157, 44158, 44160, 44202, 44204, 44205,
44206, 44207, 44208, 44210, 44211, 44212, 44300,
44310, 44312, 44314, 44316, 44320, 44322, 44340,
44345, 44346, 44615, 44620, 44625, 44626, 44640,
44650, 44660, 44661, 44700, 44950, 51597
45108, 45110, 45111, 45112, 45113, 45114, 45116,
45119, 45120, 45121, 45123, 45126, 45130, 45135,
45136, 45150, 45160, 45171, 45172, 45190, 45500,
45505, 45520, 45540, 45541, 45550, 45560, 45562,
45563, 45800, 45805, 45820, 45825
47420, 47425, 47460, 47480, 47560, 47561, 47570,
47600, 47605, 47610, 47612, 47620, 47700, 47701,
47711, 47712, 47715, 47720, 47721, 47740, 47741,
47760, 47765, 47780, 47785, 47800, 47802, 47900
48020, 48100, 48120, 48140, 48145, 48146, 48148,
48150, 48152, 48153, 48154, 48155, 48500, 48510,
48511, 48520, 48540, 48545, 48547, 48548, 48554,
48556
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SURGICAL PROCEDURE
Abdomen, Peritoneum, &
Omentum
Renal Transplant
Gynecologic Surgery
Acoustic Neuroma
Cochlear Implants
Neurological Surgery
Cardiothoracic
(Pacemaker)
General Thoracic Surgery
Foot & Ankle
49215, 49568
CPT CODE
50320, 50340, 50360, 50365, 50370, 50380
58150, 58152, 58180, 58200, 58210, 58260, 58262,
58263, 58267, 58270, 58275, 58280, 58285, 58290,
58291, 58292, 58293, 58294
61520, 61526, 61530, 61591, 61595, 61596, 61598,
61606, 61616, 61618, 61619, 69720, 69955, 69960,
69970
69930
22524, 22554, 22558, 22600, 22612, 22630, 35301,
61154, 61312, 61313, 61315, 61510, 61512, 61518,
61548, 61697, 61700, 61750, 61751, 61867, 62223,
62230, 63015, 63020, 63030, 63042, 63045, 63047,
63056, 63075, 63081, 63267, 63276
33203, 33206, 33207, 33208, 33212, 33213, 33214,
33215, 33216, 33217, 33218, 33220, 33222, 33223,
33224, 33225, 33226, 33233, 33234, 33235, 33236,
33237, 33238, 33240, 33241, 33243, 33244, 33249,
33254, 33255
19272, 21627, 21632, 21740, 21750, 21805, 21825,
31760, 31766, 31770, 31775, 31786, 31805, 32095,
32100, 32110, 32120, 32124, 32140, 32141, 32150,
32215, 32220, 32225, 32310, 32320, 32402, 32440,
32442, 32445, 32480, 32482, 32484, 32486, 32488,
32491, 32500, 32501, 32800, 32810, 32815, 32900,
32905, 32906, 32940, 33020, 33025, 33030, 33031,
33050, 33202, 33300, 33310, 33320, 33321, 33322,
34051, 35021, 35211, 35216, 35241, 35246, 35271,
35276, 35311, 35481, 35526, 37616, 38381, 38746,
39000, 39010, 39200, 39220, 39545, 39561, 60521,
60522, 64746
27702, 27703, 27704, 28192, 28193, 28293, 28415,
28420, 28445, 28465, 28485, 28505, 28525, 28531,
28555, 28585, 28615, 28645, 28675, 28705, 28715,
28725, 28730, 28735, 28737
RATIONALE:
There is no evidence there is added benefit of prolonged prophylactic parenteral antibiotic use.
Prolonged use may increase antibiotic resistant organisms.
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CLINICAL RECOMMENDATION STATEMENTS:
At a minimum, antimicrobial coverage must be provided from the time of incision to closure of the
incision. For most procedures, the duration of antimicrobial prophylaxis should be 24 hours or less,
with the exception of cardiothoracic procedures (up to 72 hours’ duration) and ophthalmic
procedures (duration not clearly established). (ASHP)
Prophylactic antimicrobials should be discontinued within 24 hours after the operation. (SIPGWW)
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Measure #23: Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When
Indicated in ALL Patients)
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older undergoing procedures for which VTE prophylaxis
is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low-Dose
Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis
to be given within 24 hours prior to incision time or within 24 hours after surgery end time
INSTRUCTIONS:
This measure is to be reported each time a procedure is performed during the reporting period for
all patients who undergo surgical procedures for which VTE prophylaxis is indicated. There is no
diagnosis associated with this measure. It is anticipated that clinicians who perform the listed
surgical procedures as specified in the denominator coding will submit this measure.
Measure Reporting via Claims:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. CPT Category II codes are used to report the numerator of the measure. If
multiple surgical procedures were performed on the same date of service and submitted on the
same claim form, it is not necessary for the same clinician to submit the CPT Category II code with
each procedure. However, if multiple NPIs are reporting this measure on the same claim, each NPI
should report the quality-data code.
When reporting the measure via claims, submit the listed CPT codes, and the appropriate CPT
Category II code OR the CPT Category II code with the modifier. The modifiers allowed for this
measure are: 1P- medical reasons, 8P- reason not otherwise specified. All measure-specific
coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. The numerator options as described in the quality-data codes are used to
report the numerator of the measure. The quality-data codes listed do not need to be submitted for
registry-based submissions; however, these codes may be submitted for those registries that utilize
claims data.
NUMERATOR:
Surgical patients who had an order for LMWH, LDUH, adjusted-dose warfarin, fondaparinux or
mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after
surgery end time
Numerator Instructions: There must be documentation of order (written order, verbal
order, or standing order/protocol) for VTE prophylaxis OR documentation that VTE
prophylaxis was given.
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Definition:
Mechanical Prophylaxis – Does not include TED hose.
OR
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Appropriate VTE Prophylaxis Ordered
CPT II 4044F: Documentation that an order was given for venous thromboembolism (VTE)
prophylaxis to be given within 24 hours prior to incision time or 24 hours after surgery end
time
Note: A single CPT Category II code is provided for VTE prophylaxis ordered or VTE
prophylaxis given. If VTE prophylaxis is given, report 4044F.
VTE Prophylaxis not Ordered for Medical Reasons
Append a modifier (1P) to CPT Category II code 4044F to report documented
circumstances that appropriately exclude patients from the denominator.
4044F with 1P: Documentation of medical reason(s) for patient not receiving any form of
VTE prophylaxis (LMWH, LDUH, adjusted-dose warfarin, fondaparinux or
mechanical prophylaxis) within 24 hours prior to incision time or 24 hours
after surgery end time
VTE Prophylaxis not Ordered, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4044F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4044F with 8P: Order was not given for venous thromboembolism (VTE) prophylaxis to be
given within 24 hours prior to incision time or 24 hours after surgery end
time, reason not otherwise specified
DENOMINATOR:
All surgical patients aged 18 years and older undergoing procedures for which VTE prophylaxis is
indicated in all patients
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Patient encounter during the reporting period (CPT): Listed below are surgical
procedures for which VTE prophylaxis is indicated.
SURGICAL PROCEDURE
Neurological Surgery
Hip Reconstruction
Knee Reconstruction
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22558, 22600, 22612, 22630, 61313, 61510,
61512, 61518, 61548, 61697, 61700, 62230,
63015, 63020, 63047, 63056, 63081, 63267,
63276
27125, 27130, 27132, 27134, 27137, 27138
27440, 27441, 27442, 27443, 27445, 27446,
27447
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SURGICAL PROCEDURE
Genitourinary Surgery
Gynecologic Surgery
Hip Fracture Surgery
General Surgery
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CPT CODE
50020, 50220, 50225, 50230, 50234, 50236,
50240, 50320, 50340, 50360, 50365, 50370,
50380, 50543, 50545, 50546, 50547, 50548,
50715, 50722, 50725, 50727, 50728, 50760,
50770, 50780, 50782, 50783, 50785, 50800,
50810, 50815, 50820, 50947, 50948, 51550,
51555, 51565, 51570, 51575, 51580, 51585,
51590, 51595, 51596, 51597, 51800, 51820,
51900, 51920, 51925, 51960, 55810, 55812,
55815, 55821, 55831, 55840, 55842, 55845,
55866
56630, 56631, 56632, 56633, 56634, 56637,
56640, 58200, 58210, 58240, 58285, 58951,
58953, 58954, 58956
27235, 27236, 27244, 27245, 27269
19260, 19271, 19272, 19301, 19302, 19303,
19304, 19305, 19306, 19307, 19316, 19318,
19324, 19325, 19328, 19330, 19342, 19350,
19355, 19357, 19361, 19364, 19366, 19367,
19368, 19369, 19370, 19371, 19380, 38100,
38101, 38115, 38120, 38571, 38572, 38700,
38720, 38724, 38740, 38745, 38747, 38760,
38765, 38770, 38780, 39501, 39502, 39503,
39520, 39530, 39531, 39540, 39541, 39545,
39560, 39561, 43020, 43030, 43045, 43100,
43101, 43107, 43108, 43112, 43113, 43116,
43117, 43118, 43121, 43122, 43123, 43124,
43130, 43135, 43279, 43280,43281, 43282,
43300, 43305, 43310, 43312, 43313, 43314,
43320, 43324, 43325, 43326, 43330, 43331,
43340, 43341, 43350, 43351, 43352, 43360,
43361, 43400, 43401, 43405, 43410, 43415,
43420, 43425, 43496, 43500, 43501, 43502,
43510, 43520, 43605, 43610, 43611, 43620,
43621, 43622, 43631, 43632, 43633, 43634,
43640, 43641, 43644, 43645, 43651, 43652,
43653, 43770, 43771, 43772, 43773, 43774,
43775, 43800, 43810, 43820, 43825, 43830,
43832, 43840, 43843, 43845, 43846, 43847,
43848, 43850, 43855, 43860, 43865, 43870,
43880, 43886, 43887, 43888, 44005, 44010,
44020, 44021, 44025, 44050, 44055, 44110,
44111, 44120, 44125, 44126, 44127, 44130,
44140, 44141, 44143, 44144, 44145, 44146,
44147, 44150, 44151, 44155, 44156, 44157,
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SURGICAL PROCEDURE
CPT CODE
44158, 44160, 44180, 44186, 44187, 44188,
44202, 44204, 44205, 44206, 44207, 44208,
44210, 44211, 44212, 44227, 44300, 44310,
44312, 44314, 44316, 44320, 44322, 44340,
44345, 44346, 44602, 44603, 44604, 44605,
44615, 44620, 44625, 44626, 44640, 44650,
44660, 44661, 44680, 44700, 44800, 44820,
44850, 44900, 44950, 44960, 44970, 45000,
45020, 45100, 45108, 45110, 45111, 45112,
45113, 45114, 45116, 45119, 45120, 45121,
45123, 45126, 45130, 45135, 45136, 45150,
45160, 45171, 45172, 45190, 45395, 45397,
45400, 45402, 45500, 45505, 45550, 45560,
45562, 45563, 45800, 45805, 45820, 45825,
46715, 46716, 46730, 46735, 46740, 46742,
46744, 46746, 46748, 46750, 46751, 46753,
46754, 46760, 46761, 46762, 47010, 47100,
47120, 47122, 47125, 47130, 47135, 47136,
47140, 47141, 47142, 47300, 47350, 47360,
47361, 47362, 47370, 47371, 47380, 47381,
47382, 47400, 47420, 47425, 47460, 47480,
47500, 47505, 47560, 47561, 47562, 47563,
47564, 47570, 47600, 47605, 47610, 47612,
47620, 47630, 47700, 47701, 47711, 47712,
47715, 47720, 47721, 47740, 47741, 47760,
47765, 47780, 47785, 47800, 47801, 47802,
47900, 48000, 48001, 48020, 48100, 48105,
48120, 48140, 48145, 48146, 48148, 48150,
48152, 48153, 48154, 48155, 48500, 48510,
48520, 48540, 48545, 48547, 48548, 48554,
48556, 49000, 49002, 49010, 49020, 49040,
49060, 49203, 49204, 49205, 49215, 49220,
49250, 49255, 49320, 49321, 49322, 49323,
49560, 49561, 49565, 49566, 49570, 50320,
50340, 50360, 50365, 50370, 50380, 60200,
60210, 60212, 60220, 60225, 60240, 60252,
60254, 60260, 60270, 60271, 60280, 60281,
60500, 60502, 60505, 60520, 60521, 60522,
60540, 60545, 60600, 60605, 60650
RATIONALE:
This measure addresses VTE risk based on surgical procedure. VTE prophylaxis is appropriate for
all patients undergoing these procedures regardless of individual patient thromboembolic risk
factors.
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Additional work is needed to determine if a physician-level measure for VTE prophylaxis can be
developed to address individual patient thromboembolic risk factors, in addition to procedural risk,
without creating data collection burden. Many of these procedures are done in hospitals and ASCs,
but quite a few are performed in the physician's office. There are many reasons for the differences
in the site of service, including that breast lesions and breast tissue varies considerably. Some
women have a small breast and a small lesion that can be expeditiously treated as a minor office
procedure done in 20 minutes under local anesthesia. In this instance, the evidence for DVT
prophylaxis is simply not present. Other patients have small or large lesions located in difficult
positions within a dense complex breast. In this instance, the patients have long procedures under
general anesthesia. Both of these instances can occur within the same CPT code. It should be
noted that the number of medical exclusions for these codes will likely be much higher than other
codes to account for the variation in major and minor procedures within the same CPT code.
Duration of VTE prophylaxis is not specified in the measure due to varying guideline
recommendations for different patient populations.
CLINICAL RECOMMENDATION STATEMENTS:
Recommend that mechanical methods of prophylaxis be used primarily in patients who are at high
risk of bleeding (Grade 1C+) or as an adjunct to anticoagulant-based prophylaxis (Grade 2A).
Recommend against the use of aspirin alone as prophylaxis against VTE for any patient group
(Grade 1A).
Recommend consideration of renal impairment when deciding on doses of LMWH, fondaparinux,
the direct thrombin inhibitors, and other antithrombotic drugs that are cleared by the kidneys,
particularly in elderly patients and those who are at high risk for bleeding (Grade 1C+).
Moderate-risk general surgery patients are those patients undergoing a non-major procedure and
are between the ages of 40 and 60 years or have additional risk factors, or those patients who
are undergoing major operations and are < 40 years of age with no additional risk factors.
Recommend prophylaxis with LDUH, 5,000 U bid or LMWH ≤ 3,400 U once daily (both Grade 1A).
Higher-risk general surgery patients are those undergoing non-major surgery and are > 60 years of
age or have additional risk factors, or patients undergoing major surgery who are > 40 years of
age or have additional risk factors. Recommend thromboprophylaxis with LDUH, 5,000 U tid or
LMWH, > 3,400 U daily (both Grade 1A).
Recommend that thromboprophylaxis be used in all major gynecologic surgery patients (Grade
1A).
For patients undergoing major, open urologic procedures, recommend routine prophylaxis with
LDUH twice daily or three times daily (Grade 1A).
Patients undergoing major orthopedic surgery, which includes hip and knee arthroplasty and hip
fracture repair, represent a group that is at particularly high risk for VTE, and routine
thromboprophylaxis has been the standard of care for > 15 years. Elective total hip replacement:
routine use of LMWH, fondaparinux, or adjusted-dose VKA (all Grade 1A). Elective total knee
arthroplasty: routine thromboprophylaxis using LMWH, fondaparinux, or adjusted-dose VKA (all
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Grade 1A). Hip fracture surgery: routine use of fondaparinux (Grade 1A), LMWH (Grade 1C+),
adjusted-dose VKA (Grade 2B), or LDUH (Grade 1B).
For major orthopedic surgical procedures, recommend that a decision about the timing of the
initiation of pharmacologic prophylaxis be based on the efficacy-to-bleeding tradeoffs for that
particular agent (Grade 1A). For LMWH, there are only small differences between starting
preoperatively or postoperatively, both options acceptable (Grade 1A).
Recommend that thromboprophylaxis be routinely used in patients undergoing major neurosurgery
(Grade 1A). (ACCP)
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Measure #24: Osteoporosis: Communication with the Physician Managing On-going Care
Post-Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 50 years and older treated for a hip, spine, or distal radial fracture with
documentation of communication with the physician managing the patient’s on-going care that a
fracture occurred and that the patient was or should be tested or treated for osteoporosis
INSTRUCTIONS:
This measure is to be reported after each occurrence of a fracture during the reporting period. It is
anticipated that clinicians who treat the hip, spine, or distal radial fracture will submit this measure.
Each occurrence of a fracture is identified by either an ICD-9-CM diagnosis code for fracture or
osteoporosis and a CPT service code OR an ICD-9-CM diagnosis code for fracture or osteoporosis
and a CPT procedure code for surgical treatment of a fracture.
Patients with a fracture of the hip, spine, or distal radius should have documentation in the medical
record of communication from the clinician treating the fracture to the clinician managing the
patient’s on-going care that the fracture occurred and that the patient was or should be tested or
treated for osteoporosis. If multiple fractures occurring on the same date of service are submitted
on the same claim form, only one instance of reporting will be counted. Claims data will be
analyzed to determine unique occurrences. Documentation must indicate that communication to
the clinician managing the on-going care of the patient occurred within three months of treatment
for the fracture. The CPT Category II code should be reported during the episode of care (e.g.,
treatment of the fracture). The reporting of the code and documentation of communication do not
need to occur simultaneously.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 8P- reason not
otherwise specified. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data.
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NUMERATOR:
Patients with documentation of communication with the physician managing the patient’s on-going
care that a fracture occurred and that the patient was or should be tested or treated for
osteoporosis
Definition:
Communication – May include documentation in the medical record indicating that the
clinician treating the fracture communicated (e.g., verbally, by letter, DXA report was sent)
with the clinician managing the patient’s on-going care OR a copy of a letter in the medical
record outlining whether the patient was or should be treated for osteoporosis.
OR
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Post Fracture Care Communication Documented
CPT II 5015F: Documentation of communication that a fracture occurred and that the
patient was or should be tested or treated for osteoporosis
Post Fracture Care not Communicated for Medical or Patient Reasons
Append a modifier (1P or 2P) to CPT Category II code 5015F to report documented
circumstances that appropriately exclude patients from the denominator.
5015F with 1P: Documentation of medical reason(s) for not communicating with physician
managing on-going care of patient that a fracture occurred and that the
patient was or should be tested or treated for osteoporosis
5015F with 2P: Documentation of patient reason(s) for not communicating with the
physician managing on-going care of patient that a fracture occurred and
that the patient was or should be tested or treated for osteoporosis
Post Fracture Care not Communicated, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 5015F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
5015F with 8P: No documentation of communication that a fracture occurred and that the
patient was or should be tested or treated for osteoporosis, reason not
otherwise specified
DENOMINATOR:
All patients aged 50 years and older treated for hip, spine, or distal radial fracture
Eligible cases are determined, and must be reported, if either of the following conditions are met:
Option 1 - Denominator Criteria (Eligible Cases):
Patients aged ≥ 50 years on date of encounter
AND
Diagnosis for hip, spine or distal radial fracture (line-item ICD-9-CM): 805.00, 805.01,
805.02, 805.03, 805.04, 805.05, 805.06, 805.07, 805.08, 805.2, 805.4, 805.6, 805.8,
813.40, 813.41, 813.42, 813.44, 813.45, 813.47, 813.50, 813.51, 813.52, 813.54, 820.00,
820.01, 820.02, 820.03, 820.09, 820.20, 820.21, 820.22, 820.8
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AND
Patient encounter during the reporting period (CPT) – Service codes: 99201, 99202,
99203, 99204, 99205, 99212, 99213, 99214, 99215
OR
Option 2 - Denominator Criteria (Eligible Cases):
Patients aged ≥ 50 years on the date of encounter
AND
Diagnosis for hip, spine or distal radial fracture (line-item ICD-9-CM): 733.00, 733.01,
733.02, 733.03, 733.09 805.00, 805.01, 805.02, 805.03, 805.04, 805.05, 805.06, 805.07,
805.08, 805.2, 805.4, 805.6, 805.8, 813.40, 813.41, 813.42, 813.44, 813.45, 813.47,
813.50, 813.51, 813.52, 813.54, 820.00, 820.01, 820.02, 820.03, 820.09, 820.20, 820.21,
820.22, 820.8
AND
Patient encounter during the reporting period (CPT) – Procedure codes: 22305,
22310, 22315, 22318, 22319, 22325, 22326, 22327, 22520, 22521, 22523, 22524, 25600,
25605, 25606, 25607, 25608, 25609, 27230, 27232, 27235, 27236, 27238, 27240, 27244,
27245, 27246, 27248
RATIONALE:
Patients who experience fragility fractures should either be treated or screened for the presence of
osteoporosis. Although the fracture may be treated by the orthopedic surgeon, the testing and/or
treatment is likely to be under the responsibility of the physician providing on-going care. It is
important the physician providing on-going care for the patient be made aware the patient has
sustained a non-traumatic fracture. There is a high degree of variability and consensus by experts
of what constitutes a fragility fracture and predictor of an underlying problem of osteoporosis. The
work group determined that only those fractures, which have the strongest consensus and
evidence that they are predictive of osteoporosis, should be included in the measure at this time.
We anticipate that the list of fractures will expand as further evidence is published supporting the
inclusion of other fractures.
CLINICAL RECOMMENDATION STATEMENTS:
The most important risk factors for osteoporosis-related fractures are a prior low-trauma fracture as
an adult and a low BMD in patients with or without fractures. (AACE)
BMD measurement should be performed in all women 40 years old or older who have sustained a
fracture. (AACE)
The decision to measure bone density should follow an individualized approach. It should be
considered when it will help the patient decide whether to institute treatment to prevent
osteoporotic fracture. It should also be considered in patients receiving glucocorticoid therapy for 2
months or more and patients with other conditions that place them at high risk for osteoporotic
fracture. (NIH)
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The most commonly used measurement to diagnose osteoporosis and predict fracture risk is
based on assessment of BMD by dual-energy X-ray absorptiometry (DXA). (NIH) Measurements of
BMD made at the hip predict hip fracture better than measurements made at other sites while BMD
measurement at the spine predicts spine fracture better than measures at other sites. (NIH)
The single most powerful predictor of a future osteoporotic fracture is the presence of previous
such fractures. (AGA)
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Measure #28: Aspirin at Arrival for Acute Myocardial Infarction (AMI)
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients, regardless of age, with an emergency department discharge diagnosis of
AMI who had documentation of receiving aspirin within 24 hours before emergency department
arrival or during emergency department stay
INSTRUCTIONS:
This measure is to be reported each time during the reporting period a patient has been discharged
from the emergency department with a diagnosis of AMI. Patients who are discharged from the
emergency department with a diagnosis of AMI should have documentation in the medical record
of having received aspirin 24 hours before emergency department arrival or during emergency
department stay. It is anticipated that clinicians who provide care in the emergency department will
submit this measure. The Part B claim form place of service field must indicate that the encounter
has taken place in the emergency department.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes and CPT codes are used to identify patients who are included
in the measure’s denominator. CPT Category II codes are used to report the numerator of the
measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 8P- reason not
otherwise specified. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes and CPT codes are used to identify patients who are included in the
measure’s denominator. The numerator options as described in the quality-data codes are used to
report the numerator of the measure. The quality-data codes listed do not need to be submitted for
registry-based submissions; however, these codes may be submitted for those registries that utilize
claims data.
NUMERATOR:
Patients who had documentation of receiving aspirin within 24 hours before emergency department
arrival or during emergency department stay
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Aspirin Received or Taken 24 Hours Before Emergency Department Arrival or
During Emergency Department Stay
CPT II 4084F: Aspirin received within 24 hours before emergency department arrival or
during emergency department stay
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OR
Aspirin not Received or Taken 24 Hours Before Emergency Department Arrival or
During Emergency Department Stay for Medical or Patient Reasons
Append a modifier (1P or 2P) to CPT Category II code 4084F to report documented
circumstances that appropriately exclude patients from the denominator.
4084F with 1P: Documentation of medical reason(s) for not receiving or taking aspirin
within 24 hours before emergency department arrival or during emergency
department stay
4084F with 2P: Documentation of patient reason(s) for not receiving or taking aspirin
within 24 hours before emergency department arrival or during emergency
department stay
Aspirin not Received or Taken 24 Hours Before Emergency Department Arrival or
During Emergency Department Stay, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4084F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4084F with 8P: Aspirin was not received within 24 hours before emergency department
arrival or during emergency department stay, reason not otherwise
specified
DENOMINATOR:
All patients, regardless of age, with an emergency department discharge diagnosis of acute
myocardial infarction
Denominator Criteria (Eligible Cases):
Diagnosis for acute myocardial infarction (line-item ICD-9-CM): 410.01, 410.11,
410.21, 410.31, 410.41, 410.51, 410.61, 410.71, 410.81, 410.91
AND
Patient encounter during the reporting period (CPT): 99281, 99282, 99283, 99284,
99285, 99291
AND
Place of Service Indicator: 23
(The Part B claim form place of service field must indicate emergency department)
RATIONALE:
The emergency physician should document that the patient received aspirin no matter where or
when the aspirin was taken.
CLINICAL RECOMMENDATION STATEMENTS:
Aspirin should be chewed by patients who have not taken aspirin before presentation with STEMI.
The initial dose should be 162 mg (Level A) to 325 mg (Level C). Although some trials have used
enteric-coated aspirin for initial dosing, more rapid buccal absorption occurs with non–entericcoated aspirin formulations. (ACC/AHA)
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Measure #30: Perioperative Care: Timely Administration of Prophylactic Parenteral
Antibiotics
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of surgical patients aged 18 years and older who receive an anesthetic when
undergoing procedures with the indications for prophylactic parenteral antibiotics for whom
administration of the prophylactic parenteral antibiotic ordered has been initiated within one hour (if
fluoroquinolone or vancomycin, two hours) prior to the surgical incision (or start of procedure when
no incision is required)
INSTRUCTIONS:
This measure is to be reported each time an anesthesia service in the denominator is provided for
surgical patients during the reporting period. There is no diagnosis associated with this measure. It
is anticipated that clinicians who provide anesthesia services, as specified in the denominator
coding*, will submit this measure - reporting on the timeliness of antibiotic administration. The
clinician providing anesthesia services does not need to be the clinician who ordered the
prophylactic parenteral antibiotic.
* The anesthesia services included in the denominator are associated with some surgical
procedures for which prophylactic parenteral antibiotics may not be indicated. As a result, clinicians
should report 4047F-8P for those instances in which anesthesia services are provided but not
associated with surgical procedures for which prophylactic parenteral antibiotics are indicated.
If the clinician providing anesthesia services orders AND administers the prophylactic antibiotic
within the appropriate timeframe, report quality-data code CPT II 4048F. Report CPT II 4048F with
the 1P modifier in circumstances where the prophylactic parenteral antibiotic was not given for
medical reasons (eg, contraindicated, patient already receiving antibiotics).
Measure Reporting via Claims:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. CPT Category II codes are used to report the numerator of the measure.
When reporting the measure via claims, submit the appropriate CPT Category II code OR the
appropriate CPT Category II code with the modifier on the same claim containing the anesthesia
codes listed in the denominator. The modifiers allowed for this measure are: 1P- medical reasons,
8P- reason not otherwise specified. All measure-specific coding should be reported ON THE SAME
CLAIM as the denominator codes.
Measure Reporting via Registry:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. The numerator options as described in the quality-data codes are used to
report the numerator of the measure. The quality-data codes listed do not need to be submitted for
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registry-based submissions; however, these codes may be submitted for those registries that utilize
claims data.
NUMERATOR:
Surgical patients for whom administration of the prophylactic parenteral antibiotic ordered has been
initiated within one hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical incision
(or start of procedure when no incision is required)
Numerator Instructions: This measure seeks to identify the timely administration of prophylactic
parenteral antibiotic. This administration should begin within one hour (if fluoroquinolone or
vancomycin, two hours) prior to surgical incision.
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
The antimicrobial drugs listed below are considered prophylactic parenteral antibiotics for
the purposes of this measure. 4048F-8P should be reported when antibiotics from this
table were not ordered.
• Ampicillin/sulbactam
• Cefuroxime
• Gentamicin
• Aztreonam
• Ciprofloxacin
• Levofloxacin
• Cefazolin
• Clindamycin
• Metronidazole
• Cefmetazole
• Ertapenem
• Moxifloxacin
• Cefotetan
• Erythromycin base
• Neomycin
• Cefoxitin
• Gatifloxacin
• Vancomycin
NUMERATOR NOTE: “Ordered” includes instances in which the prophylactic parenteral
antibiotic is ordered by the clinician performing the surgical procedure OR is ordered by
the clinician providing the anesthesia services.
OR
Documentation that Prophylactic Parenteral Antibiotic was Administered Within
Specified Timeframe
CPT II 4048F: Documentation that administration of prophylactic parenteral antibiotic was
initiated within one hour (if fluoroquinolone or vancomycin, two hours) prior to surgical
incision (or start of procedure when no incision is required), as ordered.
Prophylactic Parenteral Antibiotic not Administered for Medical Reasons (eg,
contraindicated, patient already receiving antibiotics)
Append a modifier (1P) to CPT Category II code 4048F to report documented
circumstances that appropriately exclude patients from the denominator.
4048F with 1P: Documentation of medical reason(s) for not initiating administration of
prophylactic parenteral antibiotics as specified (e.g., contraindicated,
patient already receiving antibiotics).
OR
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OR
If patient is not eligible for this measure because prophylactic parenteral antibiotic
not ordered, report:
Prophylactic Parenteral Antibiotic not Ordered
Append a reporting modifier (8P) to CPT Category II code 4047F to report circumstances
when the patient is not eligible for the measure.
4047F with 8P: No documentation of order for prophylactic parenteral antibiotics to be
given within one hour (if fluoroquinolone or vancomycin, two hours) prior
to surgical incision (or start of procedure when no incision is required)
Prophylactic Parenteral Antibiotic Ordered but not Initiated Within One Hour,
Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4048F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4048F with 8P: Administration of prophylactic parenteral antibiotic was not initiated within
one hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical
incision (or start of procedure when no incision is required), reason not
otherwise specified.
DENOMINATOR:
*All surgical patients aged 18 years and older who receive an anesthetic when undergoing
procedures** with the indications for prophylactic parenteral antibiotics.
**Anesthesia services included in denominator are associated with some surgical procedures for
which prophylactic parenteral antibiotics may not be indicated. Clinicians should report 4047F-8P
for those instances in which anesthesia services are provided but not associated with surgical
procedures for which prophylactic parenteral antibiotics are indicated.
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Patient encounter during the reporting period (CPT): Anesthesia codes for which
prophylactic parenteral antibiotics are commonly indicated for associated surgical
procedure(s):
00100, 00102, 00103, 00120, 00140, 00145, 00147, 00160, 00162, 00164, 00170, 00172,
00174, 00176, 00190, 00192, 00210, 00211, 00212, 00214, 00215, 00216, 00218, 00220,
00222, 00300, 00320, 00322, 00350, 00352, 00400, 00402, 00404, 00406, 00450, 00452,
00454, 00470, 00472, 00474, 00500, 00528, 00529, 00530, 00532, 00534, 00537, 00539,
00540, 00541, 00542, 00546, 00548, 00550, 00560, 00561, 00562, 00563, 00566, 00567,
00580, 00600, 00604, 00620, 00622, 00625, 00626, 00630, 00632, 00634, 00670, 00700,
00730, 00750, 00752, 00754, 00756, 00770, 00790, 00792, 00794, 00796, 00797, 00800,
00802, 00820, 00830, 00832, 00840, 00844, 00846, 00848, 00851, 00860, 00862, 00864,
00865, 00866, 00868, 00870, 00880, 00882, 00902, 00904, 00906, 00908, 00910, 00912,
00914, 00916, 00918, 00920, 00921, 00922, 00924, 00926, 00928, 00930, 00932, 00934,
00936, 00938, 00940, 00942, 00944, 01120, 01140, 01150, 01170, 01173, 01180, 01190,
01202, 01210, 01212, 01214, 01215, 01230, 01232, 01234, 01250, 01260, 01270, 01272,
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01274, 01320, 01360, 01382, 01392, 01400, 01402, 01404, 01430, 01432, 01440, 01442,
01444, 01464, 01470, 01472, 01474, 01480, 01482, 01484, 01486, 01500, 01502, 01520,
01522, 01610, 01622, 01630, 01634, 01636, 01638, 01650, 01652, 01654, 01656,
01670, 01710, 01712, 01714, 01716, 01732, 01740, 01742, 01744, 01756, 01758, 01760,
01770, 01772, 01780, 01782, 01810, 01829, 01830, 01832, 01840, 01842, 01844, 01850,
01852, 01924, 01925, 01926, 01951, 01952, 01953, 01961, 01962, 01963, 01965, 01966,
01968, 01969
RATIONALE:
The appropriate timing of administration of prophylactic parenteral antibiotics has been
demonstrated to reduce the incidence of surgical wound infections. Available evidence suggests
that although most surgical patients receive a prophylactic antibiotic, many do not receive the drug
within one hour before incision as recommended. The anesthesia services included in the
denominator are associated with some surgical procedures for which prophylactic parenteral
antibiotics may not be indicated. As a result, clinicians should exclude patients from the
denominator in those instances in which anesthesia services are provided but not associated with
surgical procedures for which prophylactic parenteral antibiotics are indicated.
CLINICAL RECOMMENDATION STATEMENTS:
The anti-infective drug should ideally be given within 30 minutes to 1 hour before the initial incision
to ensure its presence in an adequate concentration in the targeted tissues. For most procedures,
scheduling administration at the time of induction of anesthesia ensures adequate concentrations
during the period of potential contamination. Exceptions: cesarean procedures (after cross
clamping of the umbilical cord); colonic procedures (starting 19 hours before the scheduled time of
surgery). (ASHP)
Infusion of the first antimicrobial dose should begin within 60 minutes before incision. However,
when a fluoroquinolone or vancomycin is indicated, the infusion should begin within 120 minutes
before incision to prevent antibiotic-associated reactions. Although research has demonstrated that
administration of the antimicrobial at the time of anesthesia induction is safe and results in adequate
serum and tissue drug levels at the time of incision, there was no consensus that the infusion must
be completed before incision. (SIPGWW)
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Measure #31: Stroke and Stroke Rehabilitation: Deep Vein Thrombosis Prophylaxis (DVT)
for Ischemic Stroke or Intracranial Hemorrhage
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial
hemorrhage who received DVT prophylaxis by end of hospital day two
INSTRUCTIONS:
This measure is to be reported during each hospital stay when a patient is under active treatment
for ischemic stroke or intracranial hemorrhage during the reporting period. Part B claims data will
be analyzed to determine a hospital stay. If multiple qualifying diagnoses are submitted on the
same claim form, only one instance of reporting will be counted. It is anticipated that clinicians who
care for patients with a diagnosis of ischemic stroke or intracranial hemorrhage in the hospital
setting will submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 8P- reason not
otherwise specified. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes and patient demographics are used to identify patients who
are included in the measure’s denominator. The numerator options as described in the quality-data
codes are used to report the numerator of the measure. The quality-data codes listed do not need
to be submitted for registry-based submissions; however, these codes may be submitted for those
registries that utilize claims data.
NUMERATOR:
Patients who received Deep Vein Thrombosis (DVT) prophylaxis by the end of hospital day two
Definition:
DVT Prophylaxis – Can include Low Molecular Weight Heparin (LMWH), Low-Dose
Unfractionated Heparin (LDUH), intravenous Heparin, low-dose subcutaneous heparin, or
intermittent pneumatic compression devices.
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
DVT Prophylaxis Received
CPT II 4070F: Deep Vein Thrombosis (DVT) prophylaxis received by end of hospital day 2
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OR
OR
DVT Prophylaxis not Received for Medical or Patient Reasons
Append a modifier (1P or 2P) to CPT Category II code 4070F to report documented
circumstances that appropriately exclude patients from the denominator.
4070F with 1P: Documentation of medical reason(s) for not receiving DVT Prophylaxis by
end of hospital day 2, including physician documentation that patient is
ambulatory
4070F with 2P: Documentation of patient reason(s) for not receiving DVT Prophylaxis by
end of hospital day 2
DVT Prophylaxis not Received, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4070F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4070F with 8P: Deep Vein Thrombosis (DVT) prophylaxis was not received by end of
hospital day 2, reason not otherwise specified
DENOMINATOR:
All patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial
hemorrhage
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for ischemic stroke or intracranial hemorrhage (line-item ICD-9-CM):
431, 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 434.01, 434.11, 434.91
AND
Patient encounter during the reporting period (CPT): 99221, 99222, 99223, 99291
RATIONALE:
Patients on bed rest are at high risk for deep vein thrombosis. DVT prevention is important for all
patients who have suffered a stroke or an intracranial hemorrhage and may have decreased
mobility. The intent of this measure is to assure that adequate DVT prophylaxis is received for
either diagnosis. As noted in the clinical recommendation statements, the appropriate type of
prophylaxis differs by diagnosis. Anticoagulants are generally contraindicated in patients with
intracranial hemorrhage. These patients are still at risk for DVT so they should receive prophylaxis
with mechanical devices. Low-dose subcutaneous heparin may be initiated on the second day after
onset of the hemorrhage.
CLINICAL RECOMMENDATION STATEMENTS:
Subcutaneous unfractionated heparin, LMW heparins, and heparinoids may be considered for DVT
prophylaxis in at-risk patients with acute ischemic stroke, recognizing that nonpharmacologic
treatments for DVT prevention also exist. (Coull, AAN/ASA, 2002) (Grade A)
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The use of intermittent external compression stockings or aspirin for patients who cannot receive
anticoagulants is strongly recommended to prevent deep vein thrombosis among immobilized
patients. (Adams, ASA, 2003) (Grades A and B)
For acute stroke patients with restricted mobility, it is recommended prophylactic low-dose
subcutaneous heparin or low-molecular-weight heparins or heparinoid. (Grade 1A) In patients with
an acute ICH, it is recommended the initial use of intermittent pneumatic compression for the
prevention of DVT and PE. (Grade 1C+) In stable patients, we suggest low-dose subcutaneous
heparin may be initiated as soon as the second day after the onset of the hemorrhage. (Grade 2C)
(Albers, ACCP, 2004)
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Measure #32: Stroke and Stroke Rehabilitation: Discharged on Antiplatelet Therapy
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or transient
ischemic attack (TIA) who were prescribed antiplatelet therapy at discharge
INSTRUCTIONS:
This measure is to be reported for patients under active treatment for ischemic stroke or TIA at
discharge from a hospital during the reporting period. Part B claims data will be analyzed to
determine the hospital discharge. If multiple qualifying diagnoses are submitted on the same claim
form, only one instance of reporting will be counted. It is anticipated that clinicians who care for
patients with a diagnosis of ischemic stroke or TIA in the hospital setting will submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 8P- reason not
otherwise specified. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes and patient demographics are used to identify patients who
are included in the measure’s denominator. The numerator options as described in the quality-data
codes are used to report the numerator of the measure. The quality-data codes listed do not need
to be submitted for registry-based submissions; however, these codes may be submitted for those
registries that utilize claims data.
NUMERATOR:
Patients who were prescribed antiplatelet therapy at discharge
Numerator Instructions: If the consulting physician orders or agrees with a prior
antiplatelet therapy order (from current or previous episodes of care during the reporting
period) and there is supporting documentation, report 4073F.
Definitions:
Antiplatelet Therapy – Aspirin, combination of aspirin and extended-release
dipyridamole, clopidogrel, ticlopidine
Prescribed – May include prescription given to the patient for antiplatelet therapy during
the measurement period OR patient already taking antiplatelet therapy as documented in
the current medication list.
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OR
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Antiplatelet Therapy Prescribed
CPT II 4073F: Oral antiplatelet therapy prescribed at discharge
Antiplatelet Therapy Prescription not Prescribed for Medical or Patient Reasons
Append a modifier (1P or 2P) to CPT Category II code 4073F to report documented
circumstances that appropriately exclude patients from the denominator.
4073F with 1P: Documentation of medical reason(s) for not prescribing oral antiplatelet
therapy at discharge
4073F with 2P: Documentation of patient reason(s) for not prescribing oral antiplatelet
therapy at discharge
Antiplatelet Therapy Prescription not Prescribed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4073F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4073F with 8P: Oral antiplatelet therapy was not prescribed at discharge, reason not
otherwise specified
DENOMINATOR:
All patients aged 18 years and older with the diagnosis of ischemic stroke or transient ischemic
attack (TIA)
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for ischemic stroke or transient ischemic attack (TIA)
(line-item ICD-9-CM): 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 434.01, 434.11,
434.91, 435.0, 435.1, 435.2, 435.3, 435.8, 435.9
AND
Patient encounter during the reporting period (CPT): 99221, 99222, 99223, 99238,
99239
RATIONALE:
Following a stroke, patients should be prescribed antiplatelet therapy to decrease the risk of
additional strokes.
CLINICAL RECOMMENDATION STATEMENTS:
It is recommended that every patient who has experienced a noncardioembolic (atherothrombotic,
lacunar, or cryptogenic) stroke or TIA and has no contraindication receives an antiplatelet agent
regularly to reduce the risk of recurrent stroke and other vascular events. Aspirin, 50 to 325 mg qd;
the combination of aspirin, 25 mg, and extended-release dipyridamole, 200 mg bid; or clopidogrel,
75 mg qd, are all acceptable options for initial therapy. (Albers, ACCP, 2001) (Grade 1A)
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For patients with noncardioembolic ischemic stroke or TIA, antiplatelet agents rather than oral
anticoagulation are recommended to reduce the risk of recurrent stroke and other cardiovascular
events. (Sacco, ASA, 2006) (Class I, Level of Evidence: A)
Aspirin (50 to 325 mg/d), the combination of aspirin and extended-release dipyridamole, and
clopidogrel are all acceptable options for initial therapy. (Sacco, ASA, 2006) (Class IIa, Level of
Evidence: A)
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Measure #33: Stroke and Stroke Rehabilitation: Anticoagulant Therapy Prescribed for
Atrial Fibrillation at Discharge
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or transient
ischemic attack (TIA) with documented permanent, persistent, or paroxysmal atrial fibrillation who
were prescribed an anticoagulant at discharge
INSTRUCTIONS:
This measure is to be reported for patients under active treatment for ischemic stroke or TIA with
documented atrial fibrillation at discharge from a hospital during the reporting period. It is
anticipated that clinicians who care for patients with a diagnosis of ischemic stroke or TIA in the
hospital setting will submit this measure.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The listed numerator options are used to report
the numerator of the measure. The quality-data codes have been provided for registry only
measures for use by registries that utilize claims data. It is not necessary to submit these codes for
registry-based submissions. Do not report this measure via claims.
NUMERATOR:
Patients who were prescribed an anticoagulant at discharge
Definitions:
Persistent Atrial Fibrillation – Recurrent atrial fibrillation, not self-terminating or
terminated electrically or pharmacologically
Paroxysmal Atrial Fibrillation – Recurrent atrial fibrillation, self-terminating
Permanent Atrial Fibrillation – Long-standing atrial fibrillation (> 1 year), cardioversion
failed or not attempted
Prescribed – May include prescription given to the patient for anticoagulant therapy at
discharge or patient already taking anticoagulant therapy as documented in the current
medication list.
OR
OR
Numerator Options:
Anticoagulant therapy prescribed at discharge (4075F)
Anticoagulant therapy not prescribed at discharge for medical reason (4075F with 1P)
OR
Anticoagulant therapy not prescribed at discharge for patient reason (4075F with 2P)
Anticoagulant therapy not prescribed at discharge, reason not specified (4075F with 8P)
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DENOMINATOR:
All patients aged 18 years and older with the diagnosis of ischemic stroke or transient ischemic
attack (TIA) with documented permanent, persistent, or paroxysmal atrial fibrillation
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for ischemic stroke or transient ischemic attack (TIA) (ICD-9-CM): 433.01,
433.11, 433.21, 433.31, 433.81, 433.91, 434.01, 434.11, 434.91, 435.0, 435.1, 435.2,
435.3, 435.8, 435.9
AND
Diagnosis for atrial fibrillation (ICD-9-CM): 427.31
AND
Patient encounter during the reporting period (CPT): 99221, 99222, 99223, 99238,
99239
RATIONALE:
Patients with atrial fibrillation (permanent, persistent, or paroxysmal) and stroke should be
prescribed an anticoagulant to prevent recurrent strokes.
CLINICAL RECOMMENDATION STATEMENTS:
Administer antithrombotic therapy (oral anticoagulation or aspirin) to all patients with AF, except
those with lone AF, to prevent thromboembolism. (ACC/AHA/ESC, 2001)(Class I, Level of
Evidence: A)
It is recommended that clinicians use long-term oral anticoagulation (target INR of 2.5; range, 2.0
to 3.0) for prevention of stroke in atrial fibrillation patients who have suffered a recent stroke or TIA.
Oral anticoagulation is also beneficial for prevention of recurrent stroke in patients with several
other high-risk cardiac sources. (Albers, ACCP, 2001) (Grade 1A)
For patients with ischemic stroke or TIA with persistent or paroxysmal AF, anticoagulation with
adjusted-dose warfarin (target INR, 2.5; range 2.0 to 3.0) is recommended. (Sacco, ASA, 2006)
(Class I, Level of Evidence: A)
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Measure #35: Stroke and Stroke Rehabilitation: Screening for Dysphagia
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial
hemorrhage who underwent a dysphagia screening process before taking any foods, fluids or
medication by mouth
INSTRUCTIONS:
This measure is to be reported during each hospital stay for all patients under active treatment for
ischemic stroke or intracranial hemorrhage during the reporting period. Part B claims data will be
analyzed to determine a hospital stay. If multiple qualifying diagnoses are submitted on the same
claim form, only one instance of reporting will be counted. It is anticipated that clinicians who care
for patients with a diagnosis of ischemic stroke or intracranial hemorrhage in the hospital setting
will submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code(s) OR the CPT Category II code(s) with the modifier.
The modifiers allowed for this measure are: 1P- medical reasons, 8P- reason not otherwise
specified. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes and patient demographics are used to identify patients who
are included in the measure’s denominator. The numerator options as described in the quality-data
codes are used to report the numerator of the measure. The quality-data codes listed do not need
to be submitted for registry-based submissions; however, these codes may be submitted for those
registries that utilize claims data.
NUMERATOR:
Patients who underwent a dysphagia screening process before taking any foods, fluids or
medication by mouth
Numerator Instructions: Patients “who receive any food, fluids or medication by mouth”
may be identified by the absence of an NPO (nothing by mouth) order
Definition:
Dysphagia Screening – Use of a tested and validated dysphagia screening tool (e.g.,
Burke dysphagia screening test, 3 oz. water swallow test, Mann assessment of swallowing
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ability [MASA], standardized bedside swallowing assessment [SSA]) OR a dysphagia
screening tool approved by the hospital's speech/language pathology (SLP) services.
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Dysphagia Screening Conducted
(Two CPT II codes [6010F & 6015F] are required on the claim form to submit this
numerator option)
CPT II 6010F: Dysphagia screening conducted prior to order for or receipt of any foods,
fluids or medication by mouth
AND
CPT II 6015F: Patient receiving or eligible to receive foods, fluids or medication by mouth
Dysphagia Screening not Conducted for Medical Reasons
(Two CPT II codes [6010F-1P & 6015F] are required on the claim form to submit this
numerator option)
Append a modifier (1P) to CPT Category II code 6010F to report documented
circumstances that appropriately exclude patients from the denominator.
6010F with 1P: Documentation of medical reason(s) for not conducting dysphagia
screening prior to taking any foods, fluids or medication by mouth
AND
CPT II 6015F: Patient receiving or eligible to receive foods, fluids or medication by mouth
OR
OR
If patient is not eligible for this measure because patient is NPO, report:
(One CPT II code [6020F] is required on the claim form to submit this numerator option)
CPT II 6020F: NPO (nothing by mouth) ordered
Dysphagia Screening not Conducted, Reason not Specified
(Two CPT II codes [6010F-8P & 6015F] are required on the claim form to submit this
numerator option)
Append a reporting modifier (8P) to CPT Category II code 6010F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
6010F with 8P: Dysphagia screening was not conducted prior to order for or receipt of any
foods, fluids or medication by mouth, reason not otherwise specified
AND
CPT II 6015F: Patient receiving or eligible to receive foods, fluids or medication by mouth
DENOMINATOR:
All patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial
hemorrhage who receive any food, fluids or medication by mouth
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Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for ischemic stroke or intracranial hemorrhage (line-item ICD-9-CM):
431, 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 434.01, 434.11, 434.91
AND
Patient encounter during the reporting period (CPT): 99221, 99222, 99223
RATIONALE:
All patients should have their swallowing evaluated prior to receiving food, fluids or oral
medications to help prevent aspiration. The evaluation should be performed with a validated or
hospital-approved dysphagia screening tool; a routine cranial nerve examination is not sufficient.
CLINICAL RECOMMENDATION STATEMENTS:
Recommend that all patients have their swallow screened before initiating oral intake of fluids or
food, utilizing a simple valid bedside testing protocol. (VA/DoD, 2003) (Evidence II-2, Grade B)
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Measure #36: Stroke and Stroke Rehabilitation: Consideration of Rehabilitation Services
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial
hemorrhage for whom consideration of rehabilitation services is documented
INSTRUCTIONS:
This measure is to be reported for patients under active treatment for ischemic stroke or
intracranial hemorrhage a minimum of once during each hospital stay occurring during the
reporting period. Part B claims data will be analyzed to determine the hospital stay. If multiple
qualifying diagnoses are submitted on the same claim form, only one instance of reporting will be
counted. It is anticipated that clinicians who care for patients with a diagnosis of ischemic stroke or
intracranial hemorrhage in the hospital setting will submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
reporting modifier allowed for this measure is: 8P- reason not otherwise specified. There are no
allowable performance exclusions for this measure. All measure-specific coding should be reported
ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes and patient demographics are used to identify patients who
are included in the measure’s denominator. The numerator options as described in the quality-data
codes are used to report the numerator of the measure. The quality-data codes listed do not need
to be submitted for registry-based submissions; however, these codes may be submitted for those
registries that utilize claims data. There are no allowable performance exclusions for this measure.
NUMERATOR:
Patients for whom consideration of rehabilitation services (ordered rehabilitation or documented
that rehabilitation was not indicated) is documented
Definition:
Consideration of Rehabilitation Services – Includes an order for rehabilitation services
or documentation that rehabilitation was not indicated.
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Rehabilitation Services Ordered or Considered
CPT II 4079F: Documentation that rehabilitation services were considered
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OR
Rehabilitation Services not Ordered or Considered, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4079F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4079F with 8P: Rehabilitation services were not considered, reason not otherwise
specified
DENOMINATOR:
All patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial
hemorrhage
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for ischemic stroke or intracranial hemorrhage (line-item ICD-9-CM):
431, 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 434.01, 434.11, 434.91
AND
Patient encounter during the reporting period (CPT): 99221, 99222, 99223, 99238,
99239
RATIONALE:
All patients should be considered for rehabilitation services to meet the individual patient needs.
CLINICAL RECOMMENDATION STATEMENTS:
Strongly recommend that patients in need of rehabilitation services have access to a setting with a
coordinated and organized rehabilitation care team that is experienced in providing stroke services.
The coordination and organization of inpatient post–acute stroke care will improve patient outcome.
(VA/DoD, 2003)
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Measure #39: Screening or Therapy for Osteoporosis for Women Aged 65 Years and
Older
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of female patients aged 65 years and older who have a central dual-energy X-ray
absorptiometry (DXA) measurement ordered or performed at least once since age 60 or
pharmacologic therapy prescribed within 12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. Female patients aged 65 years and older should have a central DXA
measurement ordered or performed at least once since the time they turned 60 years or have
pharmacologic therapy prescribed to prevent or treat osteoporosis. There is no diagnosis
associated with this measure. This measure may be reported by clinicians who perform the quality
actions described in the measure based on the services provided and the measure-specific
denominator coding.
Measure Reporting via Claims:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. G-codes are used to report the numerator of the measure.
When reporting the measure via claims, submit the listed CPT codes, and the appropriate
numerator G-code. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. The numerator options as described in the quality-data codes are used to
report the numerator of the measure. The quality-data codes listed do not need to be submitted for
registry-based submissions; however, these codes may be submitted for those registries that utilize
claims data.
NUMERATOR:
Patients who had a central DXA measurement ordered or performed at least once since age 60 or
pharmacologic therapy prescribed within 12 months
Definitions:
Pharmacologic Therapy – U.S. Food and Drug Administration approved pharmacologic
options for osteoporosis prevention and/or treatment of postmenopausal osteoporosis
include, in alphabetical order: bisphosphonates (alendronate, ibandronate, and
risedronate), calcitonin, estrogens (estrogens and/or hormone therapy), parathyroid
hormone [PTH (1-34), teriparatide], and selective estrogen receptor modules or SERMs
(raloxifene).
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Prescribed – Includes patients who are currently receiving medication(s) that follow the
treatment plan recommended at an encounter during the reporting period, even if the
prescription for that medication was ordered prior to the encounter.
OR
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Central DXA Measurement Ordered or Performed or Pharmacologic Therapy
Prescribed
G8399: Patient with central Dual-energy X-Ray Absorptiometry (DXA) results documented
or ordered or pharmacologic therapy (other than minerals/vitamins) for osteoporosis
prescribed
Central DXA Measurement not Ordered or Performed or Pharmacologic Therapy not
Prescribed for Documented Reasons
G8401: Clinician documented that patient was not an eligible candidate for screening or
therapy for osteoporosis for women measure
Central DXA Measurement not Ordered or Performed or Pharmacologic Therapy not
Prescribed, Reason not Specified
G8400: Patient with central Dual-energy X-Ray Absorptiometry (DXA) results not
documented or not ordered or pharmacologic therapy (other than minerals/vitamins) for
osteoporosis not prescribed
DENOMINATOR:
All female patients aged 65 years and older
Denominator Criteria (Eligible Cases):
Patients aged ≥ 65 years on date of encounter
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Patients with elevated risk for osteoporosis should have the diagnosis of osteoporosis excluded or
be on treatment of osteoporosis.
CLINICAL RECOMMENDATION STATEMENTS:
The U.S. Preventive Services Task Force (USPSTF) recommends that women aged 65 and older
be screened routinely for osteoporosis. (B Recommendation) (USPSTF)
The USPSTF recommends that routine screening begin at age 60 for women at increased risk for
osteoporotic fractures. Use of risk factors, particularly increasing age, low weight, and non-use of
estrogen replacement, to screen younger women may identify high-risk women. (B
Recommendation) (USPSTF)
BMD measurement should be performed in all women beyond 65 years of age. Dual x-ray
absorptiometry of the lumbar spine and proximal femur provides reproducible values at important
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sites of osteoporosis-associated fracture. These sites are preferred for baseline and serial
measurements. (AACE)
The most important risk factors for osteoporosis-related fractures are a prior low-trauma fracture as
an adult and a low BMD in patients with or without fractures. (AACE)
BMD testing should be performed on:
• All women aged 65 and older regardless of risk factors
• Younger postmenopausal women with one or more risk factors (other than being white,
postmenopausal, and female)
• Postmenopausal women who present with fractures (NQF)
The decision to test for BMD should be based on an individual’s risk profile. Testing is never
indicated unless the results could influence a treatment decision. (NQF)
Markers of greater osteoporosis and fracture risk include older age, hypogonadism, corticosteroid
therapy, and established cirrhosis. (Level B Evidence) (NQF)
The single most powerful predictor of a future osteoporotic fracture is the presence of previous
such fractures. (NQF)
Pharmacologic therapy should be initiated to reduce fracture risk in women with:
• BMD T-scores below -2.0 by central dual x-ray absorptiometry (DXA) with no risk factors
• BMD T-scores below -1.5 by central dual x-ray absorptiometry (DXA) with one or more risk
factors
• A prior vertebral or hip fracture (NQF)
The decision to measure bone density should follow an individualized approach. It should be
considered when it will help the patient decide whether to institute treatment to prevent
osteoporotic fracture. It should also be considered in patients receiving glucocorticoid therapy for 2
months or more and patients with other conditions that place them at high risk for osteoporotic
fracture. (NIH)
The most commonly used measurement to diagnose osteoporosis and predict fracture risk is
based on assessment of BMD by dual-energy X-ray absorptiometry (DXA). (NIH)
Measurements of BMD made at the hip predict hip fracture better than measurements made at
other sites while BMD measurement at the spine predicts spine fracture better than measures at
other sites. (NIH)
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Measure #40: Osteoporosis: Management Following Fracture of Hip, Spine or Distal
Radius for Men and Women Aged 50 Years and Older
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 50 years and older with fracture of the hip, spine, or distal radius who
had a central dual-energy X-ray absorptiometry (DXA) measurement ordered or performed or
pharmacologic therapy prescribed
INSTRUCTIONS:
This measure is to be reported after each occurrence of a fracture during the reporting period. It is
anticipated that clinicians who treat hip, spine or distal radial fractures will submit this measure.
Each occurrence of a fracture is identified by either an ICD-9-CM diagnosis code for fracture or
osteoporosis and a CPT service code OR an ICD-9-CM diagnosis code for a fracture or
osteoporosis and a CPT procedure code for surgical treatment of fractures.
Patients with a fracture of the hip, spine, or distal radius should have a central DXA measurement
ordered or performed or pharmacologic therapy prescribed. The management (DXA ordered or
performed or pharmacologic therapy prescribed) should occur within three months of the initial visit
with the reporting clinician following the fracture. If multiple fractures occurring on the same date of
service are submitted on the same claim form, only one instance of reporting will be counted.
Claims data will be analyzed to determine unique occurrences. Patients with documentation of
prior central DXA measurement or already receiving pharmacologic therapy would automatically
meet the intent of this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 3P- system
reasons, 8P- reason not otherwise specified. All measure-specific coding should be reported ON
THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes and patient demographics are used to identify patients who
are included in the measure’s denominator. The numerator options as described in the quality-data
codes are used to report the numerator of the measure. The quality-data codes listed do not need
to be submitted for registry-based submissions; however, these codes may be submitted for those
registries that utilize claims data.
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NUMERATOR:
Patients who had a central DXA measurement ordered or performed or pharmacologic therapy
prescribed
Numerator Instruction: Modifiers may be appended to any of the CPT Category II codes
for medical reasons, patient reasons, system reasons, or reasons not otherwise specified.
Definitions:
Pharmacologic Therapy – U.S. Food and Drug Administration approved pharmacologic
options for osteoporosis prevention and/or treatment of postmenopausal osteoporosis
include, in alphabetical order: bisphosphonates (alendronate, ibandronate, and
risedronate), calcitonin, estrogens (estrogens and/or hormone therapy), parathyroid
hormone [PTH (1-34), teriparatide], and selective estrogen receptor modules or SERMs
(raloxifene).
Prescribed – May include prescription given to the patient for treatment of osteoporosis
(as listed above) at one or more encounters during the reporting period, OR
documentation that patient is already taking pharmacologic therapy for osteoporosis, as
documented in the current medical list.
OR
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Central DXA Measurement Ordered or Results Documented or Pharmacologic
Therapy Prescribed
CPT II 3096F: Central Dual-energy X-Ray Absorptiometry (DXA) ordered
OR
CPT II 3095F: Central Dual-energy X-Ray Absorptiometry (DXA) results documented
OR
CPT II 4005F: Pharmacologic therapy (other than minerals/vitamins) for osteoporosis
prescribed
Central DXA Measurement not Ordered or Results not Documented or
Pharmacologic Therapy not Prescribed for Medical, Patient, or System Reasons
Append a modifier (1P, 2P or 3P) to CPT Category II codes 3096F or 3095F or 4005F to
report documented circumstances that appropriately exclude patients from the
denominator.
3096F or 3095F or 4005F with 1P: Documentation of medical reason(s) for not ordering
or performing a central dual energy X-ray absorptiometry (DXA)
measurement or not prescribing pharmacologic therapy for osteoporosis
3096F or 3095F or 4005F with 2P: Documentation of patient reason(s) for not ordering or
performing a central dual energy X-ray absorptiometry (DXA)
measurement or not prescribing pharmacologic therapy for osteoporosis
3096F or 3095F or 4005F with 3P: Documentation of system reason(s) for not ordering or
performing a central dual energy X-ray absorptiometry (DXA)
measurement or not prescribing pharmacologic therapy for osteoporosis
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Central DXA Measurement not Ordered or Results not Documented or
Pharmacologic Therapy not Prescribed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3096F or 3095F or 4005F to
report circumstances when the action described in the numerator is not performed and the
reason is not otherwise specified.
3096F or 3095F or 4005F with 8P: Central dual energy X-ray absorptiometry (DXA)
measurement was not ordered or performed or pharmacologic therapy for
osteoporosis was not prescribed, reason not otherwise specified
DENOMINATOR:
All patients aged 50 years and older with a fracture of the hip, spine, or distal radius
Eligible cases are determined, and must be reported, if either of the following conditions are met:
Option 1 - Denominator Criteria (Eligible Cases):
Patients aged ≥ 50 years on date of encounter
AND
Diagnosis for hip, spine, or distal radial fracture (line-item ICD-9-CM): 805.00, 805.01,
805.02, 805.03, 805.04, 805.05, 805.06, 805.07, 805.08, 805.2, 805.4, 805.6, 805.8,
813.40, 813.41, 813.42, 813.44, 813.45, 813.47, 813.50, 813.51, 813.52, 813.54, 820.00,
820.01, 820.02, 820.03, 820.09, 820.20, 820.21, 820.22, 820.8
AND
Patient encounter during the reporting period (CPT) - Service codes: 99201, 99202,
99203, 99204, 99205, 99212, 99213, 99214, 99215
OR
Option 2 - Denominator Criteria (Eligible Cases):
Patients aged ≥ 50 years on date of encounter
AND
Diagnosis for hip, spine, or distal radial fracture (line-item ICD-9-CM): 733.00, 733.01,
733.02, 733.03, 733.09, 805.00, 805.01, 805.02, 805.03, 805.04, 805.05, 805.06, 805.07,
805.08, 805.2, 805.4, 805.6, 805.8, 813.40, 813.41, 813.42, 813.44, 813.45, 813.47,
813.50, 813.51, 813.52, 813.54, 820.00, 820.01, 820.02, 820.03, 820.09, 820.20, 820.21,
820.22, 820.8
AND
Patient encounter during the reporting period (CPT) - Procedure codes: 22305,
22310, 22315, 22318, 22319, 22325, 22326, 22327, 22520, 22521, 22523, 22524, 25600,
25605, 25606, 25607, 25608, 25609, 27230, 27232, 27235, 27236, 27238, 27240, 27244,
27245, 27246, 27248
RATIONALE:
Patients with a history of fracture should have a baseline bone mass measurement and/or receive
treatment for osteoporosis. Given that the majority of osteoporotic fractures occur in patients with a
diagnosis of osteoporosis by bone mass measurement, exclusion of osteoporosis by bone mass
testing does not preclude treatment of osteoporosis in a patient with a history of fracture. There is a
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high degree of variability and consensus by experts of what constitutes a fragility fracture and
predictor of an underlying problem of osteoporosis. The work group determined that only those
fractures, which have the strongest consensus and evidence that they are predictive of
osteoporosis, should be included in the measure at this time. We anticipate that the list of fractures
will expand as further evidence is published supporting the inclusion of other fractures.
CLINICAL RECOMMENDATION STATEMENTS:
The most important risk factors for osteoporosis-related fractures are a prior low-trauma fracture as
an adult and a low BMD in patients with or without fractures. (AACE)
BMD measurement should be performed in all women 40 years old or older who have sustained a
fracture. (AACE)
The single most powerful predictor of a future osteoporotic fracture is the presence of previous
such fractures. (AACE)
The decision to measure bone density should follow an individualized approach. It should be
considered when it will help the patient decide whether to institute treatment to prevent
osteoporotic fracture. It should also be considered in patients receiving glucocorticoid therapy for 2
months or more and patients with other conditions that place them at high risk for osteoporotic
fracture. (NIH)
The most commonly used measurement to diagnose osteoporosis and predict fracture risk is
based on assessment of BMD by dual-energy X-ray absorptiometry (DXA). (NIH)
Measurements of BMD made at the hip predict hip fracture better than measurements made at
other sites while BMD measurement at the spine predicts spine fracture better than measures at
other sites. (NIH)
Pharmacologic therapy should be initiated to reduce fracture risk in women with:
• BMD T-scores below -2.0 by central dual x-ray absorptiometry (DXA) with no risk factors
• BMD T-scores below -1.5 by central dual x-ray absorptiometry (DXA) with one or more risk
factors
• A prior vertebral or hip fracture (NOF)
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Measure #41: Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years
and Older
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 50 years and older with a diagnosis of osteoporosis who were
prescribed pharmacologic therapy within 12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. Patients with a diagnosis of osteoporosis should be prescribed pharmacologic
therapy to treat osteoporosis. It is anticipated that clinicians who provide services for patients with
the diagnosis of osteoporosis will submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 3P- system
reasons, 8P- reason not otherwise specified. All measure-specific coding should be reported ON
THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients who were prescribed pharmacologic therapy within 12 months
Definitions:
Pharmacologic Therapy – U.S. Food and Drug Administration approved pharmacologic
options for osteoporosis prevention and/or treatment of postmenopausal osteoporosis
include, in alphabetical order: bisphosphonates (alendronate, ibandronate, and
risedronate), calcitonin, estrogens (estrogens and/or hormone therapy), parathyroid
hormone [PTH (1-34), teriparatide], and selective estrogen receptor modules or SERMs
(raloxifene).
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Prescribed – May include prescription given to the patient for treatment of osteoporosis
(as listed above) at one or more encounters during the reporting period, OR
documentation that patient is already taking pharmacologic therapy for osteoporosis, as
documented in the current medication list.
OR
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Pharmacologic Therapy Prescribed
CPT II 4005F: Pharmacologic therapy (other than minerals/vitamins) for osteoporosis
prescribed
Pharmacologic Therapy not Prescribed for Medical, Patient, or System Reasons
Append a modifier (1P, 2P or 3P) to CPT Category II code 4005F to report documented
circumstances that appropriately exclude patients from the denominator.
4005F with 1P: Documentation of medical reason(s) for not prescribing pharmacologic
therapy for osteoporosis
4005F with 2P: Documentation of patient reason(s) for not prescribing pharmacologic
therapy for osteoporosis
4005F with 3P: Documentation of system reason for not prescribing pharmacologic
therapy for osteoporosis
Pharmacologic Therapy not Prescribed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4005F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4005F with 8P: Pharmacologic therapy for osteoporosis was not prescribed, reason not
otherwise specified
DENOMINATOR:
All patients aged 50 years and older with the diagnosis of osteoporosis
Denominator Criteria (Eligible Cases):
Patients aged ≥ 50 years on date of encounter
AND
Diagnosis for osteoporosis (line-item ICD-9-CM): 733.00, 733.01, 733.02, 733.03,
733.09
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Pharmacologic therapy is an evidence-based recommendation for the treatment of osteoporosis.
CLINICAL RECOMMENDATION STATEMENTS:
Agents approved by the FDA for osteoporosis prevention and/or treatment include (in alphabetical
order) bisphosphonates (alendronate, ibandronate, risedronate), salmon calcitonin, estrogen,
raloxifene, and teriparatide. All act by reducing bone resorption, except for teriparatide, which has
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anabolic effects on bone. Although estrogen is not approved for treatment of osteoporosis, there is
level 1 evidence for its efficacy in reducing vertebral fractures, nonvertebral fractures, and hip
fractures. Level 1 evidence of efficacy in reducing the risk of vertebral fractures is available for all
the agents approved for treatment of osteoporosis (bisphosphonates, calcitonin, raloxifene, and
teriparatide). Prospective trials have demonstrated the effectiveness of bisphosphonates and
teriparatide in reducing the risk of nonvertebral fractures (level 1), but only bisphosphonates have
been shown to reduce the risk of hip fractures in prospective controlled trials (level 1). (AACE)
US Food and Drug Administration-approved pharmacologic options for osteoporosis prevention
and/or treatment of postmenopausal osteoporosis include, in alphabetical order: bisphosphonates
(alendronate, alendronate plus D, ibandronate, and risedronate, risedronate with 500 mg of
calcium as the carbonate), calcitonin, estrogens (estrogens and/or hormone therapy), parathyroid
hormone [PTH (1-34), teriparatide], and selective estrogen receptor modulators or SERMS
(raloxifene). (NOF)
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Measure #43: Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery
(IMA) in Patients with Isolated CABG Surgery
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older undergoing isolated CABG surgery using an IMA
graft
INSTRUCTIONS:
This measure is to be reported each time an isolated CABG procedure is performed during the
reporting period. It is anticipated that clinicians who provide services for isolated CABG will submit
this measure. This measure is intended to reflect the quality of the surgical services provided for
isolated CABG patients. Isolated CABG refers to CABG using arterial and/or venous grafts only.
Part B claims data will be analyzed to determine “isolated” CABG. This measure does not include
patients undergoing repeat CABG surgery.
Measure Reporting via Claims:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. CPT Category II codes are used to report the numerator of the measure.
When reporting the measure via claims, submit the listed CPT codes, and the appropriate CPT
Category II code OR the CPT Category II code with the modifier. The modifiers allowed for this
measure are: 1P- medical reasons, 8P- reason not otherwise specified. All measure-specific
coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. The numerator options as described in the quality-data codes are used to
report the numerator of the measure. The quality-data codes listed do not need to be submitted for
registry-based submissions; however, these codes may be submitted for those registries that utilize
claims data.
NUMERATOR:
Patients who received an IMA graft in isolated CABG
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
IMA Graft Performed
CPT II 4110F: Internal mammary artery graft performed for primary, isolated coronary
artery bypass graft procedure
IMA Graft not Performed for Medical Reasons
Append a modifier (1P) to the CPT Category II code 4110F to report documented
circumstances that appropriately exclude patients from the denominator.
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OR
4110F with 1P: Documentation of medical reason(s) for not performing an internal
mammary artery graft for primary, isolated coronary artery bypass graft
procedure
IMA Graft not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4110F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4110F with 8P: Internal mammary artery graft not performed for primary, isolated coronary
artery bypass graft procedure, reason not otherwise specified
DENOMINATOR:
All patients undergoing isolated CABG
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Patient encounter during the reporting period (CPT): 33510, 33511, 33512, 33513,
33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536
RATIONALE:
A major innovation has been the introduction of off-bypass CABG, which has reduced the postprocedure length of stay in some centers to between 2 and 3 days. In some centers, this has led to
a total 3-month cost for single-vessel coronary bypass that is not significantly different from the
total 3-month cost for angioplasty of single-vessel disease. Considering the favorable long-term
patency of an internal mammary artery (IMA) graft to the LAD, the cost reductions possible with offbypass CABG may improve the relative cost-effectiveness of coronary bypass compared with
either medical therapy or percutaneous techniques, particularly for symptomatic, proximal LAD
disease.
CLINICAL RECOMMENDATION STATEMENTS:
Class I
In every patient undergoing CABG, the left internal mammary artery (IMA) should be given primary
consideration for revascularization of the left anterior descending (LAD) artery.
(Level of Evidence: B)
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Measure #44: Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in
Patients with Isolated CABG Surgery
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who received a
beta-blocker within 24 hours prior to surgical incision
INSTRUCTIONS:
This measure is to be reported each time an isolated CABG procedure is performed during the
reporting period. It is anticipated that clinicians who provide services for isolated CABG will submit
this measure. Isolated CABG refers to CABG using arterial and/or venous grafts only. Isolated
CABG refers CABG using arterial and/or venous grafts only. Part B claims data will be analyzed to
determine “isolated” CABG. The timeframe for this measure includes the entire 24 hour period
before the incision time.
Measure Reporting via Claims:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. CPT Category II codes are used to report the numerator of the measure.
When reporting the measure via claims, submit the listed CPT codes, and the appropriate CPT
Category II code OR the CPT Category II code with the modifier. The modifiers allowed for this
measure are: 1P- medical reasons, 8P- reason not otherwise specified. All measure-specific
coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. The numerator options as described in the quality-data codes are used to
report the numerator of the measure. The quality-data codes listed do not need to be submitted for
registry-based submissions; however, these codes may be submitted for those registries that utilize
claims data.
NUMERATOR:
Patients undergoing isolated CABG who received a beta-blocker within 24 hours prior to surgical
incision
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Preoperative Beta-blocker Received
CPT II 4115F: Beta blocker administered within 24 hours prior to surgical incision
Preoperative Beta-blocker not Received for Medical Reasons
Append a modifier (1P) to the CPT Category II code 4115F to report documented
circumstances that appropriately exclude patients from the denominator.
4115F with 1P: Documentation of medical reason(s) for not administering beta blocker
within 24 hours prior to surgical incision
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OR
Preoperative Beta-blocker not Received, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4115F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4115F with 8P: Beta blocker not administered within 24 hours prior to surgical incision,
reason not otherwise specified
DENOMINATOR:
All patients undergoing isolated CABG
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Patient encounter during the reporting period (CPT): 33510, 33511, 33512, 33513,
33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536
RATIONALE:
In patients at risk of cardiovascular complications in a variety of medical conditions, beta-blockers
have shown to reduce that risk. Studies show that patients with a history of myocardial infarction,
who have had beta-blocker therapy initiated and continued, have a 20 to 30% reduction in
subsequent coronary events, cardiovascular mortality, and all-cause mortality (Yusuf, 1985). In a
meta analysis by McGory et al (2005), long-term cardiac mortality and myocardial ischemia were
reduced significantly by perioperative beta blockade. Patients maintained on beta-blockers, without
complications that might warrant discontinuation, are good candidates for continuation of betablockers through the perioperative period.
CLINICAL RECOMMENDATION STATEMENTS:
Prevention of Postoperative Arrhythmias
Class I
Preoperative or early postoperative administration of beta-blockers in patients without
contraindications should be used as the standard therapy to reduce the incidence and/or clinical
sequelae of atrial fibrillation after CABG. (Level of Evidence: B)
The use of b-blockers, calcium channel blockers, and nitrates plays a significant role in ensuring
that the myocardial oxygen demand does not exceed the supply. Patients well compensated while
receiving these agents should be continued on their therapy through the perioperative period.
Special attention should be paid to avoiding excess catecholamine effects by the sudden
withdrawal of b-blocker therapy. At least one study supports the use of b-blocker immediately prior
to surgery: in 1988, Stone and colleagues gave oral b-blockers 2 hours prior to surgery and
reported a decrease in frequency of ST segment depression from 28% among control patients to
2% in treated patients. Similarly, in 1987, Pasternack and colleagues reported a reduction from
18% to 3% incidence of acute perioperative myocardial infarction in patients treated with
metoprolol immediately prior to and following surgery. More recently, Podesser and colleagues
demonstrated in patients undergoing coronary artery bypass procedures that the combination of
nifedipine and metoprolol was associated with a lower incidence of ischemic events than nifedipine
alone.
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Measure #45: Perioperative Care: Discontinuation of Prophylactic Antibiotics (Cardiac
Procedures)
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of cardiac surgical patients aged 18 years and older undergoing procedures with the
indications for prophylactic antibiotics AND who received a prophylactic antibiotic, who have an
order for discontinuation of prophylactic antibiotics within 48 hours of surgical end time
INSTRUCTIONS:
This measure is to be reported each time a procedure is performed during the reporting period for
patients who undergo cardiac procedures with the indications for prophylactic antibiotics. There is
no diagnosis associated with this measure. It is anticipated that clinicians who perform the listed
surgical procedures as specified in the denominator coding will submit this measure.
Measure Reporting via Claims:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. CPT Category II codes are used to report the numerator of the measure. If
multiple surgical procedures were performed on the same date of service and submitted on the
same claim form, it is not necessary to submit the CPT Category II code with each procedure.
When reporting the measure via claims, submit the listed CPT codes, and the appropriate CPT
Category II code(s) OR the CPT Category II code(s) with the modifier. The modifiers allowed for
this measure are: 1P- medical reasons, 8P- reason not otherwise specified. All measure-specific
coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. The numerator options as described in the quality-data codes are used to
report the numerator of the measure. The quality-data codes listed do not need to be submitted for
registry-based submissions; however, these codes may be submitted for those registries that utilize
claims data.
NUMERATOR:
Cardiac surgical patients who have an order for discontinuation of prophylactic antibiotics within 48
hours of surgical end time
Numerator Instructions: There must be documentation of order (written order, verbal
order, or standing order/protocol) specifying that prophylactic antibiotic is to be
discontinued within 48 hours of surgical end time OR specifying a course of antibiotic
administration limited to that 48-hour period (e.g., “to be given every 8 hours for three
doses” or for “one time” IV dose orders) OR documentation that prophylactic antibiotic was
discontinued within 48 hours of surgical end time.
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NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Documentation of order for discontinuation of prophylactic antibiotics (written
order, verbal order, or standing order/protocol) within 48 hours of surgical end time
(Two CPT II codes [4043F & 4046F] are required on the claim form to submit this
numerator option)
CPT II 4043F: Documentation that an order was given to discontinue prophylactic
antibiotics within 48 hours of surgical end time, cardiac procedures
Note: CPT Category II codes 4043F may be provided for documentation that antibiotic
discontinuation within 48 hours was ordered or that antibiotic discontinuation was
accomplished.
AND
CPT II 4046F: Documentation that prophylactic antibiotics were given within 4 hours prior
to surgical incision or given intraoperatively
Prophylactic Antibiotics not Discontinued for Medical Reasons
(Two CPT II codes [4043F-1P & 4046F] are required on the claim form to submit this
numerator option)
Append a modifier (1P) to CPT Category II code 4043F to report documented
circumstances that appropriately exclude patients from the denominator.
4043F with 1P: Documentation of medical reason(s) for not discontinuing prophylactic
antibiotics within 48 hours of surgical end time, cardiac procedures
AND
CPT II 4046F: Documentation that prophylactic antibiotics were given within 4 hours prior
to surgical incision or given intraoperatively
OR
OR
If patient is not eligible for this measure because patient was not documented to
have prophylactic antibiotics given within 4 hours prior to surgical incision, report:
(One CPT II code [4042F] is required on the claim form to submit this numerator option)
CPT II 4042F: Documentation that prophylactic antibiotics were neither given within 4
hours prior to surgical incision nor given intraoperatively
Prophylactic Antibiotics not Discontinued, Reason not Specified
(Two CPT II codes [4043F-8P & 4046F] are required on the claim form to submit this
numerator option)
Append a reporting modifier (8P) to CPT Category II code 4043F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4043F with 8P: Order was not given to discontinue prophylactic antibiotics within 48 hours
of surgical end time, cardiac procedures, reason not otherwise specified
AND
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CPT II 4046F: Documentation that prophylactic antibiotics were given within 4 hours prior
to surgical incision or given intraoperatively
DENOMINATOR:
All cardiac surgical patients aged 18 years and older undergoing procedures with the indications
for prophylactic antibiotics AND who received a prophylactic antibiotic
Denominator Instructions: For the purpose of this measure of antibiotic discontinuation,
patients may be counted as having “received a prophylactic antibiotic” if the antibiotic was
received within 4 hours prior to the surgical incision (or start of procedure when no incision
is required) or intraoperatively.
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Patient encounter during the reporting period (CPT): Listed below are cardiac surgical
procedures for which prophylactic antibiotics are indicated.
SURGICAL PROCEDURE
Cardiothoracic Surgery
CPT CODE
33120, 33130, 33140, 33141, 33250, 33251, 33256,
33261, 33305, 33315, 33332, 33335, 33400, 33401,
33403, 33404, 33405, 33406, 33410, 33411, 33413,
33416, 33422, 33425, 33426, 33427, 33430, 33460,
33463, 33464, 33465, 33475, 33496, 33510, 33511,
33512, 33513, 33514, 33516, 33517, 33518, 33519,
33521, 33522, 33523, 33530, 33533, 33534, 33535,
33536, 33542, 33545, 33548, 33572
RATIONALE:
There is no evidence there is added benefit of prolonged prophylactic antibiotic use. Prolonged use
may increase antibiotic resistant organisms.
CLINICAL RECOMMENDATION STATEMENTS:
At a minimum, antimicrobial coverage must be provided from the time of incision to closure of the
incision. For most procedures, the duration of antimicrobial prophylaxis should be 24 hours or less,
with the exception of cardiothoracic procedures (up to 72 hours’ duration) and ophthalmic
procedures (duration not clearly established). (ASHP)
There is evidence indicating that antibiotic prophylaxis of 48 hours duration is effective. There is
some evidence that single-dose prophylaxis or 24-hour prophylaxis may be as effective as 48-hour
prophylaxis, but additional studies are necessary before confirming the effectiveness of prophylaxis
lasting less than 48 hours. There is no evidence that prophylaxis administered for longer than 48
hours is more effective than a 48-hour regimen. Optimal practice: Antibiotic prophylaxis is not
continued for more than 48 hours postoperatively. (STS) (Class IIa, Level B)
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Measure #46: Medication Reconciliation: Reconciliation After Discharge from an Inpatient
Facility
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 65 years and older discharged from any inpatient facility (eg, hospital,
skilled nursing facility, or rehabilitation facility) and seen within 60 days following discharge in the
office by the physician providing on-going care who had a reconciliation of the discharge
medications with the current medication list in the medical record documented
INSTRUCTIONS:
This measure is to be reported at an outpatient visit occurring within 60 days of each inpatient
facility discharge date during the reporting period. This measure is appropriate for use in the
ambulatory setting only. There is no diagnosis associated with this measure. This measure may be
reported by clinicians who perform the quality actions described in the measure based on the
services provided and the measure-specific denominator coding. This measure is not to be
reported unless a patient has been discharged from an inpatient facility within 60 days prior to the
outpatient visit.
Measure Reporting via Claims:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. CPT Category II codes are used to report the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code(s) OR the CPT Category II code(s) with the modifier.
The reporting modifier allowed for this is: 8P- reason not otherwise specified. There are no
allowable performance exclusions for this measure. All measure-specific coding should be reported
ON THE SAME CLAIM.
Measure Reporting via Registry:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. The numerator options as described in the quality-data codes are used to
report the numerator of the measure. The quality-data codes listed do not need to be submitted for
registry-based submissions; however, these codes may be submitted for those registries that utilize
claims data. There are no allowable performance exclusions for this measure.
NUMERATOR:
Patients who had a reconciliation of the discharge medications with the current medication list in
the outpatient medical record documented
Definition:
Medical Record – Must indicate: The clinician is aware of the inpatient facility discharge
medications and will either keep the inpatient facility discharge medications or change the
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inpatient facility discharge medications or the dosage of an inpatient facility discharge
medication.
OR
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Documentation of Reconciliation of Discharge Medication with Current Medication
List in the Medical Record
(Two CPT II codes [1111F & 1110F] are required on the claim form to submit this
numerator option)
CPT II 1111F: Discharge medications reconciled with the current medication list in
outpatient medical record
AND
CPT II 1110F: Patient discharged from an inpatient facility (eg, hospital, skilled nursing
facility, or rehabilitation facility) within the last 60 days
If patient is not eligible for this measure because patient was not discharged from
an inpatient facility within the last 60 days, there are no reporting requirements in
this case.
Discharge Medication not Reconciled with Current Medication List in the Medical
Record, Reason Not Specified
(Two CPT II codes [1111F & 1110F] are required on the claim form to submit this
numerator option)
Append a reporting modifier (8P) to CPT Category II code 1111F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
1111F with 8P: Discharge medications not reconciled with the current medication list in
outpatient medical record, reason not specified
AND
CPT II 1110F: Patient discharged from an inpatient facility (eg hospital, skilled nursing
facility, or rehabilitation facility) within the last 60 days
DENOMINATOR:
All patients aged 65 years and older discharged from any inpatient facility (e.g., hospital, skilled
nursing facility, or rehabilitation facility) and seen within 60 days following discharge in the office by
the physician providing on-going care
Denominator Criteria (Eligible Cases):
Patients aged ≥ 65 years on date of encounter
AND
Patient encounter during the reporting period (CPT): 90801, 90802, 90804, 90805,
90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90845, 90862,
99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99324, 99325, 99326,
99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347,
99348, 99349, 99350
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RATIONALE:
Medications are often changed while a patient is hospitalized. Continuity between inpatient and ongoing care is essential.
CLINICAL RECOMMENDATION STATEMENTS:
No trials of the effects of physician acknowledgment of medications post-discharge were found.
However, patients are likely to have their medications changed during a hospitalization. One
observational study showed that 1.5 new medications were initiated per patient during
hospitalization, and 28% of chronic medications were canceled by the time of hospital discharge.
Another observational study showed that at one week post-discharge, 72% of elderly patients were
taking incorrectly at least one medication started in the inpatient setting, and 32% of medications
were not being taken at all. One survey study faulted the quality of discharge communication as
contributing to early hospital readmission, although this study did not implicate medication
discontinuity as the cause. (ACOVE)
First, a medication list must be collected. It is important to know what medications the patient has
been taking or receiving prior to the outpatient visit in order to provide quality care. This applies
regardless of the setting from which the patient came — home, long-term care, assisted living, etc.
The medication list should include all medications (prescriptions, over-the-counter, herbals,
supplements, etc.) with dose, frequency, route, and reason for taking it. It is also important to verify
whether the patient is actually taking the medication as prescribed or instructed, as sometimes this
is not the case.
At the end of the outpatient visit, a clinician needs to verify three questions:
1. Based on what occurred in the visit, should any medication that the patient was taking or
receiving prior to the visit be discontinued or altered?
2. Based on what occurred in the visit, should any prior medication be suspended pending
consultation with the prescriber?
3. Have any new prescriptions been added today?
These questions should be reviewed by the physician who completed the procedure, or the
physician who evaluated and treated the patient.
• If the answer to all three questions is “no,” the process is complete.
• If the answer to any question is “yes,” the patient needs to receive clear instructions about
what to do — all changes, holds, and discontinuations of medications should be
specifically noted. Include any follow-up required, such as calling or making appointments
with other practitioners and a timeframe for doing so. (IHI)
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Measure #47: Advance Care Plan
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
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 reported a minimum of once per reporting period for patients seen during the
reporting period. There is no diagnosis associated with this measure. This measure may be
reported by clinicians who perform the quality actions described in the measure based on the
services provided and the measure-specific denominator coding.
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.
Measure Reporting via Claims:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. CPT Category II codes are used to report the numerator of the measure.
When reporting the measure via claims, submit the listed CPT codes, and the appropriate CPT
Category II codes OR the CPT Category II code(s) with the modifier. The reporting modifier
allowed for this measure is: 8P- reason not otherwise specified. There are no allowable
performance exclusions for this measure. All measure-specific coding should be reported ON THE
SAME CLAIM.
Measure Reporting via Registry:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. The numerator options as described in the quality-data codes are used to
report the numerator of the measure. The quality-data codes listed do not need to be submitted for
registry-based submissions; however, these codes may be submitted for those registries that utilize
claims data. There are no allowable performance exclusions for this measure.
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
Numerator Instruction: If patient’s cultural and/or spiritual beliefs preclude a discussion of
advance care planning, report 1124F.
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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
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Advance Care Planning Discussed and Documented
CPT II 1123F: Advance Care Planning discussed and documented; advance care plan or
surrogate decision maker documented in the medical record
OR
CPT II 1124F: 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
Advance Care Planning not Documented, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 1123F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
1123F with 8P: Advance care planning not documented, reason not otherwise specified
DENOMINATOR:
All patients aged 65 years and older
Denominator Criteria (Eligible Cases):
Patients aged ≥ 65 years on date of encounter
AND
Patient encounter during the reporting period (CPT): 99201, 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
*Clinicians indicating the place of service as the emergency department will not be
included in this measure.
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 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
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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.
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Measure #48: Urinary Incontinence: Assessment of Presence or Absence of Urinary
Incontinence in Women Aged 65 Years and Older
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of female patients aged 65 years and older who were assessed for the presence or
absence of urinary incontinence within 12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. This measure is appropriate for use in the ambulatory setting only and is
considered a general screening measure. There is no diagnosis associated with this measure. This
measure may be reported by clinicians who perform the quality actions described in the measure
based on the services provided and the measure-specific denominator coding.
Measure Reporting via Claims:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. CPT Category II codes are used to report the numerator of the measure.
When reporting the measure via claims, submit the listed CPT codes, and the appropriate CPT
Category II code OR the CPT Category II code with the modifier. The modifiers allowed for this
measure are: 1P- medical reasons, 8P- reason not otherwise specified. All measure-specific
coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. The numerator options as described in the quality-data codes are used to
report the numerator of the measure. The quality-data codes listed do not need to be submitted for
registry-based submissions; however, these codes may be submitted for those registries that utilize
claims data.
NUMERATOR:
Patients who were assessed for the presence or absence of urinary incontinence within 12 months
Definition:
Urinary Incontinence – Any involuntary leakage of urine.
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Presence or Absence of Urinary Incontinence Assessed
CPT II 1090F: Presence or absence of urinary incontinence assessed
Presence or Absence of Urinary Incontinence not Assessed for Medical Reasons
Append a modifier (1P) to CPT Category II code 1090F to report documented
circumstances that appropriately exclude patients from the denominator.
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OR
1090F with 1P: Documentation of medical reason(s) for not assessing for the presence or
absence of urinary incontinence
Presence or Absence of Urinary Incontinence not Assessed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 1090F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
1090F with 8P: Presence or absence of urinary incontinence not assessed, reason not
otherwise specified
DENOMINATOR:
All female patients aged 65 years and older
Denominator Criteria (Eligible Cases):
Patients aged ≥ 65 years on date of encounter
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99324, 99325, 99326, 99327, 99328, 99334, 99335,
99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350
RATIONALE:
Female patients may not volunteer information regarding incontinence so they should be asked by
their physician.
CLINICAL RECOMMENDATION STATEMENTS:
Strategies to increase recognition and reporting of UI are required and especially the perception
that it is an inevitable consequence of aging for which little or nothing can be done. (ICI)
Patients with urinary incontinence should undergo a basic evaluation that includes a history,
physical examination, measurement of post-void residual volume, and urinalysis. (ACOG) (Level C)
Health care providers should be able to initiate evaluation and treatment of UI basing their
judgment on the results of history, physical examination, post-voiding residual and urinalysis. (ICI)
(Grade B for women)
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Measure #49: Urinary Incontinence: Characterization of Urinary Incontinence in Women
Aged 65 Years and Older
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence
whose urinary incontinence was characterized at least once within 12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. This measure is appropriate for use in the ambulatory setting only. It is anticipated
that clinicians who provide services for patients with the diagnosis of urinary incontinence will
submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
reporting modifier allowed for this measure is: 8P- reason not otherwise specified. There are no
allowable performance exclusions for this measure. All measure-specific coding should be reported
ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data. There are no allowable performance exclusions for this
measure.
NUMERATOR:
Patients whose urinary incontinence was characterized (may include one or more of the following:
frequency, volume, timing, type of symptoms or how bothersome to the patient) at least once within
12 months
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Urinary Incontinence Characterized
CPT II 1091F: Urinary incontinence characterized (eg frequency, volume, timing, type of
symptoms, how bothersome)
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Urinary Incontinence not Characterized, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 1091F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
1091F with 8P: Urinary incontinence not characterized (eg frequency, volume, timing, type
of symptoms, how bothersome), reason not otherwise specified
DENOMINATOR:
All female patients aged 65 years and older with a diagnosis of urinary incontinence
Denominator Criteria (Eligible Cases):
Patients aged ≥ 65 years on date of encounter
AND
Diagnosis for urinary incontinence (line-item ICD-9-CM): 307.6, 625.6, 788.30, 788.31,
788.33, 788.34, 788.35, 788.36, 788.37, 788.38, 788.39
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99324, 99325, 99326, 99327, 99328, 99334, 99335,
99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350
RATIONALE:
Treatment indications are dependent on the severity and impact on the patient.
CLINICAL RECOMMENDATION STATEMENTS:
Patients with urinary incontinence should undergo a basic evaluation that includes a history,
physical examination, measurement of post-void residual volume, and urinalysis. (ACOG) (Level C)
Health care providers should be able to initiate evaluation and treatment of UI basing their
judgment on the results of history, physical examination, post-voiding residual and urinalysis. (ICI)
(Grade B for women)
Bladder diaries provide valuable information on severity and bladder capacity in older persons
without disability in the community. (ICI) (Grade B)
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Measure #50: Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged
65 Years and Older
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence
with a documented plan of care for urinary incontinence at least once within 12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. This measure is appropriate for use in the ambulatory setting only. It is anticipated
that clinicians who provide services for patients with the diagnosis of urinary incontinence will
submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
reporting modifier allowed for this measure is: 8P- reason not otherwise specified. There are no
allowable performance exclusions for this measure. All measure-specific coding should be reported
ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data. There are no allowable performance exclusions for this
measure.
NUMERATOR:
Patients with a documented plan of care for urinary incontinence at least once within 12 months
Definition:
Plan of Care – May include behavioral interventions (e.g., bladder training, pelvic floor
muscle training, prompted voiding), referral to specialist, surgical treatment, reassess at
follow-up visit, lifestyle interventions, addressing co-morbid factors, modification or
discontinuation of medications contributing to urinary incontinence, or pharmacologic
therapy.
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OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Plan of Care for Urinary Incontinence Documented
CPT II 0509F: Urinary incontinence plan of care documented
Plan of Care for Urinary Incontinence not Documented, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 0509F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
0509F with 8P: Urinary incontinence plan of care not documented, reason not otherwise
specified
DENOMINATOR:
All female patients aged 65 years and older with a diagnosis of urinary incontinence
Denominator Criteria (Eligible Cases):
Patients aged ≥ 65 years on date of encounter
AND
Diagnosis for urinary incontinence (line-item ICD-9-CM): 307.6, 625.6, 788.30, 788.31,
788.33, 788.34, 788.35, 788.36, 788.37, 788.38, 788.39
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99324, 99325, 99326, 99327, 99328, 99334, 99335,
99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350
RATIONALE:
A treatment option should be documented for the patient with incontinence.
CLINICAL RECOMMENDATION STATEMENTS:
All conservative management options used in younger adults can be used in selected frail, older,
motivated people. This includes:
• Bladder retraining
• Pelvic muscle exercises including biofeedback and/or electro-stimulation (ICI) (Grade B)
Pharmacologic agents, especially oxybutynin and tolterodine, may have a small beneficial effect on
improving symptoms of detrusor overactivity in women. (ACOG) (Level A)
Oxybutynin and potentially other bladder relaxants can improve the effectiveness of behavioral
therapies in frail older persons. (ICI) (Grade B)
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Measure #51: Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of COPD who had spirometry
evaluation results documented
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period using the most recent
spirometry results in the patient record for patients seen during the reporting period. Do not limit
the search for spirometry results to the reporting period. This measure may be reported by
clinicians who perform the quality actions described in the measure based on the services provided
and the measure-specific denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis code, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 3P- system
reasons, 8P- reason not otherwise specified. All measure-specific coding should be reported ON
THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients with documented spirometry results in the medical record (FEV1 and FEV1/FVC)
Numerator Instructions: Look for most recent documentation of spirometry evaluation
results in the medical record; do not limit the search to the reporting period.
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Spirometry Results Documented
CPT II 3023F: Spirometry results documented and reviewed
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OR
Spirometry Results not Documented for Medical, Patient, or System Reasons
Append a modifier (1P, 2P or 3P) to CPT Category II code 3023F to report documented
circumstances that appropriately exclude patients from the denominator.
3023F with 1P: Documentation of medical reason(s) for not documenting and reviewing
spirometry results
3023F with 2P: Documentation of patient reason(s) for not documenting and reviewing
spirometry results
3023F with 3P: Documentation of system reason(s) for not documenting and reviewing
spirometry results
Spirometry Results not Documented, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3023F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3023F with 8P: Spirometry results not documented and reviewed, reason not otherwise
specified
DENOMINATOR:
All patients aged 18 and older with a diagnosis of COPD
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for COPD (line-item ICD-9-CM): 491.0, 491.1, 491.20, 491.21, 491.22, 491.8,
491.9, 492.0, 492.8, 496
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Evaluation of lung function for a patient with COPD is vital to determine what treatments are
needed and whether those treatments are effective.
CLINICAL RECOMMENDATION STATEMENTS:
Spirometry should be performed in all patients suspected of COPD. This is necessary for
diagnosis, assessment of severity of the disease and for following the progress of the disease.
(ATS and ERS)
For the diagnosis and assessment of COPD, spirometry is the gold standard as it is the most
reproducible, standardized, and objective way of measuring airflow limitation. FEV1/FVC < 70%
and a postbronchodilator FEV1 < 80% predicted confirms the presence of airflow limitation that is
not fully reversible. (NHLBI/WHO)
A patient's decline in lung function is best tracked by periodic spirometry measurements. Useful
information about lung function decline is unlikely from spirometry measurements performed more
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than once a year. Spirometry should be performed if there is a substantial increase in symptoms or
a complication. (NHLBI/WHO)
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Measure #52: Chronic Obstructive Pulmonary Disease (COPD): Bronchodilator Therapy
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of COPD and who have an
FEV1/FVC less than 70% and have symptoms who were prescribed an inhaled bronchodilator
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all COPD patients seen
during the reporting period. This measure may be reported by clinicians who perform the quality
actions described in the measure based on the services provided and the measure-specific
denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code(s) OR the CPT Category II code(s) with the modifier.
The modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 3P- system
reasons, 8P- reason not otherwise specified. All measure-specific coding should be reported ON
THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients who were prescribed an inhaled bronchodilator
Definition:
Prescribed – Includes patients who are currently receiving medication(s) that follow the
treatment plan recommended at an encounter during the reporting period, even if the
prescription for that medication was ordered prior to the encounter.
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
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OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Patient Prescribed Inhaled Bronchodilator Therapy
(Two CPT II codes [4025F & 3025F] are required on the claim form to submit this
numerator option)
CPT II 4025F: Inhaled bronchodilator prescribed
AND
CPT II 3025F: Spirometry test results demonstrate FEV1/FVC < 70% with COPD
symptoms (eg, dyspnea, cough/sputum, wheezing)
Patient not Documented to have Inhaled Bronchodilator Prescribed for Medical,
Patient, or System Reasons
(Two CPT II codes [4025F-xP & 3025F] are required on the claim form to submit this
numerator option)
Append a modifier (1P, 2P or 3P) to CPT Category II code 4025F to report documented
circumstances that appropriately exclude patients from the denominator.
4025F with 1P: Documentation of medical reason(s) for not prescribing an inhaled
bronchodilator
4025F with 2P: Documentation of patient reason(s) for not prescribing an inhaled
bronchodilator
4025F with 3P: Documentation of system reason(s) for not prescribing an inhaled
bronchodilator
AND
CPT II 3025F: Spirometry test results demonstrate FEV1/FVC < 70% with COPD
symptoms (eg, dyspnea, cough/sputum, wheezing)
OR
OR
If patient is not eligible for this measure because spirometry results demonstrate
FEV1/FVC ≥ 70% or patient does not have COPD symptoms, report:
Spirometry Results Demonstrate FEV1/FVC ≥ 70% or Patient Does not Have COPD
Symptoms
(One CPT II code [3027F] is required on the claim form to submit this numerator option)
CPT II 3027F: Spirometry test results demonstrate FEV1/FVC ≥ 70% or patient does not
have COPD symptoms
OR
Spirometry Test not Performed or Documented
(One CPT II code [3025F-8P] is required on the claim form to submit this numerator
option)
Append a reporting modifier (8P) to CPT Category II code 3025F to report circumstances
when the patient is not eligible for the measure.
3025F with 8P: Spirometry test not performed or documented
Patient not Documented to have Inhaled Bronchodilator Prescribed, Reason not
Specified
(Two CPT II codes [4025F-8P & 3025F] are required on the claim form to submit this
numerator option)
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Append a reporting modifier (8P) to CPT Category II code 4025F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4025F with 8P: Inhaled bronchodilator not prescribed, reason not otherwise specified
AND
CPT II 3025F: Spirometry test results demonstrate FEV1/FVC < 70% with COPD
symptoms (eg, dyspnea, cough/sputum, wheezing)
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of COPD, who have an FEV1/FVC <70% and
have symptoms (e.g., dyspnea, cough/sputum, wheezing)
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for COPD (line-item ICD-9-CM): 491.0, 491.1, 491.20, 491.21, 491.22, 491.8,
491.9, 492.0, 492.8, 496
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Inhaled bronchodilator therapy is effective in treating and managing the symptoms of COPD,
particularly, for those patients with moderate to very severe COPD, and improving a patient’s
quality of life.
CLINICAL RECOMMENDATION STATEMENTS:
Short-acting bronchodilators can increase exercise tolerance acutely in COPD. (ATS and ERS)
Bronchodilator medications are central to the symptomatic management of COPD. (Evidence A)
(NHLBI/ WHO)
A combination of a short-acting β2-agonist and an anticholinergic produces greater and more
sustained improvements in FEV1 than either alone and does not produce evidence of tachyphylaxis
over 90 days of treatment. (Evidence A) (NHLBI/WHO)
In patients with Stage II: Moderate COPD to Stage IV: Very Severe COPD whose symptoms are
not adequately controlled with as-needed short-acting bronchodilators, adding regular treatment
with a long-acting inhaled bronchodilator is recommended. (Evidence A) NHLBI/WHO)
Regular treatment with long-acting bronchodilators is more effective and convenient than treatment
with short-acting bronchodilators, but more expensive. (Evidence A) (NHLBI/WHO)
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Measure #53: Asthma: Pharmacologic Therapy
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 5 through 40 years with a diagnosis of mild, moderate, or severe
persistent asthma who were prescribed either the preferred long-term control medication (inhaled
corticosteroid) or an acceptable alternative treatment
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all asthma patients seen
during the reporting period. This measure may be reported by clinicians who perform the quality
actions described in the measure based on the services provided and the measure-specific
denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code(s) OR the CPT Category II code(s) with the modifier.
The modifiers allowed for this measure are: 2P- patient reasons, 8P- reason not otherwise
specified. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients who were prescribed either the preferred long-term control medication (inhaled
corticosteroid or inhaled corticosteroid with long-acting inhaled beta2-agonist) or an acceptable
alternative treatment (leukotriene modifiers, cromolyn sodium, nedocromil sodium, or sustainedreleased methylaxanthines)
Numerator Instructions: Documentation of persistent asthma must be present. One
method of identifying persistent asthma is at least daily use of short-acting bronchodilators.
Definition:
Prescribed – May include prescription given to the patient for long-term control medication
(inhaled corticosteroid or inhaled corticosteroid with long-acting inhaled beta2-agonist) or
an acceptable alternative treatment (leukotriene modifiers, cromolyn sodium, nedocromil
sodium, or sustained-released methylaxanthines) at one or more visits in the 12-month
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period or patient already taking long-term control medication or an acceptable alternative
treatment as documented in current medication list.
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Preferred Long-Term Control Medication or Acceptable Alternative Treatment
Prescribed
(Two CPT II codes [4015F & 1038F] are required on the claim form to submit this
numerator option)
CPT II 4015F: Persistent asthma, preferred long term control medication or acceptable
alternative treatment prescribed
AND
CPT II 1038F: Persistent asthma (mild, moderate or severe)
Preferred Long-Term Control Medication or Acceptable Alternative Treatment not
Prescribed for Patient Reasons
(Two CPT II codes [4015F-2P & 1038F] are required on the claim form to submit this
numerator option)
Append a modifier (2P) to CPT Category II code 4015F to report documented
circumstances that appropriately exclude patients from the denominator.
4015F with 2P: Documentation of patient reason(s) for not prescribing either the preferred
long-term control medication (inhaled corticosteroid or inhaled
corticosteroid with long-acting inhaled beta2-agonist) or an acceptable
alternative treatment (leukotriene modifiers, cromolyn sodium, nedocromil
sodium, or sustained-released methylaxanthines)
AND
CPT II 1038F: Persistent asthma (mild, moderate or severe)
OR
OR
If patient is not eligible for this measure because patient does not have persistent
asthma, report:
(One CPT II code [1039F] is required on the claim form to submit this numerator option)
CPT II 1039F: Intermittent asthma
Preferred Long-Term Control Medication or Acceptable Alternative Treatment not
Prescribed, Reason not Specified
(Two CPT II codes [4015F-8P & 1038F] are required on the claim form to submit this
numerator option)
Append a reporting modifier (8P) to CPT Category II code 4015F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4015F with 8P: Persistent asthma, preferred long term control medication or acceptable
alternative treatment not prescribed, reason not otherwise specified
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AND
CPT II 1038F: Persistent asthma (mild, moderate or severe)
DENOMINATOR:
All patients aged 5 through 40 years with a diagnosis of mild, moderate, or severe persistent
asthma
Denominator Criteria (Eligible Cases):
Patients aged 5 through 40 years on date of encounter
AND
Diagnosis for asthma (line-item ICD-9-CM): 493.00, 493.01, 493.02, 493.10, 493.11,
493.12, 493.20, 493.21, 493.22, 493.81, 493.82, 493.90, 493.91, 493.92
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Although current guidelines recommend inhaled corticosteroids as the preferred pharmacological
treatment for persistent asthma, other long-term control medications are acceptable alternatives.
Long Acting-inhaled Beta2 Agonists (LABA) are recommended in combination with Inhaled
Corticosteroids.
CLINICAL RECOMMENDATION STATEMENTS:
A stepwise approach to therapy is recommended to maintain long-term control:
Step 1: Mild Intermittent Asthma
• No daily medication needed
Step 2: Mild Persistent Asthma
• Preferred treatment: Low-dose inhaled corticosteroids (ICS)
• Alternative treatment: Cromolyn, leukotriene modifier, nedocromil, OR sustained-release
theophylline
Step 3: Moderate Persistent Asthma
• Preferred treatment: Low-medium dose ICS + long-acting inhaled beta2-agonists (LABA)
• Alternative treatment: Increase medium-dose ICS OR low-medium dose ICS and either
leukotriene modifier or theophylline (If needed, may increase ICS within medium-dose
range in either treatment)
Step 4: Severe Persistent Asthma
• Preferred treatment: High-dose ICS + LABA AND, if needed, corticosteroid tablets or syrup
long-term
Studies comparing ICS to cromolyn, nedocromil, theophylline, or leukotriene receptor antagonists
are limited, but available evidence shows that none of these long-term control medications appear
to be as effective as ICS in improving asthma outcomes.
For quick relief for all patients, a short-acting bronchodilator is recommended as needed for
symptoms. (NAEPP/NHLBI)
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Measure #54: 12-Lead Electrocardiogram (ECG) Performed for Non-Traumatic Chest Pain
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 40 years and older with an emergency department discharge
diagnosis of non-traumatic chest pain who had a 12-lead ECG performed
INSTRUCTIONS:
This measure is to be reported each time a patient has been discharged from the emergency
department with a discharge diagnosis of non-traumatic chest pain during the reporting period.
Claims data will be analyzed to determine the emergency department discharge. Patients who
were discharged from an emergency department with a diagnosis of non-traumatic chest pain
should have documentation in the medical record of having a 12-lead ECG performed. It is
anticipated that clinicians who provide care in the emergency department will submit this measure.
The Part B claim form place of service field must indicate that the encounter has taken place in the
emergency department.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 8P- reason not
otherwise specified. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients who had a 12-lead ECG performed
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
12-Lead ECG Performed
CPT II 3120F: 12-Lead ECG Performed
12-Lead ECG not Performed for Medical or Patient Reasons
Append a modifier (1P or 2P) to CPT Category II code 3120F to report documented
circumstances that appropriately exclude patients from the denominator.
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OR
3120F with 1P: Documentation of medical reason(s) for not performing a 12-Lead ECG
3120F with 2P: Documentation of patient reason(s) for not performing a 12-Lead ECG
12-Lead ECG not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3120F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3120F with 8P: 12-Lead ECG not performed, reason not otherwise specified
DENOMINATOR:
All patients aged 40 years and older with an emergency department discharge diagnosis of nontraumatic chest pain
Denominator Criteria (Eligible Cases):
Patients aged ≥ 40 years on date of encounter
AND
Diagnosis for non-traumatic chest pain (line-item ICD-9-CM): 413.0, 413.1, 413.9,
786.50, 786.51, 786.52, 786.59
AND
Patient encounter during the reporting period (CPT): 99281, 99282, 99283, 99284,
99285, 99291
AND
Place of Service Indicator: 23
(The Part B claim form place of service field must indicate emergency department)
RATIONALE:
All patients in the age group for which CAD/ACS is part of the differential diagnosis, should have a
12-lead ECG performed.
CLINICAL RECOMMENDATION STATEMENTS:
A 12-lead ECG should be performed and shown to an experienced emergency physician within 10
minutes of ED arrival for all patients with chest discomfort (or anginal equivalent) or other
symptoms of STEMI. (ACC/AHA)(Class I, Level C)
If pain is severe or pressure or substernal or exertional or radiating to jaw, neck, shoulder or arm,
then the following are recommended:
• 12-lead ECG (Rule)
• IV access, supplemental oxygen, cardiac monitor, serum cardiac markers (e.g.,
CKMB), CXR, nitrates, management of on-going pain, admit (ACEP)
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Measure #55: 12-Lead Electrocardiogram (ECG) Performed for Syncope
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 60 years and older with an emergency department discharge
diagnosis of syncope who had a 12-lead ECG performed
INSTRUCTIONS:
This measure is to be reported each time a patient has been discharged from the emergency
department with a discharge diagnosis of syncope during the reporting period. Claims data will be
analyzed to determine the emergency department discharge. Patients who experienced syncope
should have documentation in the medical record of having a 12-lead ECG performed. It is
anticipated that clinicians who provide care in the emergency department will submit this measure.
The Part B claim form place of service field must indicate that the encounter has taken place in the
emergency department.
Measure Reporting via Claims:
Line-item ICD-9-CM codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. CPT Category II codes are used to report the
numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 8P- reason not
otherwise specified. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients who had a 12-lead ECG performed
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
12-Lead ECG Performed
CPT II 3120F: 12-Lead ECG Performed
12-Lead ECG not Performed for Medical or Patient Reasons
Append a modifier (1P or 2P) to CPT Category II code 3120F to report documented
circumstances that appropriately exclude patients from the denominator.
3120F with 1P: Documentation of medical reason(s) for not performing a 12-Lead ECG
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OR
3120F with 2P: Documentation of patient reason(s) for not performing a 12-Lead ECG
12-Lead ECG not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3120F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3120F with 8P: 12-Lead ECG not performed, reason not otherwise specified
DENOMINATOR:
All patients aged 60 years and older with an emergency department discharge diagnosis of
syncope
Denominator Criteria (Eligible Cases):
Patients aged ≥ 60 years on date of encounter
AND
Diagnosis for syncope (line-item ICD-9-CM): 780.2
AND
Patient encounter during the reporting period (CPT): 99281, 99282, 99283, 99284,
99285, 99291
AND
Place of Service Indicator: 23
(The Part B claim form place of service field must indicate emergency department)
RATIONALE:
12-lead ECG can occasionally pick up potentially life-threatening conditions such as pre-excitation
syndromes, prolonged QT syndromes, or Brugada’s syndrome in otherwise healthy appearing
young adults. 12-lead ECG testing is performed inconsistently, even in high risk patients; the
largest study to date of 12-lead ECG testing variation in ED syncope visits using a 9 year national
sample illustrated that 12-lead ECG testing was documented in only 59% of ED syncope visits.
CLINICAL RECOMMENDATION STATEMENTS:
Obtain a standard 12-lead ECG in patients with syncope when history and physical examination do
not reveal a diagnosis. (ACEP) (Level A)
• A patient with normal 12-lead ECG has a low likelihood of dysrhythmias as a cause of
syncope.
• Abnormal 12-lead ECG has been associated as being the most important predictor of
serious outcomes and a multivariate predictor for arrhythmia or death within 1 year after
the syncopal episode.
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Measure #56: Community-Acquired Pneumonia (CAP): Vital Signs
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial
pneumonia with vital signs documented and reviewed
INSTRUCTIONS:
This measure is to be reported once for each occurrence of community-acquired bacterial
pneumonia during the reporting period. Each unique occurrence is defined as a 45-day period from
onset of community-acquired bacterial pneumonia. Claims data will be analyzed to determine
unique occurrences. All patients 18 years and older with a diagnosis of community acquired
bacterial pneumonia should have documentation in the medical record of having vital signs
recorded and reviewed. It is anticipated that clinicians who provide care in the emergency
department or office setting will submit this measure. Clinicians utilizing the critical care code must
indicate the emergency department place of service code in order to be counted in the measure’s
denominator.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
reporting modifier allowed for this measure is: 8P- reason not otherwise specified. There are no
allowable performance exclusions for this measure. All measure-specific coding should be reported
ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data. There are no allowable performance exclusions for this
measure.
NUMERATOR:
Patients with vital signs (temperature, pulse, respiratory rate, and blood pressure) documented and
reviewed
Definition:
Medical Record – May include one of the following: Clinician documentation that vital
signs were reviewed, dictation by the clinician including vital signs, clinician initials in the
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chart that vital signs were reviewed, or other indication that vital signs had been
acknowledged by the clinician.
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Vital Signs Documented and Reviewed
CPT II 2010F: Vital signs (temperature, pulse, respiratory rate, and blood pressure)
documented and reviewed
Vital Signs not Documented and Reviewed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 2010F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
2010F with 8P: Vital signs (temperature, pulse, respiratory rate, and blood pressure) not
documented and reviewed, reason not otherwise specified
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for community-acquired bacterial pneumonia (line-item ICD-9-CM):
481, 482.0, 482.1, 482.2, 482.30, 482.31, 482.32, 482.39, 482.40, 482.41, 482.42, 482.49,
482.81, 482.82, 482.83, 482.84, 482.89, 482.9, 483.0, 483.1, 483.8, 485, 486, 487.0
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99281, 99282, 99283, 99284, 99285, 99291*, 99324,
99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344,
99345, 99347, 99348, 99349, 99350
* Clinicians utilizing the critical care code (99291) must indicate the emergency department
place of service (23) on the Part B claim form in order to report this measure.
RATIONALE:
Each of the vital signs should be recorded in the emergency department. While vital signs may be
routinely recorded, there likely is a gap in care on acting on those values that warrant further
evaluation. Moreover, it is important for physicians to review the vital signs to ensure continuous
quality improvement and consistent patient care.
CLINICAL RECOMMENDATION STATEMENTS:
It is necessary to assess the severity of illness. This includes the radiographic findings (multilobar
pneumonia or pleural effusion) and physical findings (respiratory rate, systolic and diastolic blood
pressure, signs of dehydrations and mental status). (ATS) (Level II Evidence)
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Measure #57: Community-Acquired Pneumonia (CAP): Assessment of Oxygen Saturation
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial
pneumonia with oxygen saturation documented and reviewed
INSTRUCTIONS:
This measure is to be reported once for each occurrence of community-acquired bacterial
pneumonia during the reporting period. Each unique occurrence is defined as a 45-day period from
onset of community-acquired bacterial pneumonia. Claims data will be analyzed to determine
unique occurrences. All patients 18 years and older with a diagnosis of community-acquired
bacterial pneumonia should have documentation in the medical record of having oxygen saturation
assessed. It is anticipated that clinicians who provide care in the emergency department or office
setting will submit this measure. Clinicians utilizing the critical care code must indicate the
emergency department place of service code in order to be counted in the measure’s denominator.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 3P- system
reasons, 8P- reason not otherwise specified. Clinicians utilizing the critical care code must indicate
the emergency department place of service code in order to be counted in the measure’s
denominator. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients with oxygen saturation documented and reviewed
Definition:
Medical Record – May include one of the following: Clinician documentation that oxygen
saturation was reviewed, dictation by the clinician including oxygen saturation, clinician
initials in the chart that oxygen saturation was reviewed, or other indication that oxygen
saturation had been acknowledged by the clinician.
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OR
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Oxygen Saturation Documented and Reviewed
CPT II 3028F: Oxygen saturation results documented and reviewed (includes assessment
through pulse oximetry or arterial blood gas measurement)
Oxygen Saturation not Documented and Reviewed for Medical, Patient, or System
Reasons
Append a modifier (1P, 2P or 3P) to CPT Category II code 3028F to report documented
circumstances that appropriately exclude patients from the denominator.
3028F with 1P: Documentation of medical reason(s) for not documenting and reviewing
oxygen saturation
3028F with 2P: Documentation of patient reason(s) for not documenting and reviewing
oxygen saturation
3028F with 3P: Documentation of system reason(s) for not documenting and reviewing
oxygen saturation
Oxygen Saturation not Documented and Reviewed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3028F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3028F with 8P: Oxygen saturation results not documented and reviewed, reason not
otherwise specified
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for community-acquired bacterial pneumonia (line-item ICD-9-CM):
481, 482.0, 482.1, 482.2, 482.30, 482.31, 482.32, 482.39, 482.40, 482.41, 482.42, 482.49,
482.81, 482.82, 482.83, 482.84, 482.89, 482.9, 483.0, 483.1, 483.8, 485, 486, 487.0
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99281, 99282, 99283, 99284, 99285, 99291*, 99324,
99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344,
99345, 99347, 99348, 99349, 99350
* Clinicians utilizing the critical care code (99291) must indicate the emergency department
place of service (23) on the Part B claim form in order to report this measure.
RATIONALE:
The assessment of oxygenation helps to assess the severity of the illness.
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CLINICAL RECOMMENDATION STATEMENTS:
It is necessary to assess the severity of illness. This includes the radiographic findings (multilobar
pneumonia or pleural effusion) and physical findings (respiratory rate, systolic and diastolic blood
pressure, signs of dehydrations and mental status). For those patients with chronic heart or lung
disease, the assessment of oxygenation by pulse oximetry will help identify the need for
hospitalization. (ATS) (Level II Evidence)
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Measure #58: Community-Acquired Pneumonia (CAP): Assessment of Mental Status
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial
pneumonia with mental status assessed
INSTRUCTIONS:
This measure is to be reported once for each occurrence of community-acquired bacterial
pneumonia during the reporting period. Each unique occurrence is defined as a 45-day period from
onset of community-acquired bacterial pneumonia. Claims data will be analyzed to determine
unique occurrences. All patients 18 years and older with a diagnosis of community acquired
bacterial pneumonia should have documentation in the medical record of having mental status
assessed. It is anticipated that clinicians who provide care in the emergency department or office
setting will submit this measure. Clinicians utilizing the critical care code must indicate the
emergency department place of service code in order to be counted in the measure’s denominator.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
reporting modifier allowed for this measure is: 8P- reason not otherwise specified. There are no
allowable performance exclusions for this measure. All measure-specific coding should be reported
ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data. There are no allowable performance exclusions for this
measure.
NUMERATOR:
Patients for whom mental status was assessed
Definition:
Medical Record – May include: Documentation by clinician that patient’s mental status
was noted (e.g., patient is oriented or disoriented).
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OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Mental Status Assessed
CPT II 2014F: Mental status assessed
Mental Status not Assessed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 2014F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
2014F with 8P: Mental status not assessed, reason not otherwise specified
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for community-acquired bacterial pneumonia (line-item ICD-9-CM):
481, 482.0, 482.1, 482.2, 482.30, 482.31, 482.32, 482.39, 482.40, 482.41, 482.42, 482.49,
482.81, 482.82, 482.83, 482.84, 482.89, 482.9, 483.0, 483.1, 483.8, 485, 486, 487.0
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99281, 99282, 99283, 99284, 99285, 99291*, 99324,
99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344,
99345, 99347, 99348, 99349, 99350
* Clinicians utilizing the critical care code (99291) must indicate the emergency department
place of service (23) on the Part B claim form in order to report this measure.
RATIONALE:
The assessment of mental status helps to assess the severity of the illness.
CLINICAL RECOMMENDATION STATEMENTS:
It is necessary to assess the severity of illness. This includes the radiographic findings (multilobar
pneumonia or pleural effusion) and physical findings (respiratory rate, systolic and diastolic blood
pressure, signs of dehydrations and mental status). (ATS) (Level II Evidence)
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Measure #59: Community-Acquired Pneumonia (CAP): Empiric Antibiotic
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial
pneumonia with an appropriate empiric antibiotic prescribed
INSTRUCTIONS:
This measure is to be reported once for each occurrence of community-acquired bacterial
pneumonia during the reporting period. Each unique occurrence is defined as a 45-day period from
onset of community-acquired bacterial pneumonia. Claims data will be analyzed to determine
unique occurrences. All patients 18 years and older with a diagnosis of community acquired
bacterial pneumonia should have documentation in the medical record of having an appropriate
empiric antibiotic prescribed. It is anticipated that clinicians who provide care in the emergency
department or office setting will submit this measure. Clinicians utilizing the critical care code must
indicate the emergency department place of service code in order to be counted in the measure’s
denominator.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 3P- system
reasons, 8P- reason not otherwise specified. All measure-specific coding should be reported ON
THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients with appropriate empiric antibiotic prescribed
Definitions:
Appropriate Empiric Antibiotic – For treatment of community-acquired bacterial
pneumonia (CAP) should include any medication from one of the following four drug
classes: Fluoroquinolones, Macrolides, Doxycycline, Beta Lactam with Macrolide or
Doxycycline (as defined by current ATS/IDSA guidelines).
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Prescribed – Includes patients who are currently receiving medication(s) that follow the
treatment plan recommended at an encounter during the reporting period, even if the
prescription for that medication was ordered prior to the encounter.
OR
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Appropriate Empiric Antibiotic Prescribed
CPT II 4045F: Appropriate empiric antibiotic prescribed
Appropriate Empiric Antibiotic not Prescribed for Medical, Patient, or System
Reasons
Append a modifier (1P, 2P or 3P) to CPT Category II code 4045F to report documented
circumstances that appropriately exclude patients from the denominator.
4045F with 1P: Documentation of medical reason(s) for not prescribing appropriate
empiric antibiotic
4045F with 2P: Documentation of patient reason(s) for not prescribing appropriate empiric
antibiotic
4045F with 3P: Documentation of system reason(s) for not prescribing appropriate empiric
antibiotic
Appropriate Empiric Antibiotic not Prescribed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4045F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4045F with 8P: Appropriate empiric antibiotic not prescribed, reason not otherwise
specified
DENOMINATOR:
All patients aged 18 years and older with the diagnosis of community-acquired bacterial pneumonia
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for community-acquired bacterial pneumonia (line-item ICD-9-CM):
481, 482.0, 482.1, 482.2, 482.30, 482.31, 482.32, 482.39, 482.40, 482.41, 482.42, 482.49,
482.81, 482.82, 482.83, 482.84, 482.89, 482.9, 483.0, 483.1, 483.8, 485, 486, 487.0
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99281, 99282, 99283, 99284, 99285, 99291*, 99324,
99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344,
99345, 99347, 99348, 99349, 99350
* Clinicians utilizing the critical care code (99291) must indicate the emergency department
place of service (23) on the Part B claim form in order to report this measure.
RATIONALE:
All patients need to be treated empirically according to the guideline recommendations.
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CLINICAL RECOMMENDATION STATEMENTS:
All patients should be treated empirically. Patients treated as outpatients with no cardiopulmonary
disease and no modifying factors should be treated with advanced generation macrolide:
azithromycin or clarithromycin or doxycycline. Patients treated as an outpatient with
cardiopulmonary disease and/or risk factors should be treated with beta lactam plus macrolide or
doxycycline or fluoroquinolone alone. Empiric therapy based on the ATS guidelines lead to better
outcomes than if the guidelines are not followed. (ATS) (Level II Evidence)
Fluoroquinolones (gatifloxacin, gemifloxacin, levofloxacin, and moxifloxacin) are recommended for
initial empiric therapy of selected outpatients with CAP. (Level A Recommendation, Level I
Evidence)
Other options (macrolides and doxycycline) are generally preferred for uncomplicated infections in
outpatients. (IDSA) (Level A Recommendation, Level I Evidence)
A macrolide is recommended as monotherapy for selected outpatients, such as those who were
previously well and not recently treated with antibiotics. (Level A Recommendation, Level l
Evidence)
A macrolide plus a beta lactam is recommended for initial empiric treatment of outpatients in whom
resistance is an issue. (IDSA) (Level A Recommendation, Level I Evidence)
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Measure #64: Asthma: Asthma Assessment
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 5 through 40 years with a diagnosis of asthma who were evaluated
during at least one office visit within 12 months for the frequency (numeric) of daytime and
nocturnal asthma symptoms
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with asthma
seen during the reporting period. This measure may be reported by clinicians who perform the
quality actions described in the measure based on the services provided and the measure-specific
denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
reporting modifier allowed for this measure is: 8P- reason not otherwise specified. There are no
allowable performance exclusions for this measure. All measure-specific coding should be reported
ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data. There are no allowable performance exclusions for this
measure.
NUMERATOR:
Patients who were evaluated during at least one office visit within 12 months for the frequency
(numeric) of daytime and nocturnal asthma symptoms
Numerator Instructions: To be counted in calculation of this measure, symptom
frequency must be numerically quantified. Measure may also be met by clinician
documentation or patient completion of an asthma assessment tool/survey/questionnaire.
Assessment tool may include the Quality Metric Asthma Control Test™, National Asthma
Education & Prevention Program (NAEPP) Asthma Symptoms, and Peak Flow Diary.
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OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Asthma Symptom Frequency Evaluated
CPT II 1005F: Asthma symptoms evaluated (includes physician documentation of numeric
frequency of symptoms or patient completion of an asthma assessment
tool/survey/questionnaire)
Asthma Symptom Frequency not Evaluated, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 1005F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
1005F with 8P: Asthma symptoms not evaluated, reason not otherwise specified
DENOMINATOR:
All patients aged 5 through 40 years with a diagnosis of asthma
Denominator Criteria (Eligible Cases):
Patients aged 5 through 40 years on date of encounter
AND
Diagnosis for asthma (line-item ICD-9-CM): 493.00, 493.01, 493.02, 493.10, 493.11,
493.12, 493.20, 493.21, 493.22, 493.81, 493.82, 493.90, 493.91, 493.92
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Appropriate treatment of asthma patients requires accurate classification of asthma severity.
Physician assessment of the frequency of asthma symptoms is the first step in classifying asthma
severity.
CLINICAL RECOMMENDATION STATEMENTS:
To determine whether the goals of therapy are being met, monitoring is recommended in the 6
areas listed below:
• Signs and symptoms (daytime; nocturnal awakening) of asthma
• Pulmonary function (spirometry; peak flow monitoring)
• Quality of life/functional status
• History of asthma exacerbations
• Pharmacotherapy (as-needed use of inhaled short-acting beta2-agonist, adherence to
regimen of long-term-control medications)
• Patient-provider communication and patient satisfaction (NAEPP/NHLBI)
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Measure #65: Treatment for Children with Upper Respiratory Infection (URI): Avoidance
of Inappropriate Use
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of children aged 3 months through 18 years with a diagnosis of URI who were not
prescribed or dispensed an antibiotic prescription on or within 3 days of the initial date of service
INSTRUCTIONS:
This measure is to be reported once for each occurrence of upper respiratory infection during the
reporting period. Claims data will be analyzed to determine unique occurrences. This measure may
be reported by clinicians who perform the quality actions described in the measure based on the
services provided and the measure-specific denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifier allowed for this measure is: 1P- medical reasons. All measure-specific coding should be
reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients who were not dispensed an antibiotic prescription on or within 3 days of the initial date of
service
Numerator Instructions: For performance, the measure will be calculated as the number
of patients for whom antibiotics were neither prescribed nor dispensed over the number of
patients in the denominator (patients aged 3 months through 18 years with URI). A higher
score indicates appropriate treatment of patients with URI (e.g., the proportion for whom
antibiotics were not prescribed or dispensed).
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OR
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Antibiotic not Prescribed or Dispensed
CPT II 4124F: Antibiotic neither prescribed nor dispensed
Antibiotic Prescribed or Dispensed for Medical Reasons
Append a modifier (1P) to CPT Category II code 4120F to report documented
circumstances that appropriately exclude patients from the denominator.
4120F with 1P: Documentation of medical reason(s) for prescribing or dispensing antibiotic
Antibiotic Prescribed or Dispensed
CPT II 4120F: Antibiotic prescribed or dispensed
DENOMINATOR:
All patients aged 3 months through 18 years with a diagnosis of upper respiratory infection
Denominator Criteria (Eligible Cases):
Patients aged 3 months through 18 years on date of encounter
AND
Diagnosis for URI (line-item ICD-9-CM): 460, 465.0, 465.8, 465.9
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220
RATIONALE:
Existing clinical guidelines do not support the use of antibiotics for the common cold/upper
respiratory infection.
CLINICAL RECOMMENDATION STATEMENTS:
Recent clinical practice guidelines set out the evidence supporting the recommendations for
treating a host of upper respiratory tract infections in pediatrics. The guidelines do not recommend
antibiotics for a majority of upper respiratory tract infections, except for conditions with bacterial
etiology such as acute otitis media, bacterial sinusitis, mucopurulent rhinitis with prolonged
symptoms, i.e., at least 10 days of continual symptoms, and group A streptococcal pharyngitis (but
only cases with a confirmatory test for group A strep). The guidelines support targeting treatment of
non-specific URI (the common cold) or viral rhinosinusitis with antibiotics as an indicator of
inappropriate antibiotic prescribing.
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Measure #66: Appropriate Testing for Children with Pharyngitis
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of children aged 2 through 18 years with a diagnosis of pharyngitis, who were
prescribed an antibiotic and who received a group A streptococcus (strep) test for the episode
INSTRUCTIONS:
This measure is to be reported once for each occurrence of pharyngitis during the reporting period.
Claims data will be analyzed to determine unique occurrences. This measure is intended to reflect
the quality of services provided for the primary management of patients with pharyngitis who were
dispensed an antibiotic. This measure may be reported by clinicians who perform the quality
actions described in the measure based on the services provided and the measure-specific
denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code(s) OR the CPT Category II code(s) with the modifier.
The modifiers allowed for this measure are: 1P- medical reasons, 8P- reason not otherwise
specified. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients who were dispensed an antibiotic and who received a group A streptococcus (strep) test
for the episode
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
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Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Group A Streptococcus Test Performed and Antibiotic Prescribed
(Two CPT II codes [3210F & 4120F] are required on the claim form to submit this
numerator option)
OR
CPT II 3210F: Group A Strep Test Performed
AND
CPT II 4120F: Antibiotic prescribed or dispensed
Group A Streptococcus Test not Performed for Medical Reasons
(Two CPT II codes [3210F-1P & 4120F] are required on the claim form to submit this
numerator option)
Append a modifier (1P) to CPT Category II codes 3210F to report documented
circumstances that appropriately exclude patients from the denominator.
3210F with 1P: Documentation of medical reason(s) for not Performing Group A Strep
Test
AND
CPT II 4120F: Antibiotic prescribed or dispensed
OR
OR
If patient is not eligible for this measure because patient was not prescribed
antibiotics, report:
(One CPT II code [4124F] is required on the claim form to submit this numerator option)
CPT II 4124F: Antibiotic neither prescribed nor dispensed
Group A Streptococcus Test not Performed, Reason not Specified
(Two CPT II codes [3210F-8P & 4120F] are required on the claim form to submit this
numerator option)
Append a reporting modifier (8P) to CPT Category II code 3210F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3210F with 8P: Group A Strep Test not Performed, reason not otherwise specified
AND
CPT II 4120F: Antibiotic prescribed or dispensed
DENOMINATOR:
All patients aged 2 through 18 years with a diagnosis of pharyngitis
Denominator Criteria (Eligible Cases):
Patients aged 2 through 18 years on date of encounter
AND
Diagnosis for pharyngitis (line-item ICD-9-CM): 034.0, 462, 463
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220
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RATIONALE:
Clinical practice guidelines recommend group A streptococcus pharyngitis be treated with
antibiotics (Schwartz et al, 1998).
CLINICAL RECOMMENDATION STATEMENTS:
The group A strep test (rapid assay or throat culture) is the definitive test of group A strep
pharyngitis. Pharyngitis is the only respiratory tract infection with an objective diagnostic test that
can be validated with administrative data, and not medical records. A process measure that
requires the performance of a group A strep test for children given antibiotics for pharyngitis is
supported by the guidelines. (Ibid)
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Measure #67: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline
Cytogenetic Testing Performed on Bone Marrow
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of MDS or an acute leukemia who
had baseline cytogenetic testing performed on bone marrow
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period, regardless of when the baseline testing is performed. It is anticipated that
clinicians who provide services for patients with the diagnosis of myelodysplastic syndromes or an
acute leukemia (not in remission) will submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 3P- system
reasons, 8P- reason not otherwise specified. All measure-specific coding should be reported ON
THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients who had baseline cytogenetic testing performed on bone marrow
Definition:
Baseline Cytogenetic Testing – Testing that is performed at time of diagnosis or prior to
initiating treatment (transfusion, growth factors, or antineoplastic therapy) for that diagnosis
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Baseline Cytogenetic Testing Performed
CPT II 3155F: Cytogenetic testing performed on bone marrow at time of diagnosis or prior
to initiating treatment
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OR
OR
Baseline Cytogenetic Testing not Performed for Medical, Patient, or System
Reasons
Append a modifier (1P, 2P or 3P) to CPT Category II code 3155F to report documented
circumstances that appropriately exclude patients from the denominator.
3155F with 1P: Documentation of medical reason(s) for not performing baseline
cytogenetic testing on bone marrow (e.g., no liquid bone marrow or fibrotic
marrow)
3155F with 2P: Documentation of patient reason(s) for not performing baseline
cytogenetic testing on bone marrow (e.g., at time of diagnosis receiving
palliative care or not receiving treatment as defined above)
3155F with 3P: Documentation of system reason(s) for not performing baseline
cytogenetic testing on bone marrow (e.g., patient previously treated by
another physician at the time cytogenetic testing performed)
Baseline Cytogenetic Testing not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3155F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3155F with 8P: Cytogenetic testing not performed on bone marrow at time of diagnosis or
prior to initiating treatment, reason not otherwise specified
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of MDS or an acute leukemia
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for MDS or acute leukemia – not in remission (line-item ICD-9-CM):
204.00, 204.02, 205.00, 205.02, 206.00, 206.02, 207.00, 207.02, 207.20, 207.22, 208.00,
208.02, 238.72, 238.73, 238.74, 238.75
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
For MDS:
Cytogenetic testing is an integral component in calculating the International Prognostic Scoring
System (IPSS) score. Cytogenetic testing should be performed on the bone marrow of patients
with MDS in order to guide treatment options, determine prognosis, and predict the likelihood of
disease evolution to leukemia.
For acute leukemias:
In addition to establishing the type of acute leukemia, cytogenetic testing is essential to detect
chromosomal abnormalities that have diagnostic, prognostic, and therapeutic significance.
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CLINICAL RECOMMENDATION STATEMENTS:
For MDS:
Bone marrow aspiration and biopsy are needed to calculate the degree of hematopoietic cell
maturation abnormalities and relative proportions, percentage of marrow blasts, marrow cellularity,
presence or absence of ringed sideroblasts (and presence of iron per se), and fibrosis. Marrow
cytogenetics should be obtained because they are of major importance for prognosis (Category 2A
Recommendation). (NCCN)
The decision to treat patients having marrow blasts in the range of 20% to 30% with intensive AML
therapy is thus complex and should be individualized. The clinician should consider such factors as
age, antecedent factors, cytogenetics, comorbidities, pace of disease, and performance status
(Category 2A Recommendation). (NCCN)
A chromosome abnormality confirms the presence of a clonal disorder aiding the distinction
between MDS and reactive causes of dysplasia, and in addition has major prognostic value.
Cytogenetic analysis should therefore be performed for all patients in whom a bone marrow
examination is indicated. (BCSH)
For acute leukemias:
The initial evaluation has two objectives. The first is to identify the pathology causing the disease
including factors such as prior toxic exposure or myelodysplasia, cytogenetics and molecular
markers that may have an impact on chemoresponsiveness and propensity for relapse which may
guide choice of treatment. The second objective focuses on patient-specific factors including
comorbid conditions that may affect an individual's ability to tolerate chemotherapy (Category 2A
Recommendation). (NCCN)
Although cytogenetic information is usually unknown when treatment is initiated in patients with de
novo AML, karyotype represents the single most important prognostic factor for predicting
remission rate, relapse, and overall survival. Therefore, the importance of obtaining sufficient
samples of marrow or peripheral blood blasts at diagnosis for this analysis cannot be
overemphasized (Category 2A Recommendation). (NCCN)
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Measure #68: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in
Patients Receiving Erythropoietin Therapy
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of MDS who are receiving
erythropoietin therapy with documentation of iron stores prior to initiating erythropoietin therapy
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all MDS patients seen
during the reporting period, regardless of when the documentation of iron stores occurs. It is
anticipated that clinicians who provide services for patients with the diagnosis of myelodysplastic
syndromes will submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code(s) OR the CPT Category II code(s) with the modifier.
The modifiers allowed for this measure are: 3P- system reasons, 8P- reason not otherwise
specified. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients with documentation of iron stores prior to initiating erythropoietin therapy
Definitions:
Documentation of Iron Stores – Includes either: bone marrow examination including iron
stain OR serum iron measurement by ferritin or serum iron and TIBC.
Erythropoietin Therapy – Includes the following medications: epoetin and darbepoetin for
the purpose of this measure.
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
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OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Documentation of Iron Stores Prior to Initiating Erythropoietin Therapy Performed
(Two CPT II codes [3160F & 4090F] are required on the claim form to submit this
numerator option)
CPT II 3160F: Documentation of iron stores prior to initiating erythropoietin therapy
AND
CPT II 4090F: Patient receiving erythropoietin therapy
Documentation of Iron Stores Prior to Initiating Erythropoietin Therapy not
Performed for System Reasons
(Two CPT II codes [3160F-3P & 4090F] are required on the claim form to submit this
numerator option)
Append a modifier (3P) to CPT Category II code 3160F to report documented
circumstances that appropriately exclude patients from the denominator.
3160F with 3P: Documentation of system reason(s) for not documenting iron stores prior
to initiating erythropoietin therapy
AND
CPT II 4090F: Patient receiving erythropoietin therapy
OR
OR
If patient is not eligible for this measure because patient is not receiving
erythropoietin therapy, report:
(One CPT II code [4095F] is required on the claim form to submit this numerator option)
CPT II 4095F: Patient not receiving erythropoietin therapy
Documentation of Iron Stores Prior to Initiating Erythropoietin Therapy not
Performed, Reason not Specified
(Two CPT II codes [3160F-8P & 4090F] are required on the claim form to submit this
numerator option)
Append a reporting modifier (8P) to CPT Category II code 3160F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3160F with 8P: Iron stores prior to initiating erythropoietin therapy not documented,
reason not otherwise specified
AND
CPT II 4090F: Patient receiving erythropoietin therapy
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of MDS who are receiving erythropoietin
therapy
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for MDS (line-item ICD-9-CM): 238.72, 238.73, 238.74, 238.75
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AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
To be effective erythropoietin requires that adequate iron stores be present due to iron’s
importance in red-blood-cell synthesis. Iron deficiency presents a major limitation to the efficacy of
erythropoietin therapy.
CLINICAL RECOMMENDATION STATEMENTS:
Anemia related to MDS generally presents as a hypoproductive macrocytic anemia, often
associated with suboptimal elevation of serum Epo levels. Iron repletion needs to be verified before
instituting Epo therapy (Category 2A Recommendation). (NCCN)
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Measure #69: Multiple Myeloma: Treatment with Bisphosphonates
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of multiple myeloma, not in
remission, who were prescribed or received intravenous bisphosphonate therapy within the 12month reporting period
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. It is anticipated that clinicians who provide services for the patients with the
diagnosis of multiple myeloma, not in remission, will submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 8P- reason not
otherwise specified. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients who were prescribed or received intravenous bisphosphonate therapy within the 12 month
reporting period
Definitions:
Bisphosphonate Therapy – Includes the following medications: pamidronate and
zoledronate.
Prescribed – Includes patients who are currently receiving medication(s) that follow the
treatment plan recommended at an encounter during the reporting period, even if the
prescription for that medication was ordered prior to the encounter.
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Intravenous Bisphosphonate Therapy Prescribed or Received
CPT II 4100F: Bisphosphonate therapy, intravenous, ordered or received
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OR
Intravenous Bisphosphonate Therapy not Prescribed or Received for Medical or
Patient Reasons
Append a modifier (1P or 2P) to CPT Category II code 4100F to report documented
circumstances that appropriately exclude patients from the denominator.
4100F with 1P: Documentation of medical reason(s) for not prescribing bisphosphonates
(eg, patients who do not have bone disease, patients with dental disease,
patients with renal insufficiency)
4100F with 2P: Documentation of patient reason(s) for not prescribing bisphosphonates
Intravenous Bisphosphonate Therapy not Prescribed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4100F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4100F with 8P: Bisphosphonate therapy, intravenous, not ordered or received, reason not
otherwise specified
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of multiple myeloma, not in remission
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for multiple myeloma – not in remission (line-item ICD-9-CM): 203.00,
203.02
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Multiple myeloma is a disease characterized by bone destruction, in the form of diffuse osteopenia
and/or osteolytic lesions, which develop in 85% of patients. Bisphosphonates can inhibit bone
resorption by reducing the number and activity of osteoclasts and therefore could “reduce pain and
bone fractures in people with multiple myeloma”.
CLINICAL RECOMMENDATION STATEMENTS:
Based on published data and clinical experience, the guidelines recommend the use of
bisphosphonates for all patients with multiple myeloma who have bone disease, including
osteopenia. In 10% to 20% of patients with earlier-stage disease who do not have bone disease,
bisphosphonates may be considered but preferably in a clinical trial (Category 1
Recommendation). (NCCN)
Intravenous bisphosphonates should be administered monthly for patients with MM and lytic
disease evident on plain radiographs (Grade A, Level II). It is reasonable to start intravenous
bisphosphonates in patients with MM who do not have lytic bone disease if there is evidence of
osteopenia or osteoporosis on bone mineral density studies (Consensus Recommendation, Level
N/A). No randomized clinical trials support the use of bisphosphonates in patients with smoldering
MM. We believe that bisphosphonates should be used only in the setting of a clinical trial [in these
patients] (Consensus Recommendation, Level N/A). (Mayo Clinic)
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Measure #70: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of CLL who had baseline flow
cytometry studies performed
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period, regardless of when the baseline flow cytometry studies are performed. It is
anticipated that clinicians who provide services for patients with the diagnosis of chronic
lymphocytic leukemia, not in remission, will submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 3P- system
reasons, 8P- reason not otherwise specified. All measure-specific coding should be reported ON
THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients who had baseline flow cytometry studies performed
Definition:
Baseline Flow Cytometry Studies – Refer to testing that is performed at time of
diagnosis or prior to initiating treatment for that diagnosis. Treatment may include antineoplastic therapy.
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Baseline Flow Cytometry Studies Performed
CPT II 3170F: Flow cytometry studies performed at time of diagnosis or prior to initiating
treatment
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OR
OR
Baseline Flow Cytometry Studies not Performed for Medical, Patient, or System
Reasons
Append a modifier (1P, 2P or 3P) to CPT Category II code 3170F to report documented
circumstances that appropriately exclude patients from the denominator.
3170F with 1P: Documentation of medical reason(s) for not performing baseline flow
cytometry studies
3170F with 2P: Documentation of patient reason(s) for not performing baseline flow
cytometry studies (eg, receiving palliative care or not receiving treatment
as defined above).
3170F with 3P: Documentation of system reason(s) for not performing baseline flow
cytometry studies (eg, patient previously treated by another physician at
the time baseline flow cytometry studies were performed).
Baseline Flow Cytometry Studies not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3170F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3170F with 8P: Flow cytometry studies not performed at time of diagnosis or prior to
initiating treatment, reason not otherwise specified
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of CLL
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for CLL – not in remission (line-item ICD-9-CM): 204.10, 204.12
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Due to the distinct pattern of protein antigens expressed in CLL, flow cytometry should be
performed in order to confirm the diagnosis, correctly characterize the pathological cells, and
determine prognosis. In some instances, flow cytometry may also offer additional therapeutically
relevant information.
CLINICAL RECOMMENDATION STATEMENTS:
As with all the lymphoid neoplasms, adequate hematopathologic review is essential to establish an
accurate diagnosis of chronic lymphocytic leukemia and small lymphocytic lymphoma CLL/SLL.
…a combination of morphologic and flow cytometric studies may provide adequate information to
provide a diagnosis. This is particularly true for the diagnosis of CLL. Flow cytometric studies
performed on patients with leukemic cell burden include kappa/lambda to [assess] clonality…
Distinguishing CLL/SLL from mantle cell lymphoma is essential (Category 2A Recommendation).
(NCCN)
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Measure #71: Breast Cancer: Hormonal Therapy for Stage IC–IIIC Estrogen Receptor/
Progesterone Receptor (ER/PR) Positive Breast Cancer
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of female patients aged 18 years and older with Stage IC through IIIC, ER or PR
positive breast cancer who were prescribed tamoxifen or aromatase inhibitor (AI) during the 12month reporting period
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all female patients with
breast cancer seen during the reporting period. Review estrogen receptor (ER) or progesterone
receptor (PR) AND breast cancer stage status AND tumor size to determine which quality-data
codes should be submitted. It is anticipated that clinicians who treat female breast cancer patients
will submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II codes OR the CPT Category II code(s) with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 3P- system
reasons, 8P- reason not otherwise specified. All measure-specific coding should be reported ON
THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients who were prescribed tamoxifen or aromatase inhibitor (AI) within the12 months reporting
period
Definition:
Prescribed – Prescribed may include prescription given to the patient for tamoxifen or
aromatase inhibitor (AI) at one or more visits in the 12-month period OR patient already
taking tamoxifen or aromatase inhibitor (AI) as documented in the current medication list.
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NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Tamoxifen or Aromatase Inhibitor Prescribed
(Three CPT II codes [4179F & 337xF & 3315F] are required on the claim form to submit
this numerator option)
CPT II 4179F: Tamoxifen or aromatase inhibitor (AI) prescribed
AND
CPT II 3374F: AJCC Breast Cancer Stage I: TIC (tumor size > 1cm to 2cm), documented
OR
CPT II 3376F: AJCC Breast Cancer Stage II, documented
OR
CPT II 3378F: AJCC Breast Cancer Stage III, documented
OR
AND
CPT II 3315F: Estrogen receptor (ER) or progesterone receptor (PR) positive breast
cancer
Tamoxifen or Aromatase Inhibitor not Prescribed for Medical, Patient, or System
Reasons
(Three CPT II codes [4179F-xP & 337xF & 3315F] are required on the claim form to submit
this numerator option)
Append a modifier (1P, 2P or 3P) to CPT Category II code 4179F to report documented
circumstances that appropriately exclude patients from the denominator.
4179F with 1P: Documentation of medical reason(s) for not prescribing tamoxifen or
aromatase inhibitor (eg, patient’s disease has progressed to metastatic;
patient is receiving a gonadotropin-releasing hormone analogue, patient
has received oophorectomy, patient is receiving radiation or
chemotherapy, patient’s diagnosis date was ≥ 5 years from reporting
date)
4179F with 2P: Documentation of patient reason(s) for not prescribing tamoxifen or
aromatase inhibitor (eg, patient refusal)
4179F with 3P: Documentation of system reason(s) for not prescribing tamoxifen or
aromatase inhibitor (eg, patient is currently enrolled in a clinical trial)
AND
CPT II 3374F: AJCC Breast Cancer Stage I: T1C (tumor size > 1cm to 2cm), documented
OR
CPT II 3376F: AJCC Breast Cancer Stage II, documented
OR
CPT II 3378F: AJCC Breast Cancer Stage III, documented
AND
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CPT II 3315F: Estrogen receptor (ER) or progesterone receptor (PR) positive breast
cancer
OR
If patient is not eligible for this measure because patient is not stage IC through IIIC
breast cancer, report:
Patient not Stage IC through IIIC Breast Cancer
(One CPT II code [33xxF] is required on the claim form to submit this numerator option)
Note: If reporting a code from the category below (3370F or 3372F or 3380F), it is not
necessary to report the patient’s ER/PR status.
CPT II 3370F: AJCC Breast Cancer Stage 0, documented
OR
CPT II 3372F: AJCC Breast Cancer Stage I: T1 mic, T1a or T1b (tumor size < 1cm),
documented
OR
CPT II 3380F: AJCC Breast Cancer Stage IV, documented
OR
If patient is not eligible for this measure because patient is estrogen receptor (ER)
and progesterone receptor (PR) negative, report:
Patient is Estrogen Receptor (ER) and Progesterone Receptor (PR) Negative
(One CPT II code [3316F] is required on the claim form to submit this numerator option)
Note: If reporting code 3316F, it is not necessary to report the patient’s AJCC Cancer
Stage.
CPT II 3316F: Estrogen receptor (ER) and progesterone receptor (PR) negative breast
cancer
OR
OR
If patient is not eligible for this measure because the cancer stage is not
documented OR the ER/PR is not documented, report:
Cancer Stage not Documented OR ER/PR not Documented
(One CPT II code [33xxF-8P] is required on the claim form to submit this numerator option)
Append a reporting modifier (8P) to CPT Category II codes 3370F or 3316F to report
circumstances when the patient is not eligible for the measure.
3370F with 8P: No documentation of cancer stage
OR
3316F with 8P: No documentation of estrogen receptor (ER) and progesterone receptor
(PR) status
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Tamoxifen or Aromatase Inhibitor not Prescribed, Reason not Specified
(Three CPT II codes [4179F-8P & 337xF & 3315F] are required on the claim form to
submit this numerator option)
Append a reporting modifier (8P) to CPT Category II code 4179F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4179F with 8P: Tamoxifen or aromatase inhibitor not prescribed, reason not otherwise
specified
AND
CPT II 3374F: AJCC Breast Cancer Stage: TIC (tumor size > 1cm to 2cm), documented
OR
CPT II 3376F: AJCC Breast Cancer Stage II, documented
OR
CPT II 3378F: AJCC Breast Cancer Stage III, documented
AND
CPT II 3315F: Estrogen receptor (ER) or progesterone receptor (PR) positive breast
cancer
DENOMINATOR:
All female patients aged 18 years and older with Stage IC through IIIC, estrogen receptor (ER) or
progesterone receptor (PR) positive breast cancer
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for breast cancer (line-item ICD-9-CM): 174.0, 174.1, 174.2, 174.3, 174.4,
174.5, 174.6, 174.8, 174.9, V10.3
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Despite evidence suggesting the role of adjuvant endocrine therapy in lowering the risk of tumor
recurrence, many female patients who should be receiving this therapy are not. This measure
assesses whether patients with a certain stage of breast cancer (IC through IIIC) and ER/PR+ are
currently receiving the therapy. There are allowable medical, patient, and system reasons to
document instances in which a woman with stage IC through IIIC, ER/PR+ may not be a candidate
for the therapy.
Note: The reporting/managing physician does not need to have actually written the prescription;
however the reporting/managing physician must verify that the patient already has been prescribed
the hormonal therapy by another physician.
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CLINICAL RECOMMENDATION STATEMENTS:
Adjuvant therapy for postmenopausal women with hormone receptor–positive breast cancer should
include an aromatase inhibitor in order to lower the risk of tumor recurrence. Aromatase inhibitors
are appropriate as initial treatment for women with contraindications to tamoxifen. For all other
postmenopausal women, treatment options include 5 years of aromatase inhibitors treatment or
sequential therapy consisting of tamoxifen (for either 2 to 3 years or 5 years) followed by
aromatase inhibitors for 2 to 3, or 5 years (ASCO guidelines include narrative rankings). (ASCO)
Patients intolerant of aromatase inhibitors should receive tamoxifen. Women with hormone
receptor–negative tumors should not receive adjuvant endocrine therapy (ASCO guidelines include
narrative rankings). (ASCO)
Patients with invasive breast cancers that are estrogen or progesterone receptor positive should be
considered for adjuvant endocrine therapy regardless of patient age, lymph node status, or
whether or not adjuvant chemotherapy is to be administered (Category 2A). (NCCN)
The most firmly established adjuvant endocrine therapy is tamoxifen for both premenopausal and
postmenopausal women. Prospective, randomized trials demonstrate that the optimal duration of
tamoxifen appears to be five years. In patients receiving both tamoxifen and chemotherapy,
chemotherapy should be given first, followed by sequential tamoxifen. Several studies have
evaluated aromatase inhibitors in the treatment of postmenopausal women with early-stage breast
cancer (Category 2A). (NCCN)
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Measure #72: Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with Stage IIIA through IIIC colon cancer who are
referred for adjuvant chemotherapy, prescribed adjuvant chemotherapy, or have previously
received adjuvant chemotherapy within the 12-month reporting period
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all patients with colon
cancer seen during the reporting period. It is anticipated that clinicians who treat patients with
Stage IIIA through IIIC colon cancer will submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II codes OR the CPT Category II code(s) with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 3P- system
reasons, 8P- reason not otherwise specified. All measure-specific coding should be reported ON
THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients who are referred for adjuvant chemotherapy, prescribed adjuvant chemotherapy, or who
have previously received adjuvant chemotherapy within the 12 month reporting period
Definitions:
Adjuvant Chemotherapy – According to current NCCN guidelines, the following therapies
are recommended: 5-fluorouracil/leucovorin or capecitabine, or 5fluorouracil/leucovorin/oxaliplatin.
Prescribed – may include prescription ordered for the patient for adjuvat chemotherapy at
one or more visits in the 12-month period OR patient already receiving adjuvant
chemotherapy as documented in the current medication list.
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NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Adjuvant Chemotherapy Referred, Prescribed or Previously Received
(Two CPT II codes [4180F & 3388F] are required on the claim form to submit this
numerator option)
CPT II 4180F: Adjuvant chemotherapy referred, prescribed or previously received for
Stage IIIA through Stage IIIC colon cancer
AND
CPT II 3388F: AJCC Colon Cancer Stage III, documented
Adjuvant Chemotherapy not Referred, Prescribed or Previously Received for
Medical, Patient, or System Reasons
(Two CPT II codes [4180F-xP & 3388F] are required on the claim form to submit this
numerator option)
Append a modifier (1P, 2P or 3P) to CPT Category II code 4180F to report documented
circumstances that appropriately exclude patients from the denominator.
4180F with 1P: Documentation of medical reason(s) for not referring for or prescribing
adjuvant chemotherapy (eg, medical comorbidities, diagnosis date more
than 5 years prior to the current visit date; patient’s cancer has
metastasized; medical contraindication/allergy, poor performance status)
4180F with 2P: Documentation of patient reason(s) for not referring for or prescribing
adjuvant chemotherapy (eg, patient refusal)
4180F with 3P: Documentation of system reason(s) for not referring for or prescribing
adjuvant chemotherapy (eg, patient is currently enrolled in a clinical trial
that precludes prescription of chemotherapy)
AND
CPT II 3388F: AJCC Colon Cancer Stage III, documented
OR
If patient is not eligible for this measure because patient is not stage III colon
cancer, report:
Patient not Stage III Colon Cancer
(One CPT II code [33xxF] is required on the claim form to submit this numerator option)
CPT II 3382F: AJCC Colon Cancer Stage 0, documented
OR
CPT II 3384F: AJCC Colon Cancer Stage I, documented
OR
CPT II 3386F: AJCC Colon Cancer Stage II, documented
OR
CPT II 3390F: AJCC Colon Cancer Stage IV, documented
OR
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OR
If patient is not eligible for this measure because cancer stage is not documented,
report:
Cancer Stage not Documented
(One CPT II code [3382F-8P] is required on the claim form to submit this category)
Append a reporting modifier (8P) to CPT Category II code 3382F to report circumstances
when the patient is not eligible for the measure.
3382F with 8P: No documentation of cancer stage
Adjuvant Chemotherapy not Referred, Prescribed or Previously Received, Reason
not Specified
(Two CPT II codes [4180F-8P & 3388F] are required on the claim form to submit this
numerator option)
Append a reporting modifier (8P) to CPT Category II code 4180F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4180F with 8P: Adjuvant chemotherapy not prescribed or previously received, reason not
otherwise specified
AND
CPT II 3388F: AJCC Colon Cancer Stage III, documented
DENOMINATOR:
All patients aged 18 years and older with Stage IIIA through IIIC colon cancer
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for colon cancer (line-item ICD-9-CM): 153.0, 153.1, 153.2, 153.3, 153.4,
153.5, 153.6, 153.7, 153.8, 153.9, V10.05
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Patients with Stage IIIA through Stage IIIC colon cancer do not always receive the recommended
treatment of adjuvant chemotherapy. This measure is intended to determine whether and how
often chemotherapy is administered. The specific chemotherapy drugs specified in this measure
reflect the most current guidelines of the National Comprehensive Cancer Network.
CLINICAL RECOMMENDATION STATEMENTS:
Following primary surgical treatment, the panel recommends six months of 5-fluorouracil/leucovorin
capecitabine, or 5-fluorouracil/leucovorin/oxaliplatin as adjuvant chemotherapy for patients with
stage III (T1-4, N1-2, M0) colon cancer (Category 2A). (NCCN)
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Measure #76: Prevention of Catheter-Related Bloodstream Infections (CRBSI): Central
Venous Catheter (CVC) Insertion Protocol
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients, regardless of age, who undergo CVC insertion for whom CVC was inserted
with all elements of maximal sterile barrier technique [cap AND mask AND sterile gown AND sterile
gloves AND a large sterile sheet AND hand hygiene AND 2% chlorhexidine for cutaneous
antisepsis (or acceptable alternative antiseptics per current guideline)] followed
INSTRUCTIONS:
This measure is to be reported each time a CVC insertion is performed during the reporting period.
There is no diagnosis associated with this measure. It is anticipated that clinicians who perform
CVC insertion will submit this measure.
Measure Reporting via Claims:
CPT procedure codes are used to identify patients who are included in the measure’s denominator.
CPT Category II codes are used to report the numerator of the measure.
When reporting the measure via claims, submit the listed CPT codes, and the appropriate CPT
Category II code OR the CPT Category II code with the modifier. The modifiers allowed for this
measure are: 1P- medical reasons, 8P- reason not otherwise specified. All measure-specific
coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
CPT codes are used to identify patients who are included in the measure’s denominator. The
numerator options as described in the quality-data codes are used to report the numerator of the
measure. The quality-data codes listed do not need to be submitted for registry-based
submissions; however, these codes may be submitted for those registries that utilize claims data.
NUMERATOR:
Patients for whom central venous catheter (CVC) was inserted with all elements of maximal sterile
barrier technique [cap AND mask AND sterile gown AND sterile gloves AND a large sterile sheet
AND hand hygiene AND 2% chlorhexidine for cutaneous antisepsis (or acceptable alternative
antiseptics, per current guideline)] followed
Definition:
Maximal Sterile Barrier Technique during CVC Insertion – Includes use of all of the
following: Cap AND mask AND sterile gown AND sterile gloves AND a large sterile sheet
AND hand hygiene AND 2% chlorhexidine for cutaneous antisepsis (or acceptable
alternative antiseptics, per current guideline).
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
All Elements of Maximal Sterile Barrier Technique Followed
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OR
OR
CPT II 6030F: All elements of maximal sterile barrier technique followed including: cap
AND mask AND sterile gown AND sterile gloves AND a large sterile sheet AND hand
hygiene AND 2% chlorhexidine for cutaneous antisepsis (or acceptable alternative
antiseptics, per current guideline)
All Elements of Maximal Sterile Barrier Technique not Followed for Medical Reasons
Append a modifier (1P) to CPT Category II code 6030F to report documented
circumstances that appropriately exclude patients from the denominator.
6030F with 1P: Documentation of medical reason(s) for not following all elements of
maximal sterile barrier technique during CVC insertion (including CVC
insertion performed on emergency basis)
All Elements of Maximal Sterile Barrier Technique not Followed, Reason not
Specified
Append a reporting modifier (8P) to CPT Category II code 6030F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
6030F with 8P: All elements of maximal sterile barrier technique not followed including:
cap AND mask AND sterile gown AND sterile gloves AND a large sterile
sheet AND hand hygiene AND 2% chlorhexidine for cutaneous antisepsis
(or acceptable alternative antiseptics, per current guideline), reason not
otherwise specified
DENOMINATOR:
All patients, regardless of age, who undergo CVC insertion
Denominator Criteria (Eligible Cases):
Patient encounter during the reporting period (CPT): 36555, 36556, 36557, 36558,
36560, 36561, 36563, 36565, 36566, 36568, 36569, 36570, 36571, 36578, 36580, 36581,
36582, 36583, 36584, 36585, 93503
RATIONALE:
Catheter-related bloodstream infection is a costly complication of central venous catheter insertion,
but may be avoided with routine use of aseptic technique during catheter insertion. This measure is
constructed to require that all of the listed elements of aseptic technique are followed and
documented.
Existing hospital-level measures for this topic were consulted and, to the extent feasible,
harmonization between physician- and hospital- level measurement was achieved.
CLINICAL RECOMMENDATION STATEMENTS:
Maximal sterile barrier precautions during catheter insertion: Use aseptic technique including the
use of a cap, mask, sterile gown, sterile gloves, and a large sterile sheet, for the insertion of CVCs
(including PICCS) or guidewire exchange. (CDC/MMWR) (Category IA)
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Hand hygiene: Observe proper hand-hygiene procedures either by washing hands with
conventional antiseptic-containing soap and water or with waterless alcohol-based gels or foams.
Observe hand hygiene before and after palpating catheter insertion sites, as well as before and
after inserting, replacing, accessing, repairing, or dressing an intravascular catheter. Palpation of
the insertion site should not be performed after the application of antiseptic, unless aseptic
technique is maintained. Use of gloves does not obviate the need for hand hygiene. (CDC/MMWR)
(Category IA)
Cutaneous antisepsis: Disinfect clean skin with an appropriate antiseptic before catheter insertion
and during dressing changes. Although a 2% chlorhexidine-based preparation is preferred, tincture
of iodine, an iodophor, or 70% alcohol can be used. (CDC/MMWR) (Category IA)
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Measure #79: End Stage Renal Disease (ESRD): Influenza Immunization in Patients with
ESRD
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of ESRD and receiving dialysis
who received the influenza immunization during the flu season (September through February)
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for ESRD patients receiving
dialysis seen during the reporting period. This measure is intended to determine whether or not
ESRD patients receiving dialysis received or had an order for influenza immunization during the flu
season (September through February). It is anticipated that clinicians providing care for patients
with ESRD will submit this measure.
•
•
If reporting this measure between January 1, 2010 and August 31, 2010, CPT Category II
code 4037F should be reported when the influenza vaccination is ordered or administered
to the patient during the months of September, October, November, December of 2009 or
January and February of 2010 for the flu season ending February 28, 2010.
If reporting this measure between September 1, 2010 and December 31, 2010, CPT
Category II code 4037F should be reported when the influenza vaccination is ordered or
administered to the patient during the months of September, October, November, and
December of 2010 for the flu season ending February 28, 2011.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 3P- system
reasons, 8P- reason not otherwise specified. All measure-specific coding should be reported ON
THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes and patient demographics are used to identify patients who
are included in the measure’s denominator. The numerator options as described in the quality-data
codes are used to report the numerator of the measure. The quality-data codes listed do not need
to be submitted for registry-based submissions; however, these codes may be submitted for those
registries that utilize claims data.
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NUMERATOR:
Patients who received the influenza immunization during the flu season (September through
February)
NUMERATOR NOTE: Report 4037F - If eligible professional verified that influenza
immunization was previously administered during the current flu season.
OR
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Influenza Immunization Received
CPT II 4037F: Influenza immunization ordered or administered
Influenza Immunization not Received for Medical, Patient, or System Reasons
Append a modifier (1P, 2P or 3P) to CPT Category II code 4037F to report documented
circumstances that appropriately exclude patients from the denominator.
4037F with 1P: Documentation of medical reason(s) for patient not receiving the influenza
immunization
4037F with 2P: Documentation of patient reason(s) for patient not receiving the influenza
immunization
4037F with 3P: Documentation of system reason(s) for patient not receiving the influenza
immunization
Influenza Immunization not Received, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4037F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4037F with 8P: Influenza immunization not ordered or administered, reason not otherwise
specified
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of ESRD and receiving dialysis
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for ESRD (line-item ICD-9-CM): 585.6
AND
Patient encounter during the reporting period (CPT or HCPCS): 90935, 90937, 90945,
90947, 90957, 90958, 90959, 90960, 90961, 90962, 90965, 90966, 90969, 90970
RATIONALE:
Infectious disease is a common cause of death in late-stage kidney disease patients. Immunizing
this high risk population is therefore critical to increasing patient well-being and potentially reducing
morbidity and mortality. Despite its importance, a review of Medicare billing data has indicated that
the ESRD population had a less than 50% immunization rate for the years 1997 to 1998 and 1998
to 1999.
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CLINICAL RECOMMENDATION STATEMENTS:
Annual influenza vaccine is recommended for all persons aged 65 and older and persons in
selected high-risk groups. (B recommendation) (USPSTF)
Vaccination is recommended for the following persons who are at increased risk for complications
from influenza: adults and children who have required regular medical follow-up or hospitalization
during the preceding year because of chronic metabolic diseases (including diabetes mellitus),
renal dysfunction, hemoglobinopathies, or immunosuppression (including immunosuppression
caused by medications or by human immunodeficiency virus [HIV]); (CDC)
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Measure #81: End Stage Renal Disease (ESRD): Plan of Care for Inadequate
Hemodialysis in ESRD Patients
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of calendar months during the 12-month reporting period in which patients aged 18
years and older with a diagnosis of ESRD receiving hemodialysis have a Kt/V ≥ 1.2 OR patients
who have a Kt/V < 1.2 with a documented plan of care for inadequate hemodialysis
INSTRUCTIONS:
This measure is to be reported each calendar month hemodialysis is performed on ESRD patients
seen during the reporting period. It is anticipated that clinicians providing care for patients with
ESRD will submit this measure.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The listed numerator options are used to report
the numerator of the measure. The quality-data codes have been provided for registry only
measures for use by registries that utilize claims data. It is not necessary to submit these codes for
registry-based submissions. There are no allowable performance exclusions for this measure. Do
not report this measure via claims.
NUMERATOR:
Number of patient calendar months during which patients have a Kt/V ≥1.2 OR have Kt/V <1.2 with
a documented plan of care for inadequate hemodialysis
Definition:
Documented Plan of Care – May include checking for adequacy of the AV access,
increasing the blood flow, increasing the dialyzer size, increasing the time of dialysis
sessions, adjusting dialysis prescription, or documenting residual renal function.
Numerator Options:
Kt/V ≥ 1.2 and less than 1.7 (Clearance of urea (Kt)/volume(V)) (3083F)
OR
Kt/V ≥ 1.7 (Clearance of urea (Kt)/volume(V)) (3084F)
OR
OR
Kt/V < 1.2 (Clearance of urea (Kt)/volume(V)) (3082F)
AND
Hemodialysis plan of care documented (0505F)
Kt/V not performed or documented, reason not specified (3083F with 8P)
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OR
Hemodialysis plan of care not documented, reason not specified (0505F with 8P)
AND
Kt/V < 1.2 (Clearance of urea (Kt)/volume(V)) (3082F)
DENOMINATOR:
Calendar months for all patients aged 18 years and older with a diagnosis of ESRD who are
receiving hemodialysis
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for ESRD (ICD-9-CM): 585.6
AND
Patient encounter during the reporting period (CPT): 90935, 90937, 90957, 90958,
90959, 90960, 90961, 90962
RATIONALE:
Patients receiving hemodialysis must be monitored (by assessing Kt/V) regularly to ensure that
their dialysis dose is sufficient. A patient receiving hemodialysis whose Kt/V level is less than 1.2 is
not receiving optimal dialysis. This measure assesses whether the treating physician addressed
the low Kt/V level. A plan of care (action defined as checking for adequacy of the AV access,
increasing the blood flow, increasing the dialyzer size, or increasing the time of dialysis sessions)
should be documented by the physician for every time Kt/V is less than 1.2.
CLINICAL RECOMMENDATION STATEMENTS:
Quantifying HD is the first step toward assessment of its adequacy. Fortunately, the intermittent
rapid decrease in urea concentration during HD allows a relatively easy measurement of the dose.
The delivered dose of HD should be measured at regular intervals no less than monthly(A).
(KDOQITM )
The minimally adequate dose of HD given 3 times per week to patients with Kr less than 2
mL/min/1.73 m2 should be an spKt/V (excluding RKF) of 1.2 per dialysis. For treatment times less
than 5 hours, an alternative minimum dose is a URR of 65% (A). The target dose for HD given 3
times per week with Kr less than 2 mL/min/1.73 m2 should be an spKt/V of 1.4 per dialysis not
including RKF, or URR of 70% (A). (KDOQITM)
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Measure #82: End Stage Renal Disease (ESRD): Plan of Care for Inadequate Peritoneal
Dialysis
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of ESRD receiving peritoneal
dialysis who have a Kt/V ≥ 1.7 OR patients who have a Kt/V < 1.7 with a documented plan of care
for inadequate peritoneal dialysis at least three times (every 4 months) during the 12-month
reporting period
INSTRUCTIONS:
This measure is to be reported up to three times per reporting year for ESRD patients receiving
peritoneal dialysis during the entire reporting period and seen during the reporting period.
This measure should be reported according to the following frequency, depending on the number
of months during the reporting period a patient is receiving peritoneal dialysis:
• 1-4 months – report once during the reporting period
• 5-8 months – report twice during the reporting period
• 9-12 months – report three times during the reporting period
It is anticipated that clinicians providing care for patients with ESRD will submit this measure.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The listed numerator options are used to report
the numerator of the measure. The quality-data codes have been provided for registry only
measures for use by registries that utilize claims data. It is not necessary to submit these codes for
registry-based submissions. There are no allowable performance exclusions for this measure. Do
not report this measure via claims.
NUMERATOR:
Patients who have a Kt/V ≥1.7 OR have a Kt/V <1.7 with a documented plan of care for inadequate
peritoneal dialysis at least three times (every 4 months) during the 12 month reporting period
Definition:
Documented Plan of Care – May include assessing for non-adherence with the peritoneal
prescription, sampling, and collection; assessing for error in the peritoneal dialysis
prescription and/or inadequate monitoring of the delivered dose; performing peritoneal
equilibrium testing; assessing for inadequate patient education; increasing the exchange
volume; increasing the number of exchanges per 24 hours; assessing for modality (CAPD
or CCPD).
Numerator Options:
Kt/V ≥ 1.7 (Clearance of urea (Kt)/volume(V)) (3084F)
OR
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Kt/V < 1.2 (Clearance of urea (Kt)/volume(V)) (3082F)
OR
Kt/V ≥ 1.2 and less than 1.7 (Clearance of urea (Kt)/volume(V)) (3083F)
OR
AND
Peritoneal dialysis plan of care documented (0507F)
Kt/V not performed or documented, reason not specified (3084 with 8P)
OR
Peritoneal dialysis plan of care not documented, reason not specified (0507F with 8P)
AND
Kt/V < 1.2 (Clearance of urea (Kt)/volume(V)) (3082F)
OR
Kt/V ≥ 1.2 and less than 1.7 (Clearance of urea (Kt)/volume(V)) (3083F)
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of ESRD receiving peritoneal dialysis
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for ESRD (ICD-9-CM): 585.6
AND
Patient encounter during the reporting period (CPT): 90945, 90947, 90965, 90966,
90969, 90970
RATIONALE:
Patients receiving peritoneal dialysis must be monitored (by assessing Kt/V) regularly to ensure
that their dialysis dose is sufficient. A patient receiving peritoneal dialysis whose Kt/V level is less
than 1.7 is not receiving optimal dialysis. This measure assesses whether the treating physician
addressed the low Kt/V level. A plan of care (may include assessing for non-adherence with the
peritoneal prescription, sampling, and collection; assessing for error in the peritoneal dialysis
prescription and/or inadequate monitoring of the delivered dose; performing peritoneal equilibrium
testing; assessing for inadequate patient education; increasing the exchange volume; or increasing
the number of exchanges per 24 hours) should be documented by the physician for every time Kt/V
is less than 1.7.
CLINICAL RECOMMENDATION STATEMENTS:
Total solute clearance (residual kidney and peritoneal, in terms of Kt/Vurea) should be measured
within the first month after initiating dialysis therapy and at least once every 4 months thereafter
(B). (KDOQITM)
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For patients with residual kidney function (considered to be significant when urine volume is > 100
mL/d): The minimal “delivered” dose of total small-solute clearance should be a total (peritoneal
and kidney) Kt/Vurea of at least 1.7 per week (B).
For patients without RKF (considered insignificant when urine volume is ≤ 100 mL/d): The minimal
“delivered” dose of total small-solute clearance should be a peritoneal Kt/Vurea of at least 1.7 per
week measured within the first month after starting dialysis therapy and at least once every 4
months thereafter (B). (KDOQITM )
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Measure #83: Hepatitis C: Testing for Chronic Hepatitis C – Confirmation of Hepatitis C
Viremia
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of hepatitis C seen for an initial
evaluation who had HCV RNA testing ordered or previously performed
INSTRUCTIONS:
This measure should be reported on the first visit occurring during the reporting period for all
patients with a diagnosis of hepatitis C seen during the reporting period. This measure may be
reported by clinicians who perform the quality actions described in the measure based on the
services provided and the measure-specific denominator coding.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The listed numerator options are used to report
the numerator of the measure. The quality-data codes have been provided for registry only
measures for use by registries that utilize claims data. It is not necessary to submit these codes for
registry-based submissions. Do not report this measure via claims.
NUMERATOR:
Patients for whom HCV RNA testing was ordered or previously performed
OR
Numerator Options:
Ribonucleic acid (RNA) testing for Hepatitis C viremia ordered or results documented
(3265F)
AND
Initial evaluation for condition (1119F)
Documentation of medical reason(s) for not ordering or performing RNA testing for HCV
(3265F with 1P)
OR
Documentation of patient reason(s) for not ordering or performing RNA testing for HCV
(3265F with 2P)
AND
Initial evaluation for condition (1119F)
OR
OR
Subsequent evaluation for condition (1121F)
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RNA testing for HCV was not ordered or results not documented, reason not otherwise
specified (3265F with 8P)
AND
Initial evaluation for condition (1119F)
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of hepatitis C seen for initial evaluation
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for hepatitis C (ICD-9-CM): 070.51, 070.54, 070.70
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
HCV RNA testing is needed to establish and confirm diagnosis of chronic hepatitis C. HCV is an
RNA virus of the Flaviviridae family. HCV replicates preferentially in hepatocytes but is not directly
cytopathic, leading to persistent infection. During chronic infection, HCV RNA reaches high levels,
generally ranging from 105 to 107 international units (IU)/mL, but the levels can fluctuate widely.
However, within the same individual, RNA levels are usually relatively stable. (NIH)
After initial exposure, HCV RNA can be detected in blood within 1 to 3 weeks and is present at the
onset of symptoms.
Antibodies to HCV are detected by enzyme immunoassay (EIA) in only 50 to 70 percent of patients
at the onset of symptoms, increasing to more than 90 percent after 3 months.
The clinical utility of serial HCV viral levels in a patient is predicated on continued use of the same
specific quantitative assay that was used in the initial determination of the viral level. While there is
little correlation between disease severity or disease progression with the absolute level of HCV
RNA, quantitative determination of the HCV level provides important information on the likelihood
of response to treatment in patients undergoing antiviral therapy.
CLINICAL RECOMMENDATION STATEMENTS:
HCV ribonucleic acid (RNA) testing should be performed in:
a. patients with a positive anti-HCV test (Grade II-2);
b. patients for whom antiviral treatment is being considered, using a quantitative assay
(Grade II-2);
c. patients with unexplained liver disease whose anti-HCV test is negative and who are
immunocompromised or suspected of having acute HCV infection (Grade II-2). (AASLD)
The diagnosis of chronic hepatitis C infection is often suggested by abnormalities in ALT levels and
is established by EIA followed by confirmatory determination of HCV RNA. (NIH)
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Measure #84: Hepatitis C: Ribonucleic Acid (RNA) Testing Before Initiating Treatment
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
If reporting Measure #84: Hepatitis C: RNA Testing Before Initiating Treatment, also report
Measure #85: Hepatitis C HCV Genotype Testing Prior to Treatment.
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are
receiving antiviral treatment for whom quantitative HCV RNA testing was performed within 6
months prior to initiation of antiviral treatment
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all patients with a
diagnosis of chronic hepatitis C seen during the reporting period. This measure is intended to
reflect the quality of services provided for patients with chronic hepatitis C who are receiving
antiviral treatment. This measure may be reported by clinicians who perform the quality actions
described in the measure based on the services provided and the measure-specific denominator
coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code(s) OR the CPT Category II code(s) with the modifier.
The modifiers allowed for this measure are: 1P- medical reasons, 8P- reason not otherwise
specified. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients for whom quantitative HCV RNA testing was performed within 6 months prior to initiation
of antiviral treatment
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
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OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
RNA Testing Performed within Six Months
(Two CPT II codes [3218F & 4150F] are required on the claim form to submit this
numerator option)
CPT II 3218F: RNA testing for Hepatitis C documented as performed within six months
prior to initiation of antiviral treatment for Hepatitis C
AND
CPT II 4150F: Patient receiving antiviral treatment for Hepatitis C
RNA Testing not Performed within Six Months for Medical Reason
(Two CPT II codes [3218F-1P & 4150F] are required on the claim form to submit this
numerator option)
Append a modifier (1P) to CPT Category II code 3218F to report documented
circumstances that appropriately exclude patients from the denominator.
3218F with 1P: Documentation of medical reason(s) for not performing RNA testing within
six months prior to initiation of antiviral treatment for Hepatitis C (eg, if
patient is first seen by physician after initiation of treatment)
AND
CPT II 4150F: Patient receiving antiviral treatment for Hepatitis C
OR
OR
If patient is not eligible for this measure because patient is not receiving antiviral
treatment, report:
(One CPT II code [4151F] is required on the claim form to submit this numerator option)
CPT II 4151F: Patient not receiving antiviral treatment for Hepatitis C
RNA Testing not Performed within Six Months, Reason not Specified
(Two CPT II codes [3218F-8P & 4150F] are required on the claim form to submit this
numerator option)
Append a reporting modifier (8P) to CPT Category II code 3218F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3218F with 8P: RNA testing for Hepatitis C was not documented as performed within six
months prior to initiation of antiviral treatment for Hepatitis C, reason not
otherwise specified
AND
CPT II 4150F: Patient receiving antiviral treatment for Hepatitis C
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving
antiviral treatment
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
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Diagnosis for chronic hepatitis C (line-item ICD-9-CM): 070.54
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Establish baseline level against which to monitor virologic response and indicate likelihood of
response. The clinical utility of serial HCV viral levels in a patient is predicated on continued use of
the same specific quantitative assay that was used in the initial determination of the viral level.
While there is little correlation between disease severity or disease progression with the absolute
level of HCV RNA, quantitative determination of the HCV level provides important information on
the likelihood of response to treatment in patients undergoing antiviral therapy. (NIH)
CLINICAL RECOMMENDATION STATEMENTS:
HCV RNA testing should be performed in patients with a positive anti-HCV test (Grade II-2),
patients for whom antiviral treatment is being considered, using a quantitative assay (Grade II-2),
patients with unexplained liver disease whose anti-HCV test is negative and patients who are
immune compromised or suspected of having acute HCV infection (Grade II-2). (AASLD)
All candidates for antiviral therapy should be tested for HCV RNA with a quantitative amplification
assay, which provides both a baseline level against which to monitor virologic response and a
prognostic indicator of the likelihood of response. (AGA)
The diagnosis of chronic hepatitis C infection is often suggested by abnormalities in ALT levels and
is established by EIA followed by confirmatory determination of HCV RNA. (NIH)
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Measure #85: Hepatitis C: HCV Genotype Testing Prior to Treatment
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
If reporting Measure #85: Hepatitis C HCV Genotype Testing Prior to Treatment, also report
Measure #84: Hepatitis C: RNA Testing Before Initiating Treatment.
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are
receiving antiviral treatment for whom HCV genotype testing was performed prior to initiation of
antiviral treatment
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all patients with a
diagnosis of chronic hepatitis C seen during the reporting period. This measure is intended to
reflect the quality of services provided for patients with chronic hepatitis C who are receiving
antiviral treatment. This measure may be reported by clinicians who perform the quality actions
described in the measure based on the services provided and the measure-specific denominator
coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes and/or G-codes
are used to report the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code AND/OR G-code OR the CPT Category II code with the
modifier AND G-code. The reporting modifier allowed for this measure is: 8P- reason not otherwise
specified. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients for whom HCV genotype testing was performed prior to initiation of antiviral treatment
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
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OR
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Hepatitis C Genotype Testing Performed
(One CPT II code & one G-code [3266F & G8459] are required on the claim form to submit
this numerator option)
CPT II 3266F: Hepatitis C genotype testing documented as performed prior to initiation of
antiviral treatment for Hepatitis C
AND
G8459: Clinician documented that patient is receiving antiviral treatment for Hepatitis C
If patient is not eligible for this measure because patient is not receiving antiviral
treatment, report:
(One G-code [G8458] is required on the claim form to submit this numerator option)
G8458: Clinician documented that patient is not an eligible candidate for genotype testing;
patient not receiving antiviral treatment for Hepatitis C
Genotype Testing not Performed, Reason not Specified
(One CPT II code & one G-code [3266F-8P & G8459] are required on the claim form to
submit this numerator option)
Append a reporting modifier (8P) to CPT Category II code 3266F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3266F with 8P: Hepatitis C genotype testing was not documented as performed prior to
initiation of antiviral treatment for Hepatitis C, reason not otherwise
specified
AND
G8459: Clinician documented that patient is receiving antiviral treatment for Hepatitis C
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving
antiviral treatment
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for chronic hepatitis C (line-item ICD-9-CM): 070.54
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
To guide treatment decisions regarding duration of therapy and likelihood of response. There are 6
HCV genotypes and more than 50 subtypes. These genotypes differ by as much as 31 to 34
percent in their nucleotide sequences, whereas subtypes differ by 20 to 23 percent based on fulllength genomic sequence comparisons. Genotype determinations influence treatment decisions.
Patients with genotypes 2 or 3 have better response rates to re-treatment than those with genotype
1. (NIH)
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CLINICAL RECOMMENDATION STATEMENTS:
HCV genotype should be determined in all HCV-infected persons prior to treatment in order to
determine the duration of therapy and likelihood of response (Grade I). (AASLD)
Information on the genotype of the virus is important to guide treatment decisions. Genotype 1,
most commonly found in the United States, is less amenable to treatment than genotypes 2 or 3.
(NIH)
All candidates for antiviral therapy should be tested for HCV RNA with a quantitative amplification
assay and should be tested for HCV genotype. (AGA)
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Measure #86: Hepatitis C: Antiviral Treatment Prescribed
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who were
prescribed peginterferon and ribavirin therapy within the 12-month reporting period
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with a
diagnosis of chronic hepatitis C seen during the reporting period. This measure may be reported by
clinicians who perform the quality actions described in the measure based on the services provided
and the measure-specific denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 3P- system
reasons, 8P- reason not otherwise specified. All measure-specific coding should be reported ON
THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients who were prescribed peginterferon and ribavirin therapy within the 12 month reporting
period
Definition:
Prescribed – May include prescription given to the patient for peginterferon and ribavirin
theray at one or more visits in the 12-month period OR patient already taking peginterferon
and ribavirin therapy as documented in current medication list.
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Peginterferon and Ribavirin Therapy Prescribed
CPT II 4153F: Combination peginterferon and ribavirin therapy prescribed
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OR
Peginterferon and Ribavirin Therapy not Prescribed for Medical, Patient or System
Reasons
Append a modifier (1P, 2P or 3P) to CPT Category II code 4153F to report documented
circumstances that appropriately exclude patients from the denominator.
4153F with 1P: Documentation of medical reason(s) for not prescribing peginterferon and
ribavarin therapy within 12 month reporting period (eg, patient was not a
candidate for therapy, could not tolerate).
4153F with 2P: Documentation of patient reason(s) for not prescribing peginterferon and
ribavirin therapy within 12 month reporting period (eg, patient declined).
4153F with 3P: Documentation of system reason(s) for not prescribing peginterferon
andribavirin therapy within 12 month reporting period (eg, patient has no
insurance coverage, therapy not covered).
Peginterferon and Ribavirin Therapy not Prescribed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4153F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4153F with 8P: Combination peginterferon and ribavirin therapy was not prescribed,
reason not otherwise specified
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of chronic hepatitis C
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for chronic hepatitis C (line-item ICD-9-CM): 070.54
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Assure that antiviral therapy is prescribed for all patients with confirmed Hepatitis C.
The current standard of care for the treatment of previously untreated patients with chronic
hepatitis C is combination pegylated interferon (PEG-IFN) alfa by subcutaneous injection once a
week and oral ribavirin daily. For patients with contraindications to ribavirin but who have
indications for antiviral therapy, PEG-IFN represents the best available treatment. (AGA)
Current contraindications to therapy include decompensated cirrhosis, pregnancy, uncontrolled
depression or severe mental illness, active substance abuse in the absence of concurrent
participation in a drug treatment program, advanced cardiac or pulmonary disease, severe
cytopenias, poorly controlled diabetes, retinopathy, seizure disorders, immunosuppressive
treatment, autoimmune diseases, or other inadequately controlled comorbid conditions. (AGA)
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CLINICAL RECOMMENDATION STATEMENTS:
The treatment of choice is peginterferon plus ribavirin (Grade I). (AASLD)
The current standard of care for the treatment of previously untreated patients with chronic
hepatitis C is combination pegylated interferon (PEG-IFN) alfa by subcutaneous injection once a
week and oral ribavirin daily. For patients with contraindications to ribavirin but who have
indications for antiviral therapy, PEG-IFN represents the best available treatment. (Category I)
(AGA summ)
Current contraindications to therapy include decompensated cirrhosis, pregnancy, uncontrolled
depression or severe mental illness, active substance abuse in the absence of concurrent
participation in a drug treatment program, advanced cardiac or pulmonary disease, severe
cytopenias, poorly controlled diabetes, retinopathy, seizure disorders, immunosuppressive
treatment, autoimmune diseases, or other inadequately controlled comorbid conditions (Category
I). (AGA)
Combination therapy results in better treatment responses than monotherapy, but the highest
response rates have been achieved with pegylated interferon in combination with ribavirin. (NIH)
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Measure #87: Hepatitis C: HCV Ribonucleic Acid (RNA) Testing at Week 12 of Treatment
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are
receiving antiviral treatment for whom quantitative HCV RNA testing was performed at 12 weeks
from the initiation of antiviral treatment
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all patients with a
diagnosis of chronic hepatitis C seen during the reporting period. This measure is intended to
reflect the quality of services provided for patients with chronic hepatitis C who are receiving
antiviral treatment. This measure may be reported by clinicians who perform the quality actions
described in the measure based on the services provided and the measure-specific denominator
coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes and/or G-codes
are used to report the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code AND/OR G-code OR the CPT Category II code with the
modifier AND G-code. The modifiers allowed for this measure are: 1P- medical reasons, 2Ppatient reasons, 8P- reason not otherwise specified. All measure-specific coding should be
reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients for whom quantitative HCV RNA testing was performed at 12 weeks from the initiation of
antiviral treatment
Definition:
12 Weeks from Initiation – Patients for whom testing was performed between 11-13
weeks from the initiation of antiviral treatment will meet the numerator for this measure.
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NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Hepatitis C Quantitative RNA Testing at 12 weeks
(One CPT II code & one G-code [3220F & G8461] are required on the claim form to submit
this numerator option)
CPT II 3220F: Hepatitis C quantitative RNA testing documented as performed at 12 weeks
from initiation of antiviral treatment
AND
G8461: Patient receiving antiviral treatment for Hepatitis C
Hepatitis C Quantitative RNA Testing not Performed at 12 Weeks for Medical or
Patient Reasons
(One CPT II code & one G-code [3220F-xP & G8461] are required on the claim form to
submit this numerator option)
Append a modifier (1P or 2P) to CPT Category II code 3220F to report documented
circumstances that appropriately exclude patients from the denominator.
3220F with 1P: Documentation of medical reason(s) for not performing quantitative HCV
RNA at 12 weeks from initiation of antiviral treatment
3220F with 2P: Documentation of patient reason(s) for not performing quantitative HCV
RNA at 12 weeks from initiation of antiviral treatment
AND
G8461: Patient receiving antiviral treatment for Hepatitis C
OR
OR
If patient is not eligible for this measure because patient is not receiving antiviral
treatment, report:
(One G-code [G8460] is required on the claim form to submit this numerator option)
G8460: Clinician documented that patient is not an eligible candidate for quantitative RNA
testing at week 12; patient not receiving antiviral treatment for Hepatitis C
Hepatitis C Quantitative RNA Testing not Performed at 12 Weeks, Reason not
Specified
(One CPT II code & one G-code [3220F-8P & G8461] are required on the claim form to
submit this numerator option)
Append a reporting modifier (8P) to CPT Category II code 3220F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3220F with 8P: Hepatitis C quantitative RNA testing was not documented as performed at
12 weeks from initiation of antiviral treatment, reason not otherwise
specified
AND
G8461: Patient receiving antiviral treatment for Hepatitis C
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DENOMINATOR:
All patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving
antiviral treatment
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for chronic hepatitis C (line-item ICD-9-CM): 070.54
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Monitor effectiveness of antiviral therapy. An early virologic response (EVR), during the first 12
weeks of therapy, is a valuable clinical milestone. In the absence of an EVR, the likelihood of an
SVR is 0–3%. If the only goal of therapy is to achieve an SVR, therapy can be discontinued after
12 weeks if an EVR is not achieved. Potentially, histologic benefit can accrue even in the absence
of an SVR; therefore, some authorities treat beyond 12 weeks even in patients who have not
achieved an EVR. For documentation of a virologic response at the end of therapy (end-oftreatment response) or an SVR ≥ 6 months after completing therapy, a more sensitive quantitative
assay with a lower limit of ≤ 50 IU/mL, if available, or a qualitative HCV RNA assay is
recommended.
CLINICAL RECOMMENDATION STATEMENTS:
Baseline and 12-week monitoring of HCV RNA levels should be performed with the same
quantitative amplification assay. An early virologic response (EVR), defined as a ≥ 2-log10
reduction in HCV RNA levels during the first 12 weeks of therapy, is a valuable clinical milestone
(Category I). (AGA)
Clinical and virologic monitoring during therapy should be conducted at intervals ranging from once
a month to once every 3 months. Frequent hematologic monitoring is necessary to identify marked
anemia, neutropenia, and thrombocytopenia; monitoring of thyroid stimulating hormone level is
indicated to identify hypothyroidism or hyperthyroidism (Category I). (AGA)
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Measure #89: Hepatitis C: Counseling Regarding Risk of Alcohol Consumption
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who were
counseled about the risks of alcohol use at least once within 12-months.
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with a
diagnosis of hepatitis C seen during the reporting period. This measure may be reported by
clinicians who perform the quality actions described in the measure based on the services provided
and the measure-specific denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
reporting modifier allowed for this measure is: 8P- reason not otherwise specified. There are no
allowable performance exclusions for this measure. All measure-specific coding should be reported
ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data. There are no allowable performance exclusions for this
measure.
NUMERATOR:
Patients who were counseled about the risks of alcohol use at least once within the 12 month
reporting period
Definition:
Counseling – May include documentation of a discussion regarding the risks of
alcohol, or notation to decrease or abstain from alcohol intake.
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Counseling Regarding Risk of Alcohol Consumption
CPT II 4158F: Patient counseled about risks of alcohol use
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Counseling Regarding Risk of Alcohol Consumption not Performed, Reason not
Specified
Append a reporting modifier (8P) to CPT Category II code 4158F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4158F with 8P: Patient counseled about risks of alcohol use not performed, reason not
otherwise specified
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of hepatitis C
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for hepatitis C (line-item ICD-9-CM): 070.51, 070.54, 070.70
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Minimize progression of liver disease. Higher levels of alcohol promote the development of
progressive liver disease, with strong evidence for the detrimental effects of 30 g/day in men
(~ equivalent to 2 beers, 2 glasses of wine, or 2 mixed drinks) and 20 g/day in women. Lower
amounts of alcohol also may increase the risk of liver damage associated with HCV. (NIH)
CLINICAL RECOMMENDATION STATEMENTS:
Higher levels of alcohol use play an important role in promoting the development of progressive
liver disease, with strong evidence for the detrimental effects of 30 g/day in men (~ equivalent to 2
beers, 2 glasses of wine, or 2 mixed drinks) and 20 g/day in women. Lower amounts of alcohol
also may increase the risk of liver damage associated with HCV. (NIH)
Abstinence should be recommended before and during antiviral treatment in alcoholic persons, and
treatment of alcohol abuse should be linked with efforts to treat hepatitis C in alcoholic patients. A
safe level of alcohol consumption in patients with hepatitis C has not been established (Category II1b). (AGA)
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Measure #90 Hepatitis C: Counseling Regarding Use of Contraception Prior to Antiviral
Therapy
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of female patients aged 18 through 44 years and all men aged 18 years and older with
a diagnosis of chronic hepatitis C who are receiving antiviral treatment who were counseled
regarding contraception prior to the initiation of treatment
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all patients with a
diagnosis of chronic hepatitis C seen during the reporting period. This measure is intended to
reflect the quality of services provided for patients with chronic hepatitis C who are receiving
antiviral treatment. This measure may be reported by clinicians who perform the quality actions
described in the measure based on the services provided and the measure-specific denominator
coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes and/or G-codes
are used to report the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code AND/OR G-code OR the CPT Category II code with the
modifier AND G-code. The modifiers allowed for this measure are: 1P- medical reasons, 8Preason not otherwise specified. All measure-specific coding should be reported ON THE SAME
CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients who were counseled regarding contraception prior to the initiation of treatment
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
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OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Counseling Regarding Contraception Received
(One CPT II code & one G-code [4159F & G8463] are required on the claim form to submit
this numerator option)
CPT II 4159F: Counseling regarding contraception received prior to initiation of antiviral
treatment
AND
G8463: Patient receiving antiviral treatment for Hepatitis C documented
Counseling Regarding Contraception not Received for Medical Reason
(One CPT II code & one G-code [4159F-1P & G8463] are required on the claim form to
submit this numerator option)
Append a modifier (1P) to CPT Category II code 4159F to report documented
circumstances that appropriately exclude patients from the denominator.
4159F with 1P: Documentation of medical reason(s) for not counseling patient regarding
contraception
AND
G8463: Patient receiving antiviral treatment for Hepatitis C documented
OR
OR
If patient is not eligible for this measure because patient is not receiving antiviral
treatment, report:
(One G-code [G8462] is required on the claim form to submit this numerator option)
G8462: Clinician documented that patient is not an eligible candidate for counseling
regarding contraception prior to antiviral treatment; patient not receiving antiviral treatment
for Hepatitis C
Counseling Regarding Contraception not Received, Reason not Specified
(One CPT II code & one G-code [4159F-8P & G8463] are required on the claim form to
submit this numerator option)
Append a reporting modifier (8P) to CPT Category II code 4159F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4159F with 8P: Counseling regarding contraception not received prior to initiation of
antiviral treatment, reason not otherwise specified
AND
G8463: Patient receiving antiviral treatment for Hepatitis C documented
DENOMINATOR:
All women aged 18 through 44 years and all men aged 18 years and older with a diagnosis of
chronic hepatitis C who are receiving antiviral treatment
Denominator Criteria (Eligible Cases):
Patients (females aged 18 through 44 years or males aged ≥ 18 years) on date of
encounter
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AND
Diagnosis for chronic hepatitis (line-item ICD-9-CM): 070.54
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Ribavirin is contraindicated in pregnancy. Therefore, counseling regarding strict precautions and
contraception in women of childbearing age and their sexual partners and in HCV-infected men
with female partners of childbearing age needs to be provided to those receiving treatment for
chronic hepatitis C prior to the initiation of treatment. Although this measure only captures data
related to counseling prior to therapy it should be subsequently re-enforced during treatment and
for a period of 6 months after treatment.
CLINICAL RECOMMENDATION STATEMENTS:
Because of the concern of birth defects from the use of ribavirin, it is imperative that persons who
receive the drug use strict contraception methods both during treatment and for a period of 6
months after treatment. (AASLD)
Ribavirin is contraindicated in pregnancy, necessitating strict precautions and contraception in
women of childbearing age and their sexual partners and in HCV-infected men with female
partners of childbearing age. (AGA)
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Measure #91: Acute Otitis Externa (AOE): Topical Therapy
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed
topical preparations
INSTRUCTIONS:
This measure is to be reported once for each occurrence of AOE during the reporting period. Each
unique occurrence is defined as a 30-day period from onset of AOE. Claims data will be analyzed
to determine unique occurrences. If multiple claims are submitted within that 30-day period, only
one instance of reporting will be counted. This measure may be reported by clinicians who perform
the quality actions described in the measure based on the services provided and the measurespecific denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the appropriate ICD-9-CM diagnosis codes, CPT
codes, and the appropriate CPT Category II code OR the CPT Category II code with the modifier.
The modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 8P- reason
not otherwise specified. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients who were prescribed topical preparations
Definition:
Prescribed – Includes patients who are currently receiving medication(s) that follow the
treatment plan recommended at an encounter during the reporting period, even if the
prescription for that medication was ordered prior to the encounter.
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Topical Preparations Prescribed
CPT II 4130F: Topical preparations (including OTC) prescribed for acute otitis externa
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OR
Topical Preparations not Prescribed for Medical or Patient Reasons
Append a modifier (1P or 2P) to CPT Category II code 4130F to report documented
circumstances that appropriately exclude patients from the denominator.
4130F with 1P: Documentation of medical reason(s) for not prescribing topical
preparations (including OTC) for acute otitis externa
4130F with 2P: Documentation of patient reason(s) for not prescribing topical preparations
(including OTC) for acute otitis externa
Topical Preparations not Prescribed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4130F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4130F with 8P: Topical preparations (including OTC) for acute otitis externa (AOE) not
prescribed, reason not otherwise specified
DENOMINATOR:
All patients aged 2 years and older with a diagnosis of AOE
Denominator Criteria (Eligible Cases):
Patients aged ≥ 2 years on date of encounter
AND
Diagnosis for AOE (line-item ICD-9-CM): 380.10, 380.11, 380.12, 380.13, 380.22
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Topical preparations should be used to treat AOE as they are active against the most common
bacterial pathogens in AOE, Pseudomonas aeruginosa and Staphylococcus aureus. Topical
preparations have demonstrated efficacy in the treatment of AOE with resolution in about 65-90%
of patients.
CLINICAL RECOMMENDATION STATEMENTS:
Clinicians should use topical preparations for initial therapy of diffuse, uncomplicated AOE.
(Recommendation based on randomized controlled trials with minor limitations and a
preponderance of benefit over harm. [Aggregate evidence quality – Grade B]) (AAO-HNSF)
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Measure #92: Acute Otitis Externa (AOE): Pain Assessment
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patient visits for those patients aged 2 years and older with a diagnosis of AOE with
assessment for auricular or periauricular pain
INSTRUCTIONS:
This measure is to be reported at each visit for patients with AOE during the reporting period. This
measure may be reported by clinicians who perform the quality actions described in the measure
based on the services provided and the measure-specific denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the appropriate ICD-9-CM diagnosis codes, CPT
codes, and the appropriate CPT Category II code OR the CPT Category II code with the modifier.
The modifiers allowed for this measure are: 1P- medical reasons, 8P- reason not otherwise
specified. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patient visits with assessment for auricular or periauricular pain
OR
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Auricular or Periauricular Pain Assessed
CPT II 1116F: Auricular or periauricular pain assessed
Auricular or Periauricular Pain not Assessed for Medical Reasons
Append a modifier (1P) to CPT Category II code 1116F to report documented
circumstances that appropriately exclude patients from the denominator.
1116F with 1P: Documentation of medical reason(s) for not assessing auricular or
periauricular pain
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Auricular or Periauricular Pain not Assessed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 1116F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
1116F with 8P: Auricular or periauricular pain not assessed, reason not otherwise
specified
DENOMINATOR:
All patient visits for those patients aged 2 years and older with a diagnosis of AOE
Denominator Criteria (Eligible Cases):
Patients aged ≥ 2 years on date of encounter
AND
Diagnosis for AOE (line-item ICD-9-CM): 380.10, 380.11, 380.12, 380.13, 380.22
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Pain relief is a major goal in the management of AOE. Frequent use of analgesics is often
necessary to permit patients to achieve comfort, rest, and to resume normal activities. On-going
assessment of the severity of discomfort is essential for proper management.
CLINICAL RECOMMENDATION STATEMENTS:
The management of diffuse AOE should include an assessment of pain. The clinician should
recommend analgesic treatment based on the severity of pain. (Strong recommendation based on
well-designed randomized trials with a preponderance of benefit over harm. [Aggregate evidence
quality – Grade B]) (AAO-HNSF)
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Measure #93: Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance
of Inappropriate Use
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed
systemic antimicrobial therapy
INSTRUCTIONS:
This measure is to be reported once for each occurrence of AOE during the reporting period. Each
unique occurrence is defined as a 30-day period from onset of AOE. Claims data will be analyzed
to determine unique occurrences. If multiple claims are submitted within that 30-day period, only
one instance of reporting will be counted. This measure may be reported by clinicians who perform
the quality actions described in the measure based on the services provided and the measurespecific denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the appropriate ICD-9-CM diagnosis codes, CPT
codes, and the appropriate CPT Category II code OR the CPT Category II code with the modifier.
The modifier allowed for this measure is: 1P- medical reasons. All measure-specific coding should
be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients who were not prescribed systemic antimicrobial therapy
Numerator Instructions: For performance, the measure will be calculated as the number
of patients for whom systemic antimicrobial therapy was not prescribed over the number of
patients in the denominator (patients aged 2 years and older with acute otitis externa). A
higher score indicates appropriate treatment of patients with AOE (e.g., the proportion for
whom systemic antimicrobials were not prescribed).
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OR
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Systemic Antimicrobial Therapy not Prescribed
CPT II 4132F: Systemic antimicrobial therapy not prescribed
Systemic Antimicrobial Therapy Prescribed for Medical Reasons
Append a modifier (1P) to CPT Category II code 4131F to report documented
circumstances that appropriately exclude patients from the denominator.
4131F with 1P: Documentation of medical reason(s) for prescribing systemic antimicrobial
therapy
Systemic Antimicrobial Therapy Prescribed
CPT II 4131F: Systemic antimicrobial therapy prescribed
DENOMINATOR:
All patients aged 2 years and older with a diagnosis of AOE
Denominator Criteria (Eligible Cases):
Patients aged ≥ 2 years on date of encounter
AND
Diagnosis for AOE (line-item ICD-9-CM): 380.10, 380.11, 380.12, 380.13, 380.22
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Despite their limited utility, many patients with AOE receive systemic antimicrobial therapy, often in
addition to topical therapy. “There are no data on the efficacy of systemic therapy with the use of
appropriate antibacterials and stratified by severity of the infection. Moreover, orally administered
antibiotics have significant adverse effects that include rashes, vomiting, diarrhea, allergic
reactions, altered nasopharyngeal flora, and development of bacterial resistance.” The use of
systemic antimicrobial therapy to treat AOE should be limited only to those clinical situations in
which it is indicated.
CLINICAL RECOMMENDATION STATEMENTS:
Systemic antimicrobial therapy should not be used unless there is extension outside the ear canal
or the presence of specific host factors that would indicate a need for systemic therapy.
(Recommendation based on randomized controlled trials with minor limitations and a
preponderance of benefit over harm. [Aggregate evidence quality – Grade B]) (AAO-HNSF)
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Measure #94: Otitis Media with Effusion (OME): Diagnostic Evaluation – Assessment of
Tympanic Membrane Mobility
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patient visits for those patients aged 2 months through 12 years with a diagnosis of
OME with assessment of tympanic membrane mobility with pneumatic otoscopy or tympanometry
INSTRUCTIONS:
This measure is to be reported at each visit for children with OME during the reporting period. This
measure may be reported by clinicians who perform the quality actions described in the measure
based on the services provided and the measure-specific denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the appropriate ICD-9-CM diagnosis codes, CPT
codes, and the appropriate CPT Category II code OR the CPT Category II code with the modifier.
The modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 8P- reason
not otherwise specified. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions; however, these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patient visits with assessment of tympanic membrane mobility with pneumatic otoscopy or
tympanometry
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Tympanic Membrane Mobility Assessed
CPT II 2035F: Tympanic membrane mobility assessed with pneumatic otoscopy or
tympanometry
Tympanic Membrane Mobility not Assessed for Medical or Patient Reasons
Append a modifier (1P or 2P) to CPT Category II code 2035F to report documented
circumstances that appropriately exclude patients from the denominator.
2035F with 1P: Documentation of medical reason(s) for not assessing tympanic
membrane mobility with pneumatic otoscopy or tympanometry
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OR
2035F with 2P: Documentation of patient reason(s) for not assessing tympanic membrane
mobility with pneumatic otoscopy or tympanometry
Tympanic Membrane Mobility not Assessed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 2035F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
2035F with 8P: Tympanic membrane mobility not assessed with pneumatic otoscopy or
tympanometry, reason not otherwise specified
DENOMINATOR:
All patient visits for those patients aged 2 months through 12 years with a diagnosis of OME
Denominator Criteria (Eligible Cases):
Patients aged 2 months through 12 years on date of encounter
AND
Diagnosis for OME (line-item ICD-9-CM): 381.10, 381.19, 381.20, 381.29, 381.3, 381.4
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Correctly diagnosing middle ear effusion is essential for proper management. OME is often
characterized by a cloudy tympanic membrane with distinctly impaired mobility which can best be
determined with pneumatic otoscopy or tympanometry.
CLINICAL RECOMMENDATION STATEMENTS:
Clinicians should use pneumatic otoscopy as the primary diagnostic method for OME. OME should
be distinguished from AOM. (Strong Recommendation based on systematic review of cohort
studies and preponderance of benefit over harm. [Aggregate evidence quality – Grade A])
Tympanometry can be used to confirm the diagnosis of OME. (Option based on cohort studies and
a balance of benefit and harm. [Aggregate evidence quality – Grade B]) (AAFP/AAO-HNSF/AAP)
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Measure #99: Breast Cancer Resection Pathology Reporting: pT Category (Primary
Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of breast cancer resection pathology reports that include the pT category (primary
tumor), the pN category (regional lymph nodes), and the histologic grade
INSTRUCTIONS:
This measure is to be reported each time a breast cancer resection surgical pathology examination
is performed during the reporting period for breast cancer patients. Each unique CPT Category I
code submitted on the claim will be counted for denominator inclusion. It is anticipated that
clinicians who examine breast tissue specimens following resection in a laboratory or institution will
submit this measure. Independent laboratories (ILs) and independent diagnostic testing facilities
(IDTFs), using indicator Place of Service 81, are not included in PQRI. If the specimen is not
primary breast tissue (eg, liver, lung), report only CPT II code 3250F.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes and CPT codes are used to identify patients who are included
in the measure’s denominator. CPT Category II codes are used to report the numerator of the
measure.
When reporting the measure via claims, submit the appropriate ICD-9-CM diagnosis codes, CPT
codes, and the appropriate CPT Category II code OR the CPT Category II code with the modifier.
The modifiers allowed for this measure are: 1P- medical reasons, 8P- reason not otherwise
specified. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes and CPT codes are used to identify patients who are included in the
measure’s denominator. The numerator options as described in the quality-data codes are used to
report the numerator of the measure. The quality-data codes listed do not need to be submitted for
registry-based submissions; however, these codes may be submitted for those registries that utilize
claims data.
NUMERATOR:
Reports that include the pT category, the pN category and the histologic grade
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
pT Category, pN Category and Histologic Grade Documented
CPT II 3260F: pT category (primary tumor), pN category (regional lymph nodes), and
histologic grade documented in pathology report
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pT Category, pN Category and Histologic Grade not Documented for Medical
Reasons
Append a modifier (1P) to CPT Category II code 3260F to report documented
circumstances that appropriately exclude patients from the denominator.
3260F with 1P: Documentation of medical reason(s) for not including pT category, pN
category, and histologic grade in the pathology report (e.g., re-excision
without residual tumor)
OR
OR
If patient is not eligible for this measure because the specimen is not primary breast
tissue (eg, liver, lung) report:
CPT II 3250F: Specimen site other than anatomic location of primary tumor
pT Category, pN Category and Histologic Grade not Documented, Reason not
Specified
Append a reporting modifier (8P) to CPT Category II code 3260F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3260F with 8P: pT category, pN category, and histologic grade were not documented in
pathology report, reason not otherwise specified
DENOMINATOR:
All breast cancer resection pathology reports (excluding biopsies)
Denominator Criteria (Eligible Cases):
Diagnosis for breast cancer (line-item ICD-9-CM): 174.0, 174.1, 174.2, 174.3, 174.4,
174.5, 174.6, 174.8, 174.9, 175.0, 175.9
AND
Patient encounter during the reporting period (CPT): 88307, 88309
RATIONALE:
Therapeutic decisions for breast cancer management are stage driven and cannot be made
without a complete set of pathology descriptors. Incomplete cancer resection pathology reports
may result in misclassification of patients, rework and delays, and suboptimal management. The
College of American Pathologists (CAP) has produced evidence-based checklists of essential
pathologic parameters that are recommended to be included in cancer resection pathology reports.
These checklists have been endorsed as a voluntary standard by National Quality Forum (NQF)
and are considered the reporting standard by the Commission on Cancer (CoC) of the American
College of Surgeons (ACS).
The CAP recently conducted a structured audit of breast cancer pathology report adequacy at 86
institutions. Overall, 35% of eligible reports were missing at least one of the ten CAPrecommended breast cancer elements. Cancer Care Ontario (CCO) conducted a similar study in
2005 and found that 25% of breast cancer pathology reports did not include all of the information
required by the CAP standards.
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While the exact percentage of breast cancer resection pathology reports that are missing the pT
category, the pN category and the histologic grade is unknown, these are essential elements in
breast cancer treatment decisions and should be included in every pathology report when possible.
CLINICAL RECOMMENDATION STATEMENTS:
Patient management and treatment guidelines promote an organized approach to providing quality
care. The (American College of Surgeons Commission on Cancer) CoC requires that 90% of
pathology reports that include a cancer diagnosis contain the scientifically validated data elements
outlined in the surgical case summary checklist of the College of American Pathologists (CAP)
publication Reporting on Cancer Specimens. (ACSCoC)
All invasive breast carcinomas, with the exception of medullary carcinoma should be graded. The
grading system used must be specified in the report; the Nottingham combined histologic grade
(Elston-Ellis modification of Scarff-Bloom-Richardson grading system) is recommended. Within
each stage grouping there is a relation between histologic grade and outcome. (CAP)
TNM staging information is included in factors proven to be of prognostic import and useful in
clinical patient management. (CAP)
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Measure #100: Colorectal Cancer Resection Pathology Reporting: pT Category (Primary
Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of colon and rectum cancer resection pathology reports that include the pT category
(primary tumor), the pN category (regional lymph nodes) and the histologic grade
INSTRUCTIONS:
This measure is to be reported each time a colorectal cancer resection surgical pathology
examination is performed during the reporting period for colorectal cancer patients. Each unique
CPT Category I code submitted on the claim will be counted for denominator inclusion. It is
anticipated that clinicians who examine colorectal tissue specimens following resection in a
laboratory or institution will submit this measure. Independent Laboratories (ILs) and Independent
Diagnostic Testing Facilities (IDTFs), using indicator Place of Service 81, are not included in PQRI.
If the specimen is not primary colorectal tissue (e.g., liver, lung), report only CPT II 3250F.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes and CPT codes are used to identify patients who are included
in the measure’s denominator. CPT Category II codes are used to report the numerator of the
measure.
When reporting the measure via claims, submit the appropriate ICD-9-CM diagnosis codes, CPT
codes, and the appropriate CPT Category II code OR the CPT Category II code with the modifier.
The modifiers allowed for this measure are: 1P- medical reasons, 8P- reason not otherwise
specified. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes and CPT codes are used to identify patients who are included in the
measure’s denominator. The numerator options as described in the quality-data codes are used to
report the numerator of the measure. The quality-data codes listed do not need to be submitted for
registry-based submissions however these codes may be submitted for those registries that utilize
claims data.
NUMERATOR:
Reports that include the pT category, the pN category and the histologic grade
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
pT Category, pN Category and Histologic Grade Documented
CPT II 3260F: pT category (primary tumor), pN category (regional lymph nodes), and
histologic grade documented in pathology report
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pT Category, pN Category and Histologic Grade not Documented for Medical
Reasons
Append a modifier (1P) to CPT Category II code 3260F to report documented
circumstances that appropriately exclude patients from the denominator.
3260F with 1P: Documentation of medical reason(s) for not including pT category, pN
category and histologic grade in the pathology report (eg, anal canal)
OR
OR
If patient is not eligible for this measure because the specimen is not primary
colorectal tissue (eg, liver, lung) report:
CPT II 3250F: Specimen site other than anatomic location of primary tumor
pT Category, pN Category and Histologic Grade not Documented, Reason not
Specified
Append a reporting modifier (8P) to CPT Category II code 3260F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3260F with 8P: pT category, pN category and histologic grade were not documented in
the pathology report, reason not otherwise specified
DENOMINATOR:
All colon and rectum cancer resection pathology reports
Denominator Criteria (Eligible Cases):
Diagnosis for colon or rectum cancer (line-item ICD-9-CM): 153.0, 153.1, 153.2, 153.3,
153.4, 153.5, 153.6, 153.7, 153.8, 153.9, 154.0, 154.1, 154.8
AND
Patient encounter during the reporting period (CPT): 88309
RATIONALE:
Therapeutic decisions for colorectal cancer management are stage driven and cannot be made
without a complete set of pathology descriptors. Incomplete cancer resection pathology reports
may result in misclassification of patients, rework and delays, and suboptimal management. The
College of American Pathologists (CAP) has produced evidence-based checklists of essential
pathologic parameters that are recommended to be included in cancer resection pathology reports.
These checklists have been endorsed as a voluntary standard by National Quality Forum (NQF)
and are considered the reporting standard by the Commission on Cancer (CoC) of the American
College of Surgeons (ACS).
The CAP recently conducted a structured audit of colorectal cancer pathology report adequacy at
86 institutions. Overall, 34% of eligible reports were missing at least one of the ten CAPrecommended colorectal cancer elements. Cancer Care Ontario (CCO) conducted a similar study
in 2005 and found that 31% of colorectal cancer pathology reports did not include all of the
information required by the CAP standards.
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While the exact percentage of colorectal cancer resection pathology reports that are missing the pT
category, the pN category and the histologic grade is unknown, these are essential elements in
colorectal cancer treatment decisions and should be included in every pathology report when
possible.
CLINICAL RECOMMENDATION STATEMENTS:
Patient management and treatment guidelines promote an organized approach to providing quality
care. The American College of Surgeons Committee on Cancer (CoC) requires that 90% of
pathology reports that include a cancer diagnosis contain the scientifically validated data elements
outlined in the surgical case summary checklist of the College of American Pathologists (CAP)
publication Reporting on Cancer Specimens. (ACSCoC)
Surgical resection is the primary therapy for most colorectal carcinomas, and the most important
prognostic indicators are related to the pathologic findings in the resection specimen. The anatomic
extent of disease is by far the most important prognostic factor in colorectal cancer. Pathologic
staging depends on pathologic documentation of the anatomic extent of disease, whether or not
the primary tumor has been completely removed. If a biopsied tumor is not resected for any reason
(e.g., when technically unfeasible) and if the highest T and N categories or the M1 category of the
tumor can be confirmed microscopically, the criteria for pathologic classification and staging have
been satisfied without total removal of the primary cancer. (CAP)
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Measure #102: Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging LowRisk Prostate Cancer Patients
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low risk of
recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the
prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at
any time since diagnosis of prostate cancer
INSTRUCTIONS:
This measure is to be reported once per episode of treatment (i.e., interstitial prostate
brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR
cryotherapy) for all patients with prostate cancer who receive interstitial prostate brachytherapy,
external beam radiotherapy to the prostate, radical prostatectomy, or cryotherapy during the
reporting period. Claims data will be analyzed to determine unique episodes of radiation therapy.
Each episode of radiation therapy in an eligible patient receiving external beam radiotherapy to the
prostate occurring during the reporting period will be counted when calculating the reporting and
performance rates. The PQRI quality-data code needs to be submitted only once during the
episode of radiation therapy (e.g., 8 weeks of therapy). It is anticipated that clinicians who perform
the listed procedures as specified in the denominator coding will submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes and CPT codes are used to identify patients who are included
in the measure’s denominator. CPT Category II codes are used to report the numerator of the
measure.
When reporting the measure via claims, submit the appropriate ICD-9-CM diagnosis codes, CPT
codes, and the appropriate CPT Category II code(s) OR the CPT Category II code(s) with the
modifier. The modifiers allowed for this measure are: 1P- medical reasons, 3P- system reasons. All
measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes and CPT codes are used to identify patients who are included in the
measure’s denominator. The numerator options as described in the quality-data codes are used to
report the numerator of the measure. The quality-data codes listed do not need to be submitted for
registry-based submissions however these codes may be submitted for those registries that utilize
claims data.
NUMERATOR:
Patients who did not have a bone scan performed at any time since diagnosis of prostate cancer
Definitions:
Risk Strata: Low, Intermediate, or High
Low Risk – PSA ≤10 mg/dL; AND Gleason score 6 or less; AND clinical stage T1c or T2a2
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Intermediate Risk – PSA >10 to 20 mg/dL; OR Gleason score 7; OR clinical stage T2b,
and not qualifying for high risk2
High Risk – PSA >20 mg/dL; OR Gleason score 8 to 10; OR clinically localized stage
T3a1
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Bone Scan not Performed
(Two CPT II codes [3270F & 3271F] are required on the claim form to submit this
numerator option)
CPT II 3270F: Bone scan not performed prior to initiation of treatment nor at any time
since diagnosis of prostate cancer
AND
CPT II 3271F: Low risk of recurrence, prostate cancer
Bone Scan Performed for Medical or System Reasons
(Two CPT II codes [3269F-xP & 3271F] are required on the claim form to submit this
numerator option)
Append a modifier (1P or 3P) to CPT Category II code 3269F to report documented
circumstances that appropriately exclude patients from the denominator.
3269F with 1P: Documentation of medical reason(s) for performing a bone scan (including
documented pain, salvage therapy, other medical reasons)
3269F with 3P: Documentation of system reason(s) for performing a bone scan (including
bone scan ordered by someone other than reporting physician)
AND
CPT II 3271F: Low risk of recurrence, prostate cancer
OR
If patient is not eligible for this measure because the risk of recurrence is
intermediate, high or not determined, report:
(One CPT II code [327xF] is required on the claim form to submit this numerator option)
Intermediate Risk of Recurrence
CPT II 3272F: Intermediate risk of recurrence, prostate cancer
OR
High Risk of Recurrence
CPT II 3273F: High risk of recurrence, prostate cancer
OR
OR
Risk of Recurrence not Determined
CPT II 3274F: Prostate cancer risk of recurrence not determined or neither low,
intermediate nor high
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Bone Scan Performed
(Two CPT II codes [3269F & 3271F] are required on the claim form to submit this
numerator option)
CPT II 3269F: Bone scan performed prior to initiation of treatment or at any time since
diagnosis of prostate cancer
AND
CPT II 3271F: Low risk of recurrence, prostate cancer
DENOMINATOR:
All patients, regardless of age, with a diagnosis of prostate cancer at low risk of recurrence
receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR
radical prostatectomy, OR cryotherapy
Note: Only patients with prostate cancer with low risk of recurrence will be counted in the
performance denominator of this measure
Denominator Criteria (Eligible Cases):
Diagnosis for prostate cancer (line-item ICD-9-CM): 185
AND
Patient encounter during the reporting period (CPT): 55810, 55812, 55815, 55840,
55842, 55845, 55866, 55873, 77427, 77776, 77777, 77778, 77787
RATIONALE:
A bone scan is generally not required for staging prostate cancer in men with a low risk of
recurrence and receiving primary therapy. This measure is written as a negative measure so that
the performance goal is 100%, consistent with the other measures for this condition.
CLINICAL RECOMMENDATION STATEMENTS:
Routine use of a bone scan is not required for staging asymptomatic men with clinically localized
prostate cancer when their PSA is equal to or less than 20.0 ng/mL. (AUA)
Patients with a life expectancy > 5 years or symptomatic:
• A bone scan is appropriate for T1 to T2 disease in the presence of a PSA greater than 20
ng/mL, Gleason score of 8 or higher, clinical stage of T3 to T4, or symptomatic disease.
• Patients at higher risk of metastatic disease may undergo pelvic computed tomography (CT)
or magnetic resonance imaging (MRI) scanning with possible fine-needle aspiration of
enlarged lymph nodes or staging lymph node dissection. Nomograms or risk tables may be
used to identify patients with a higher likelihood of having metastatic disease. If the
nomogram indicates a probability of lymph node involvement greater than 20% or if the
patient is stage T3 or T4, this is recommended as a threshold for doing a staging CT scan or
MRI evaluation.
For all other patients, no additional imaging is required for staging. (NCCN) (Category 2A)
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Measure #104: Prostate Cancer: Adjuvant Hormonal Therapy for High-Risk Prostate
Cancer Patients
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients, regardless of age, with a diagnosis of prostate cancer at high risk of
recurrence receiving external beam radiotherapy to the prostate who were prescribed adjuvant
hormonal therapy (GnRH agonist or antagonist)
INSTRUCTIONS:
This measure is to be reported once per episode of radiation therapy for all patients with prostate
cancer who receive external beam radiotherapy to the prostate during the reporting period. Claims
data will be analyzed to determine unique episodes of radiation therapy. Each episode of radiation
therapy in an eligible patient receiving external beam radiotherapy to the prostate occurring during
the reporting period will be counted when calculating the reporting and performance rates. The
PQRI quality-data code needs to be submitted only once during the episode of radiation therapy
(e.g., 8 weeks of therapy). It is anticipated that clinicians who perform external beam radiotherapy
to the prostate will submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes and CPT codes are used to identify patients who are included
in the measure’s denominator. CPT Category II codes and/or G-codes are used to report the
numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code AND/OR G-code OR the CPT Category II code with the
modifier AND G-code. The modifiers allowed for this measure are: 1P- medical reasons, 2Ppatient reasons, 8P- reason not otherwise specified. All measure-specific coding should be
reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes and CPT codes are used to identify patients who are included in the
measure’s denominator. The numerator options as described in the quality-data codes are used to
report the numerator of the measure. The quality-data codes listed do not need to be submitted for
registry-based submissions however these codes may be submitted for those registries that utilize
claims data.
NUMERATOR:
Patients who were prescribed adjuvant hormonal therapy (GnRH [gonadotropin-releasing
hormone] agonist or antagonist)
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Definitions:
Risk Strata: Low, Intermediate, or High
Low Risk – PSA ≤ 10 mg/dL; AND Gleason score 6 or less; AND clinical stage T1c or
T2a2
Intermediate Risk – PSA > 10 to 20 mg/dL; OR Gleason score 7; OR clinical stage T2b,
and not qualifying for high risk2
High Risk – PSA > 20 mg/dL; OR Gleason score 8 to 10; OR clinically localized stage
T3a1
Prescribed – Includes patients who are currently receiving medication(s) that follow the
treatment plan recommended at an encounter during the reporting period, even if the
prescription for that medication was ordered prior to the encounter.
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Adjuvant Hormonal Therapy Prescribed/Administered
(One CPT II code & one G-code [4164F & G8465] are required on the claim form to submit
this numerator option)
CPT II 4164F: Adjuvant (ie, in combination with external beam radiotherapy to the prostate
for prostate cancer) hormonal therapy (GnRH [gonadotropin-releasing hormone] agonist or
antagonist) prescribed/administered
AND
G8465: High risk of recurrence of prostate cancer
Adjuvant Hormonal Therapy not Prescribed/Administered for Medical or Patient
Reasons
(One CPT II code & one G-code [4164F-xP & G8465] are required on the claim form to
submit this numerator option)
Append a modifier (1P or 2P) to CPT Category II code 4164F to report documented
circumstances that appropriately exclude patients from the denominator.
4164F with 1P: Documentation of medical reason(s) for not prescribing/administering
adjuvant hormonal therapy (eg, salvage therapy)
4164F with 2P: Documentation of patient reason(s) for not prescribing/administering
adjuvant hormonal therapy
AND
G8465: High risk of recurrence of prostate cancer
OR
If patient is not eligible for this measure because the risk of recurrence is low,
intermediate or not determined, report:
(One G-code [G8464] is required on the claim form to submit this numerator option)
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OR
G8464: Clinician documented that prostate cancer patient is not an eligible candidate for
adjuvant hormonal therapy; Low or intermediate risk of recurrence OR risk of recurrence
not determined
Adjuvant Hormonal Therapy not Prescribed/Administered, Reason not Specified
(One CPT II code & one G-code [4164F-8P & G8465] are required on the claim form to
submit this numerator option)
Append a reporting modifier (8P) to CPT Category II code 4164F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4164F with 8P: Patients who were not prescribed/administered adjuvant hormonal
therapy, reason not otherwise specified
AND
G8465: High risk of recurrence of prostate cancer
DENOMINATOR:
All patients, regardless of age, with a diagnosis of prostate cancer at high risk of recurrence
receiving external beam radiotherapy to the prostate
Note: Only patients with prostate cancer with high risk of recurrence will be counted in the
performance denominator of this measure
Denominator Criteria (Eligible Cases):
Diagnosis for prostate cancer (line-item ICD-9-CM): 185
AND
Patient encounter during the reporting period (CPT): 77427
RATIONALE:
If receiving external beam radiotherapy as primary therapy, prostate cancer patients with a high
risk of recurrence should also be prescribed hormonal therapy, which has been shown to increase
the effectiveness of the radiotherapy.
CLINICAL RECOMMENDATION STATEMENTS:
High risk patients who are considering specific treatment options should be informed of findings of
recent high quality clinical trials, including that: for those considering external beam radiotherapy,
use of hormonal therapy combined with conventional radiotherapy may prolong survival. (AUA)
(Standard)
Men with prostate cancer that is clinically localized stage T3a1, with Gleason score of 8 to 10, or
PSA level greater than 20 ng/mL are categorized by the NCCN panel to be at high risk of
recurrence after definitive therapy. Note that patients with multiple adverse factors may be shifted
into the very high-risk category. Hormonal therapy (e.g., androgen ablation) plus external-beam RT
is recommended. (NCCN) (Category 1)
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Measure #105: Prostate Cancer: Three-Dimensional (3D) Radiotherapy
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients, regardless of age, with a diagnosis of clinically localized prostate cancer
receiving external beam radiotherapy as a primary therapy to the prostate with or without nodal
irradiation (no metastases; no salvage therapy) who receive three-dimensional conformal
radiotherapy (3D-CRT) or intensity modulated radiation therapy (IMRT)
INSTRUCTIONS:
This measure is to be reported once per episode of radiation therapy for all patients with prostate
cancer who receive external beam radiotherapy to the prostate during the reporting period. Claims
data will be analyzed to determine unique episodes of radiation therapy. Each episode of radiation
therapy in an eligible patient receiving external beam radiotherapy to the prostate occurring during
the reporting period will be counted when calculating the reporting and performance rates. The
PQRI quality-data code needs to be submitted only once during the episode of radiation therapy
(e.g., 8 weeks of therapy). It is anticipated that clinicians who perform external beam radiotherapy
to the prostate will submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes and CPT codes are used to identify patients who are included
in the measure’s denominator. CPT Category II codes are used to report the numerator of the
measure.
When reporting the measure via claims, submit the appropriate ICD-9-CM diagnosis codes, CPT
codes, and the appropriate CPT Category II code(s) OR the CPT Category II code(s) with the
modifier. The reporting modifier allowed for this measure is: 8P- reason not otherwise specified. All
measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes and CPT codes are used to identify patients who are included in the
measure’s denominator. The numerator options as described in the quality-data codes are used to
report the numerator of the measure. The quality-data codes listed do not need to be submitted for
registry-based submissions however these codes may be submitted for those registries that utilize
claims data.
NUMERATOR:
Patients who receive three-dimensional conformal radiotherapy (3D-CRT) or intensity modulated
radiation therapy (IMRT)
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
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OR
OR
3D-CRT or IMRT Received
(Two CPT II codes [4165F & 4200F] are required on the claim form to submit this
numerator option)
CPT II 4165F: Three-dimensional conformal radiotherapy (3D-CRT) or intensity modulated
radiation therapy (IMRT) received
AND
CPT II 4200F: External beam radiotherapy as primary therapy to the prostate with or
without nodal irradiation
If patient is not eligible for this measure because the 3D-CRT or IMRT is to region(s)
other than the prostate only, report:
(One CPT II code [4201F] is required on the claim form to submit this numerator option)
CPT II 4201F: External beam radiotherapy with or without nodal irradiation as adjuvant or
salvage therapy for prostate cancer patient
3D-CRT or IMRT not Received, Reason not Specified
(Two CPT II codes [4165F-8P & 4200F] are required on the claim form to submit this
numerator option)
Append a reporting modifier (8P) to CPT Category II code 4165F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4165F with 8P: Patients who did not receive three-dimensional conformal radiotherapy
(3D-CRT) or intensity modulated radiation therapy (IMRT), reason not
otherwise specified
AND
CPT II 4200F: External beam radiotherapy as primary therapy to the prostate with or
without nodal irradiation
DENOMINATOR:
All patients, regardless of age, with a diagnosis of clinically localized prostate cancer receiving
external beam radiotherapy as primary therapy to the prostate with or without nodal irradiation (no
metastases; no salvage therapy)
Denominator Criteria (Eligible Cases):
Diagnosis for clinically localized prostate cancer (line-item ICD-9-CM): 185
WITHOUT
Secondary malignant neoplasm diagnosis of a specified site – respiratory, digestive,
and of other specified sites (line-item ICD-9-CM): 197.0, 197.1, 197.2, 197.3, 197.4,
197.5, 197.6, 197.7, 197.8, 198.0, 198.1, 198.2, 198.3, 198.4, 198.5, 198.6, 198.7, 198.81,
198.82, 198.89
AND
Patient encounter during the reporting period (CPT): 77427
RATIONALE:
Current, computer-aided radiotherapy techniques improve the precision of the irradiation of
cancerous tissue and should be employed for all patients receiving external beam radiotherapy as
primary therapy to the prostate.
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CLINICAL RECOMMENDATION STATEMENTS:
Three-dimensional CRT or intensity-modulated radiation therapy (IMRT) techniques should be
employed over conventional techniques. These techniques use computer software to integrate CT
images of the patients' internal anatomy in the treatment position, which allows the volume
receiving the high radiation dose to "conform" more exactly to the shape of the tumor. Threedimensional CRT has reduced both acute and late normal tissue toxicity in patients with prostate
cancer and allows higher cumulative doses to be delivered with a lower risk of late effects. (NCCN)
(Category 2A)
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Measure #106: Major Depressive Disorder (MDD): Diagnostic Evaluation
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of MDD
who met the DSM-IV criteria during the visit in which the new diagnosis or recurrent episode was
identified during the measurement period
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all patients with an
active diagnosis of major depressive disorder seen during the reporting period, including episodes
of MDD that began prior to the reporting period. This measure may be reported by clinicians who
perform the quality actions described in the measure based on the services provided and the
measure-specific denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
reporting modifier allowed for this measure is: 8P- reason not otherwise specified. There are no
allowable performance exclusions for this measure. All measure-specific coding should be reported
ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions however these codes may be submitted for
those registries that utilize claims data. There are no allowable performance exclusions for this
measure.
NUMERATOR:
Patients with documented evidence that they met the DSM-IV criteria [At least 5 elements (must
include: 1) depressed mood or 2) loss of interest or pleasure) with symptom duration of 2 weeks or
longer] during the visit in which the new diagnosis or recurrent episode was identified
Definitions:
DSM-IV Criteria – Includes presence of depressed mood, marked diminished
interest/pleasure, significant weight loss or weight gain, insomnia or hypersomnia,
psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness,
diminished ability to concentrate and recurrent suicidal ideation.
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Remission – Patient no longer meets DSM-IV criteria
NUMERATOR NOTE: PATIENTS WHOSE EPISODE OF MDD BEGAN PRIOR TO THE
CURRENT REPORTING PERIOD: The clinician should report that DSM IV criteria was
assessed during the visit in which the new diagnosis or recurrent episode was identified.
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
DSM-IV Criteria for Major Depressive Disorder Documented
CPT II 1040F: DSM-IV criteria for major depressive disorder documented at the initial
evaluation
DSM-IV Criteria for Major Depressive Disorder not Documented, Reason not
Specified
Append a reporting modifier (8P) to CPT Category II code 1040F report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
1040F with 8P: DSM-IV criteria for major depressive disorder not documented at the initial
evaluation, reason not otherwise specified
DENOMINATOR:
All patients aged 18 years and older with a new diagnosis or recurrent episode of MDD
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for MDD (line-item ICD-9-CM): 296.20, 296.21, 296.22, 296.23, 296.24,
296.30, 296.31, 296.32, 296.33, 296.34
AND
Patient encounter during the reporting period (CPT): 90801, 90802, 90804, 90805,
90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90845, 90862,
99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215
RATIONALE:
Thorough assessment of depressive symptoms sets the basis for accurate diagnosis and treatment
of major depressive disorder.
CLINICAL RECOMMENDATION STATEMENTS:
Successful treatment of patients with major depressive disorder is promoted by a thorough
assessment of the patient. (APA; Level I Recommendation)
Diagnostic criteria for 296.20-296.24 – Major Depressive Disorder, Single Episode
A.
Presence of a single Major Depressive Episode.
B.
The Major Depressive Episode is not better accounted for by Schizoaffective
Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder,
Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
C.
There has never been a Manic Episode, a Mixed Episode, or a Hypomanic
Episode.
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Note: This exclusion does not apply if all of the manic-like, mixed-like, or
hypomanic-like episodes are substance or treatment induced or are due to the
direct physiological effects of a general medical condition. (DSM IV)
Diagnostic criteria for 296.30-296.34 – Major Depressive Disorder, Recurrent
A.
Presence of two or more Major Depressive Episodes.
Note: To be considered separate episodes, there must be an interval of at least
2 consecutive months in which criteria are not met for a Major Depressive
Episode.
B.
The Major Depressive Episodes are not better accounted for by Schizoaffective
Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder,
Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
C.
There has never been a Manic Episode, a Mixed Episode, or a Hypomanic
Episode.
Note: This exclusion does not apply if all of the manic-like, mixed-like, or
hypomanic-like episodes are substance or treatment induced or are due to the
direct physiological effects of a general medical condition. (DSM IV)
Criteria for Major Depressive Episode
A.
At least five of the following symptoms have been present during the same 2-week
period and represent a change from previous functioning; at least one of the
symptoms is either 1) depressed mood or 2) loss of interest or pleasure (do not
include symptoms that are clearly due to general medical condition or moodincongruent delusions or hallucinations).
1) Depressed mood most of the day, nearly every day as indicated by either
subjective report (e.g., feels sad or empty) or observation made by others
(e.g., appears tearful)
2) Markedly diminished interest or pleasure in all, or almost all, activities most of
the day, nearly every day (as indicated by either subjective account or
observation made by others)
3) Significant weight loss when not dieting or weight gain (e.g., a change of more
than 5% body weight in a month), or decrease in appetite nearly every day
4) Insomnia or hypersomnia nearly every day
5) Psychomotor agitation or retardation nearly every day (observable by others,
not merely subjective feelings of restlessness or being slowed down)
6) Fatigue or loss of energy nearly every day
7) Feelings of worthlessness or excessive inappropriate guilt (which may be
delusional) nearly every day (not merely self-reproach or guilt about being
sick)
8) Diminished ability to think or concentrate, or indecisiveness, nearly every day
(either by subjective account or observed by others)
9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation
without a specific plan, or a suicide attempt or specific plan for committing
suicide
B.
The symptoms do not meet criteria for a mixed episode
C.
The symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning
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D.
E.
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The symptoms are not due to the direct physiological effects of a substance (e.g.,
a drug of abuse, a medication) or a general medical condition (e.g.,
hypothyroidism)
The symptoms are not better accounted for by bereavement ( i.e., after the loss of
a loved one, the symptoms persist for longer than 2 months or are characterized
by marked functional impairment, morbid preoccupation with worthlessness,
suicidal ideation, psychotic symptoms, or psychomotor retardation). (DSM-IV)
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Measure #107: Major Depressive Disorder (MDD): Suicide Risk Assessment
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of MDD
who had a suicide risk assessment completed at each visit during the measurement period
INSTRUCTIONS:
This measure is to be reported at each visit for a new diagnosis or recurrent episode of MDD, for
patients seen individually during the reporting period. This measure may be reported by clinicians
who perform the quality actions described in the measure based on the services provided and the
measure-specific denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II code(s) are used to
report the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code(s) OR the CPT Category II code with the modifier. The
reporting modifier allowed for this measure is: 8P- reason not otherwise specified. All measurespecific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions however these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients who had suicide risk assessment completed at each visit
OR
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Suicide Risk Assessed
CPT II 3085F: Suicide risk assessed
If patient is not eligible for this measure because MDD is in remission, report:
CPT II 3092F: Major depressive disorder, in remission
Suicide Risk not Assessed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3085F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
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3085F with 8P: Suicide risk not assessed, reason not otherwise specified
DENOMINATOR:
All patients aged 18 years and older with a new diagnosis or recurrent episode of MDD
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for MDD (line-item ICD-9-CM): 296.20, 296.21, 296.22, 296.23, 296.24,
296.30, 296.31, 296.32, 296.33, 296.34
AND
Patient encounter during the reporting period (CPT): 90801, 90802, 90804, 90805,
90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90845, 90862,
99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215
RATIONALE:
Research has shown that patients with major depressive disorder are at a high risk for suicide,
which makes this assessment an important aspect of care that should be assessed at each visit.
CLINICAL RECOMMENDATION STATEMENTS:
Successful treatment of patients with major depressive disorder is promoted by a thorough
assessment of the patient. (APA; Level I Recommendation)
Psychiatric management consists of a broad array of interventions and activities that should be
instituted by psychiatrists for all patients with major depressive disorder. (APA; Level I
Recommendation)
The components of an evaluation for suicide risk should include:
1) An assessment of the presence of suicidal or homicidal ideation, intent, or plans
2) Access to means for suicide and the lethality of those means
3) Presence of psychotic symptoms, command hallucinations, or severe anxiety
4) Presence of alcohol or substance abuse
5) History of seriousness of previous attempts
6) Family history or recent exposure to suicide (APA)
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Measure #108: Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug
(DMARD) Therapy
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older who were diagnosed with RA and were prescribed,
dispensed, or administered at least one ambulatory prescription for a DMARD
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for RA patients seen during
the reporting period. It is anticipated that clinicians who provide care for patients with a diagnosis of
RA will submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes can be used to
report the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifier codes allowed for this measure are: 1P- medical reasons, 8P- reason not otherwise
specified. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions however these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients who were prescribed, dispensed, or administered at least one disease modifying antirheumatic drug (DMARD)
Definitions:
Prescribed – May include prescription given to the patient for DMARD therapy at one or
more visits in the 12-month period OR patient already taking DMARD therapy as
documented in current medication list.
Biologic DMARD Therapy – Includes Adalimunab, Etanercept, Infliximab, Abatacept,
Anakinra and Rituximab
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OR
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
DMARD Prescribed, Dispensed, or Administered
CPT II 4187F: Disease modifying anti-rheumatic drug therapy prescribed, dispensed, or
administered
DMARD not Prescribed, Dispensed, or Administered for Medical Reasons
Append a modifier (1P) to CPT Category II code 4187F to report documented
circumstances that appropriately exclude patients from the denominator.
4187F with 1P: Documentation of medical reason(s) for not prescribing, dispensing, or
administering disease modifying anti-rheumatic drug therapy
DMARD not Prescribed, Dispensed, or Administered, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4187F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4187F with 8P: Disease modifying anti-rheumatic drug therapy was not prescribed,
dispensed, or administered, reason not otherwise specified
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA)
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for rheumatoid arthritis (line-item ICD-9-CM): 714.0, 714.1, 714.2, 714.81
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348,
99349, 99350
RATIONALE:
Arthritis and other rheumatic conditions comprise the leading cause of disability among adults in
the United States, and the cost of this public health burden is expected to increase as the U.S.
population ages. Rheumatoid arthritis (RA) affects 1 percent of the adult population. Although the
course of RA in individual patients is highly variable, most patients with persistent RA develop
progressive functional limitation and physical disability. In addition, there is excess mortality and
decreased survival among patients with persistent RA compared with the general population. While
the prevalence of RA is low, the associated costs are very high over the lifetime of the affected
person. Costs of RA amount to approximately 1 percent of the U.S. Gross National Product.
RA is a chronic autoimmune disorder often characterized by progressive joint destruction and
multi-system involvement. RA affects approximately 2.5 million Americans, disproportionately
women. There is no cure; consequently, the goal of treatment is to slow the progression of disease,
thereby delaying or preventing joint destruction, relieving pain and maintaining functional capacity.
RA pain is often most effectively managed in the long term by altering the natural history of the
active progressive disease with DMARDs, but analgesics and anti-inflammatory drugs also have an
important place in pain management.
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CLINICAL RECOMMENDATION STATEMENTS:
RA should be treated as early as possible with DMARDs to control symptoms and delay disease
progression.
Good Practice Point: All patients with persistent inflammatory joint disease (> 6–8 weeks duration)
already receiving simple analgesics and NSAIDs should be considered for referral for specialist
rheumatology opinion and DMARD therapy, preferably within 12 weeks.
Early DMARD therapy in RA is important to maintain function and reduce later disability.
DMARD therapy should be sustained in inflammatory disease in order to maintain disease
suppression.
American College of Rheumatology (ACR) Subcommittee on Rheumatoid Arthritis Guidelines:
Guidelines for the Management of Rheumatoid Arthritis. The majority of patients with newly
diagnosed RA should be started on DMARD therapy within three months of diagnosis. All patients
with RA are candidates for DMARD therapy. Although NSAIDs and glucocorticoids may alleviate
symptoms, joint damage may continue to occur and progress.
Initiation of DMARD therapy should not be delayed beyond three months for any patient with an
established diagnosis who, despite adequate treatment with NSAIDs, has on-going joint pain,
significant morning stiffness or fatigue, active synovitis, persistent elevation of the ESR or CRP
level or radiographic joint damage. For any untreated patient with persistent synovitis and joint
damage, DMARD treatment should be started promptly to prevent or slow further damage.
(ACR: Wherever possible, guidelines are evidence-based. However, because significant gaps in
knowledge still exist, some recommendations are based on best practices and a consensus of the
committee.)
Scottish Intercollegiate Guidelines Network: Management of Early Rheumatoid Arthritis.
There is clear evidence from placebo-controlled trials that DMARDs reduce symptoms in RA (as
measured by joint pain, swelling and tenderness, and duration and severity of morning stiffness).
DMARDs also improve global well being, as assessed by both patients and physicians. It is
becoming increasingly clear that DMARDs should be introduced as soon as possible. Protracted
benefit may be achieved in RA patients if appropriate DMARD therapy is introduced early.
Refer to Scottish Intercollegiate Guidelines Network. Management of Early Rheumatoid Arthritis,
2000.
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Measure #109: Osteoarthritis (OA): Function and Pain Assessment
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patient visits for patients aged 21 years and older with a diagnosis of OA with
assessment for function and pain
INSTRUCTIONS:
This measure is to be reported at each visit occurring during the reporting period for patients with
osteoarthritis seen during the reporting period. This measure may be reported by clinicians who
perform the quality actions described in the measure based on the services provided and the
measure-specific denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
reporting modifier allowed for this measure is: 8P- reason not otherwise specified. There are no
allowable performance exclusions for this measure. All measure-specific coding should be reported
ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions however these codes may be submitted for
those registries that utilize claims data. There are no allowable performance exclusions for this
measure.
NUMERATOR:
Patient visits with assessment for level of function and pain documented
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Osteoarthritis Symptoms and Functional Status Assessed
CPT II 1006F: Osteoarthritis symptoms and functional status assessed (may include the
use of a standardized scale or the completion of an assessment questionnaire, such as the
SF-36, AAOS Hip & Knee Questionnaire)
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Osteoarthritis Symptoms and Functional Status not Assessed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 1006F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
1006F with 8P: Osteoarthritis symptoms and functional status not assessed, reason not
otherwise specified
DENOMINATOR:
All patient visits for patients aged 21 years and older with a diagnosis of OA
Denominator Criteria (Eligible Cases):
Patients aged ≥ 21 years on date of encounter
AND
Diagnosis for OA (line-item ICD-9-CM): 715.00, 715.04, 715.09, 715.10, 715.11, 715.12,
715.13, 715.14, 715.15, 715.16, 715.17, 715.18, 715.20, 715.21, 715.22, 715.23, 715.24,
715.25, 715.26, 715.27, 715.28, 715.30, 715.31, 715.32, 715.33, 715.34, 715.35, 715.36,
715.37, 715.38, 715.80, 715.89, 715.90, 715.91, 715.92, 715.93, 715.94, 715.95, 715.96,
715.97, 715.98
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Osteoarthritis can be a debilitating condition. An assessment of patient symptoms and functional
status is important as it serves as the basis for making treatment modifications, which in turn,
assists in improving the patient’s quality of life.
CLINICAL RECOMMENDATION STATEMENTS:
Because pain is a major cause of disability in people with arthritis, assessment of functional status
should be included in the pain assessment. When selecting a functional status measure,
consideration should be given to the cognitive-developmental abilities of the person, the type of
practice setting, the domains of function to be assessed, and the time and resources needed to
complete the assessment. (APS; B Recommendation)
Any persistent pain that has an impact on physical function, psychosocial function, or other aspects
of quality of life should be recognized as a significant problem. (AGA; IIA Recommendation)
Control of pain and maintenance of activity correlate well with satisfactory quality of life. (AAOS)
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Measure #110: Preventive Care and Screening: Influenza Immunization for Patients ≥ 50
Years Old
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 50 years and older who received an influenza immunization during the
flu season (September through February)
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. This measure is intended to determine whether or not all patients aged 50 years
and older received or had an order for influenza immunization during the flu season (September
through February). There is no diagnosis associated with this measure. This measure may be
reported by clinicians who perform the quality actions described in the measure based on the
services provided and the measure-specific denominator coding.
•
•
If reporting this measure between January 1, 2010 and August 31, 2010, G-code
G8482 should be reported when the influenza vaccination is ordered or administered to the
patient during the months of September, October, November, December of 2009 or
January and February of 2010 for the flu season ending February 28, 2010.
If reporting this measure between September 1, 2010 and December 31, 2010, G-code
G8482 should be reported when the influenza vaccination is ordered or administered to the
patient during the months of September, October, November, and December of 2010 for
the flu season ending February 28, 2011.
Measure Reporting via Claims:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. G-codes are used to report the numerator of the measure.
When reporting the measure via claims, submit the listed CPT codes, and the appropriate
numerator G-code. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. The numerator options as described in the quality-data codes are used to
report the numerator of the measure. The quality-data codes listed do not need to be submitted for
registry-based submissions however these codes may be submitted for those registries that utilize
claims data.
NUMERATOR:
Patients who received an influenza immunization during the flu season (September through
February)
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OR
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Influenza Immunization Administered
G8482: Influenza immunization was ordered or administered
Influenza Immunization not Administered for Documented Reasons
G8483: Influenza immunization was not ordered or administered for reasons documented
by clinician
Influenza Immunization not Administered, Reason not Specified
G8484: Influenza immunization was not ordered or administered, reason not specified
DENOMINATOR:
All patients aged 50 years and older
Denominator Criteria (Eligible Cases):
Patients aged ≥ 50 years on date of encounter
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310,
99315, 99316, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341,
99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350
RATIONALE:
Influenza vaccination has shown to decrease hospitalizations for influenza, especially for those
with risk factors, however annual influenza vaccination rates remain low.
CLINICAL RECOMMENDATION STATEMENTS:
Annual influenza immunization is recommended for all groups who are at increased risk for
complications from influenza including persons aged ≥ 50 years. (CDC, USPSTF)
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Measure #111: Preventive Care and Screening: Pneumonia Vaccination for Patients 65
Years and Older
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 65 years and older who have ever received a pneumococcal vaccine
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. There is no diagnosis associated with this measure. Performance for this
measure is not limited to the reporting period. This measure may be reported by clinicians who
perform the quality actions described in the measure based on services provided and the measurespecific denominator coding.
Measure Reporting via Claims:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. CPT Category II codes are used to report the numerator of the measure.
When reporting the measure via claims, submit the listed CPT codes, and the appropriate CPT
Category II code OR the CPT Category II code with the modifier. The modifiers allowed for this
measure are: 1P- medical reasons, 8P- reason not otherwise specified. All measure-specific
coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. The numerator options as described in the quality-data codes are used to
report the numerator of the measure. The quality-data codes listed do not need to be submitted for
registry-based submissions however these codes may be submitted for those registries that utilize
claims data.
NUMERATOR:
Patients who have ever received a pneumococcal vaccination
OR
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Pneumonia Vaccination Administered or Previously Received
CPT II 4040F: Pneumococcal vaccine administered or previously received
Pneumonia Vaccination not Administered or Previously Received for Medical
Reasons
Append a modifier (1P) to CPT Category II code 4040F to report documented
circumstances that appropriately exclude patients from the denominator.
4040F with 1P: Documentation of medical reason(s) for not administering or previously
receiving pneumococcal vaccination
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Pneumonia Vaccination not Administered or Previously Received, Reason not
Specified
Append a reporting modifier (8P) to CPT Category II code 4040F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4040F with 8P: Pneumococcal vaccine was not administered or previously received,
reason not otherwise specified
DENOMINATOR:
All patients 65 years and older
Denominator Criteria (Eligible Cases):
Patients aged ≥ 65 years on date of encounter
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99218, 99219, 99220, 99324, 99325, 99326, 99327,
99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348,
99349, 99350, 99356, 99357
RATIONALE:
The elderly have a much higher mortality from community-acquired pneumonia due to increased
risk factors such as comorbidities, an increase in the number of medications taken and
weaknesses or disease of lung tissue. Pneumonia accounts for an estimated 20 percent of
nosocomial infections among the elderly, second only to urinary tract infections. The disease
burden is large for older adults and the potential for prevention is high. (Ely, E., 1997)
Drugs such as penicillin were once effective in treating these infections; but the disease has
become more resistant, making treatment of pneumococcal infections more difficult. This makes
prevention of the disease through vaccination even more important. (CDC. National Immunization
Program—Pneumococcal Disease, 2005)
CLINICAL RECOMMENDATION STATEMENTS:
The U.S. Preventive Services Task Force’s Guide to Clinical Preventive Services recommends
pneumococcal vaccine for all immunocompetent individuals who are 65 and older or otherwise at
increased risk for pneumococcal disease. Routine revaccination is not recommended, but may be
appropriate in immunocompetent individuals at high risk for morbidity and mortality from
pneumococcal disease (e.g., persons ≥ 75 years of age or with severe chronic disease) who were
vaccinated more than five years previously. Medicare Part B fully covers the cost of the vaccine
and its administration every five years. (United States Preventive Services Task Force, 1998)
Pneumococcal infection is a common cause of illness and death in the elderly and persons with
certain underlying conditions. In 1998, an estimated 3,400 adults aged ≥ 65 years died as a result
of invasive pneumococcal disease. Pneumococcal infection accounts for more deaths than any
other vaccine-preventable bacterial disease. (CDC, 2002; Pneumococcal Pneumonia, NIAID Fact
Sheet, December 2004.)
One of the Healthy People 2010 objectives is to increase pneumococcal immunization levels for
the non-institutionalized, high-risk populations to at least 90 percent (objective no. 14.29). While
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the percent of persons 65 years and older receiving the pneumococcal vaccine has increased, it
still remains considerably below the Health People 2010 objective. According to the National
Health Interview Survey (NHIS), which is used to track performance on year 2010 objectives, in
1998 only 46 percent of adults age 65 years and older report receiving the vaccine. The figure was
45 percent based on the 1997 Behavioral Risk Factor Surveillance System (BRFSS) survey.
(National Center for Health Statistics., 2005; CDC, 1997)
A particular strength of this measure is that it provides an opportunity to compare performance
against national, state and/or regional benchmarks, which are collected through nationally
organized and administered surveys.
At the physician practice level where a patient survey may not be feasible, data collection on
pneumonia vaccination status through chart abstraction is a viable option.
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Measure #112: Preventive Care and Screening: Screening Mammography
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of women aged 40 through 69 years who had a mammogram to screen for breast
cancer within 24 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for female patients seen
during the reporting period. There is no diagnosis associated with this measure. The patient should
either be screened for breast cancer on the date of service OR there should be documentation that
the patient was screened for breast cancer at least once within 24 months prior to the date of
service. Performance for this measure is not limited to the reporting period. This measure may be
reported by clinicians who perform the quality actions described in the measure based on services
provided and the measure-specific denominator coding.
Measure Reporting via Claims:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. CPT Category II codes are used to report the numerator of the measure.
When reporting the measure via claims, submit the listed CPT codes, and the appropriate CPT
Category II code OR the CPT Category II code with the modifier. The modifiers allowed for this
measure are: 1P- medical reasons, 8P- reason not otherwise specified. All measure-specific
coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. The numerator options as described in the quality-data codes are used to
report the numerator of the measure. The quality-data codes listed do not need to be submitted for
registry-based submissions however these codes may be submitted for those registries that utilize
claims data.
NUMERATOR:
Patients who had a mammogram at least once within 24 months
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Mammogram Performed
CPT II 3014F: Screening mammography results documented and reviewed
Mammogram not Performed for Medical Reasons
Append a modifier (1P) to CPT Category II code 3014F to report documented
circumstances that appropriately exclude patients from the denominator.
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3014F with 1P: Documentation of medical reason(s) for not performing a mammogram
(i.e., women who had a bilateral mastectomy or two unilateral
mastectomies).
OR
Mammogram not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3014F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3014F with 8P: Screening mammography results were not documented and reviewed,
reason not otherwise specified
DENOMINATOR:
All female patients aged 40 through 69 years
Denominator Criteria (Eligible Cases):
Patients aged 40 through 69 years on date of encounter
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Breast cancer ranks as the second leading cause of death in women. For women 40 to 49 years of
age mammography can reduce mortality by 17 percent. (AMA, 2003)
CLINICAL RECOMMENDATION STATEMENT:
The U.S. Preventive Services Task Force (USPSTF) recommends screening mammography, with
or without clinical breast examination (CBE), every 1-2 years for women aged 40 and older.
(USPSTF, 2002)
•
•
•
The USPSTF found fair evidence that mammography screening every 12-33 months
significantly reduces mortality from breast cancer. Evidence is strongest for women aged
50-69, the age group generally included in screening trials. (USPSTF, 2002)
For women aged 40-49, the evidence that screening mammography reduces mortality
from breast cancer is weaker, and the absolute benefit of mammography is smaller, than it
is for older women. Most, but not all, studies indicate a mortality benefit for women
undergoing mammography at ages 40-49, but the delay in observed benefit in women
younger than 50 makes it difficult to determine the incremental benefit of beginning
screening at age 40 rather than at age 50. (USPSTF, 2002)
The absolute benefit is smaller because the incidence of breast cancer is lower among
women in their 40s than it is among older women. (USPSTF, 2002)
The USPSTF concluded that the evidence is also generalizable to women aged 70 and older (who
face a higher absolute risk for breast cancer) if their life expectancy is not compromised by
comorbid disease. The absolute probability of benefits of regular mammography increases along a
continuum with age, whereas the likelihood of harms from screening (false-positive results and
unnecessary anxiety, biopsies, and cost) diminishes from ages 40-70. The balance of benefits and
potential harms, therefore, grows more favorable as women age. The precise age at which the
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potential benefits of mammography justify the possible harms is a subjective choice. (USPSTF,
2002)
American Cancer Society: Yearly Mammograms starting at age 40 and continuing for as long as a
woman is in good health. (Smith, 2003)
American College of Preventative Medicine (ACPM):
•
•
Low-risk women (no family history, familial cancer syndrome, or prior cancer). There is
inadequate evidence for or against mammography screening of women under the age of
50. Women between the ages of 50-69 should have annual or biennial, high-quality, twoview mammography. Women aged 70 and older should continue undergoing
mammography screening provided their health status permits breast cancer treatment.
(Ferrini, 1996)
Higher-risk women: Women with a family history of pre-menopausal breast cancer in a
first-degree relative or those with a history of breast and/or gynecologic cancer may
warrant more aggressive screening. Women with these histories often begin screening at
an earlier age, although there is no direct evidence of effectiveness to support this
practice. The future availability of genetic screening may define new recommendations for
screening high-risk women. (Ferrini, 1996)
The American Medical Association (AMA), the American College of Obstetricians and
Gynecologists (ACOG), and the American College of Radiology (ACR), all support screening with
mammography and CBE beginning at age 40. (AMA, 1999; ACOG, 2000; Feig, 1998)
The Canadian Task Force on Preventive Health Care (CTFPHC), and the American Academy of
Family Physicians (AAFP), recommends beginning mammography for average-risk women at age
50. (Canadian Task Force on the Periodic Health Examination, 1999; AAFP, 2005)
AAFP recommends that mammography in high-risk women begin at age 40, and recommends that
all women aged 40-49 be counseled about the risks and benefits of mammography before making
decisions about screening. (AAFP, 2005)
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Measure #113: Preventive Care and Screening: Colorectal Cancer Screening
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 50 through 75 years who received the appropriate colorectal cancer
screening
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. There is no diagnosis associated with this measure. Performance for this
measure is not limited to the reporting period. This measure may be reported by clinicians who
perform the quality actions described in the measure based on services provided and the measurespecific denominator coding.
Measure Reporting via Claims:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. CPT Category II codes are used to report the numerator of the measure.
When reporting the measure via claims, submit the listed CPT codes, and the appropriate CPT
Category II code OR the CPT Category II code with the modifier. The modifiers allowed for this
measure are: 1P- medical reasons, 8P- reason not otherwise specified. All measure-specific
coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. The numerator options as described in the quality-data codes are used to
report the numerator of the measure. The quality-data codes listed do not need to be submitted for
registry-based submissions however these codes may be submitted for those registries that utilize
claims data.
NUMERATOR:
Patients who had at least one or more screenings for colorectal cancer during or prior to the
reporting period
Numerator Instructions: Patients are considered to have appropriate screening for
colorectal cancer if any of the following are documented:
• Fecal occult blood test (FOBT) within the last 12 months
• Flexible sigmoidoscopy during the reporting period or the four years prior to the
reporting period
• Colonoscopy during the reporting period or the nine years prior to the reporting
period
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OR
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Colorectal Cancer Screening
CPT II 3017F: Colorectal cancer screening results documented and reviewed
Colorectal Cancer Screening not Performed for Medical Reasons
Append a modifier (1P) to CPT Category II code 3017F to report documented
circumstances that appropriately exclude patients from the denominator.
3017F with 1P: Documentation of medical reason(s) for not performing a colorectal cancer
screening
Colorectal Cancer Screening not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3017F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3017F with 8P: Colorectal cancer screening results were not documented and reviewed,
reason not otherwise specified
DENOMINATOR:
All patients aged 50 through 75 years
Denominator Criteria (Eligible Cases):
Patients aged 50 through 75 years on date of encounter
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310,
99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337
RATIONALE:
Colorectal cancer is the second leading cause of cancer-related death in the United States. There
were an estimated 135,400 new cases and 56,700 deaths from the disease during 2001.
Colorectal cancer (CRC) places significant economic burden on the society as well with treatment
costs over $6.5 billion per year and, among malignancies, is second only to breast cancer at $6.6
billion per year (Schrag, 1999).
Colorectal cancer screening can detect pre-malignant polyps and early stage cancers. Unlike other
screening tests that only detect disease, colorectal cancer screening can guide removal of premalignant polyps, which in theory can prevent development of colon cancer. Three tests are
currently recommended for screening: fecal occult blood testing (FOBT), flexible sigmoidoscopy,
and colonoscopy.
CLINICAL RECOMMENDATION STATEMENTS:
During the past decade, compelling evidence has accumulated that systematic screening of the
population can reduce mortality from colorectal cancer. Three randomized, controlled trials
demonstrated that fecal occult blood testing (FOBT), followed by complete diagnostic evaluation of
the colon for a positive test, reduced colorectal cancer mortality (Hardcastle et al., 1996; Mandel &
Oken, 1998; Kronborg; 1996). One of these randomized trials (Mandel et al., 1993) compared
annual FOBT screening to biennial FOBT screening, and found that annual screening resulted in
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greater reduction in colorectal cancer mortality. Two case control studies have provided evidence
that sigmoidoscopy reduces colorectal cancer mortality (Selby et al., 1992; Newcomb et al., 1992).
Approximately 75% of all colorectal cancers arise sporadically (Stephenson et al., 1991). Part of
the effectiveness of colorectal cancer screening is mediated by the removal of the precursor
lesion—an adenomatous polyp (Vogtelstein et al., 1988). It has been shown that removal of polyps
in a population can reduce the incidence of colorectal cancer (Winawer, 1993). Colorectal
screening may also lower mortality by allowing detection of cancer at earlier stages, when
treatment is more effective (Kavanaugh, 1998).
The U.S. Preventive Services Task Force (USPSTF) published an updated recommendation for
colorectal cancer screening in 2008. The guideline strongly recommends that clinicians screen
men and women ages 50 to 75 years of age for colorectal cancer (A recommendation). The
USPSTF recommends not screening adults age 85 and older due to possible harms
(D recommendation). The appropriateness of colorectal cancer screening for men and women
aged 76 to 85 years old should be considered on an individual basis (C recommendation). While
the approved modalities vary for patients 50 to 75 years old, the USPSTF found there is insufficient
evidence to assess the benefits and harms of computed tomographic colonography (CTC) and
fecal DNA (fDNA) testing as screening modalities for colorectal cancer for all patients (I statement).
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Measure #114: Preventive Care and Screening: Inquiry Regarding Tobacco Use
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years or older who were queried about tobacco use one or more
times within 24 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all patients seen during
the reporting period. The patient should either be queried about tobacco use on the date of service
OR there should be documentation that the patient was queried about tobacco use at least once
within the 24 months prior to the date of service. There is no diagnosis associated with this
measure. This measure may be reported by clinicians who perform the quality actions described in
the measure based on the services provided and the measure-specific denominator coding.
Measure Reporting via Claims:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. CPT Category II codes are used to report the numerator of the measure.
When reporting the measure via claims, submit the listed CPT service codes, and the appropriate
CPT Category II codes OR the CPT Category II code with the modifier. The reporting modifier
allowed for this measure is: 8P- reason not otherwise specified. There are no allowable
performance exclusions for this measure. All measure-specific coding should be reported ON THE
SAME CLAIM.
Measure Reporting via Registry:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. The numerator options as described in the quality-data codes are used to
report the numerator of the measure. The quality-data codes listed do not need to be submitted for
registry-based submissions however these codes may be submitted for those registries that utilize
claims data. There are no allowable performance exclusions for this measure.
NUMERATOR:
Patients who were queried about tobacco use one or more times within 24 months
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Tobacco Use Assessed
(Two CPT II codes [1000F & 103xF] are required on the claim form to submit this
numerator option)
CPT II 1000F: Tobacco use assessed
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AND
OR
CPT II 1034F: Current tobacco smoker
OR
CPT II 1035F: Current smokeless tobacco user (eg, chew, snuff)
OR
CPT II 1036F: Current tobacco non-user
Tobacco Use not Assessed, Reason not Specified
(One CPT II code [1000F-8P] is required on the claim form to submit this numerator
option)
Append a reporting modifier (8P) to CPT Category II code 1000F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
1000F with 8P: Tobacco use not assessed, reason not otherwise specified
DENOMINATOR:
All patients aged 18 years and older
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Patient encounter during the reporting period (CPT): 90801, 90802, 90804, 90805,
90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90845, 90862,
96150, 96152, 97003, 97004, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215
RATIONALE:
Tobacco use is one of the leading causes of many preventable diseases, however, not all
individuals are screened for tobacco use.
CLINICAL RECOMMENDATION STATEMENTS:
Periodic screening for tobacco use is recommended for all patients. (US Department of Health and
Human Services, USPSTF)
Tobacco cessation counseling is recommended for all patients who smoke. (USPSTF)
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Measure #115: Preventive Care and Screening: Advising Smokers and Tobacco Users to
Quit
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older and are smokers or tobacco users who received
advice to quit smoking
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all patients (whether or
not they use tobacco) seen during the reporting period. All patients identified as tobacco smokers
and/or smokeless tobacco users at any time during the reporting period should be advised to quit.
There is no diagnosis associated with this measure. This measure is appropriate for use in all
healthcare settings. This measure may be reported by clinicians who perform the quality actions
described in the measure based on the services provided and the measure-specific denominator
coding.
Measure Reporting via Claims:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. CPT Category II codes and/or G-codes are used to report the numerator
of the measure.
When reporting the measure via claims, submit the listed CPT codes, and the appropriate CPT
Category II code AND/OR G-code OR the CPT Category II code with the modifier AND G-code.
The reporting modifier allowed for this measure is: 8P- reasons not otherwise specified. All
measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. The numerator options as described in the quality-data codes are used to
report the numerator of the measure. The quality-data codes listed do not need to be submitted for
registry-based submissions however these codes may be submitted for those registries that utilize
claims data.
NUMERATOR:
Patients who received advice to quit smoking or smokeless tobacco use
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
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Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Advising Smoker or Smokeless Tobacco User to Quit
(One G-code and one CPT II code [G845x & 400xF] are required on the claim form to
submit this numerator option)
G8455: Current tobacco smoker
OR
G8456: Current smokeless tobacco user (eg, chew, snuff)
AND
OR
OR
CPT II 4000F: Tobacco use cessation intervention, counseling
OR
CPT II 4001F: Tobacco use cessation intervention, pharmacologic therapy
If patient is not eligible for this measure because patient is a non tobacco user,
report:
(One G-code [G8457] is required on the claim form to submit this numerator option)
Tobacco Non-User
G8457: Current tobacco non-user
Tobacco Smoker or Smokeless Tobacco User not Advised to Quit or Tobacco Use
not Assessed, Reason not Specified
(One CPT II code [4000F-8P] is required on the claim form to submit this numerator
option)
Append a reporting modifier (8P) to CPT Category II code 4000F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4000F with 8P: Tobacco use cessation intervention not counseled or tobacco use not
assessed, reason not otherwise specified
DENOMINATOR:
All patients aged 18 years and older
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Patient encounter during the reporting period (CPT): 90801, 90802, 90804, 90805,
90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90845, 90862,
96150, 96152, 97003, 97004, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215
RATIONALE:
Interventions to control smoking are strategically important because smoking is the leading
preventable cause of death in the United States, clinical interventions are known to be effective in
increasing cessation rates, and quitting smoking has been shown to improve health outcomes.
(Fiore, 2000)
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CLINICAL RECOMMENDATION STATEMENTS:
The Clinical Practice Guidelines: Treating tobacco use and dependence published by USDHHS
Public Health Service (Fiore, 2002) provide convincing empirical support for providing advice to
and assistance with quitting smoking for patients who smoke. Specifically, these guidelines
recommend:
1) repeated advice and support at all or most visits, and
2) delivery of cessation assistance and follow-up at all or most visits.
There have been more than 12 million premature deaths attributable to smoking since the first
published Surgeon General’s report on smoking and health in 1964. Smoking remains the leading
preventable cause of premature death in the United States.
Nearly every organ in the body is affected by smoking (USDHHS, 2004). Smoking causes many
diseases and reduces the health of smokers in general. The list of diseases caused by smoking
has been expanded to include abdominal aortic aneurysm, acute myeloid leukemia, cataract,
cervical cancer, kidney cancer, pancreatic cancer, pneumonia, periodontitis, and stomach cancer
(USDHHS, 2004).
In the US in 2003, 45.4 million adults (21.6 percent) were current smokers—24.1 percent of men
and 19.2 percent of women (CDC, 2005a). An estimated 70% of these smokers said they wanted
to quit (CDC, 2005a).
An estimated 45.9 million adults were former smokers in 2003, representing 50.3 percent of those
who had ever smoked (CDC, 2005a). For the second consecutive year, more adults had quit than
were still smoking. A large number of clinical trials have demonstrated the effectiveness of
counseling in increasing cessation rates, and the effectiveness of bupropion and NRT has been
demonstrated (Fiore, 2000). A meta-analysis of 7 studies found that physician advice to quit is
associated with a 30% increase in cessation rates (Fiore, 2000). Counseling and medication are
each associated with a doubling of cessation rates (Fiore, 2000).
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Measure #116: Antibiotic Treatment for Adults with Acute Bronchitis: Avoidance of
Inappropriate Use
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of adults aged 18 through 64 years with a diagnosis of acute bronchitis who were not
prescribed or dispensed an antibiotic prescription on or within 3 days of the initial date of service
INSTRUCTIONS:
This measure is to be reported at each visit for acute bronchitis during the reporting period. This
measure may be reported by clinicians who perform the quality actions described in the measure
based on the services provided and the measure-specific denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifier allowed for this measure is: 1P- medical reasons. All measure-specific coding should be
reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions however these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients who were not prescribed or dispensed antibiotics on or within 3 days of the initial date of
service
Numerator Instructions: For performance, the measure will be calculated as the number
of patients for whom antibiotics were neither prescribed nor dispensed on or within 3 days
of the initial date of service over the number of patients in the denominator (patients aged
18 through 64 years with acute bronchitis). A higher score indicates appropriate treatment
of patients with acute bronchitis (e.g., the proportion for whom antibiotics were not
prescribed or dispensed on or three days after the initial date of service).
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Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Table 1A: The antibiotics listed below are considered antibiotics for the purposes of this
measure.
DESCRIPTION
PRESCRIPTION
5-aminosalicylates
• sulfasalazine
Aminoglycosides
• amikacin
• kanamycin
• tobramycin
• gentamicin
• neomycin
Aminopenicillins
• amoxicillin
• ampicillin
Antipseudomonal
• piperacillin
• ticarcillin
penicillins
Beta-lactamase
• amoxicillin-clavulanate • piperacillin• ticarcillininhibitors
tazobactam
clavulanate
• ampicillin-sulbactam
First generation
• cefadroxil
• cephalexin
cephalosporins
• cefazolin
• cephradine
Fourth generation
• cefepime
cephalosporins
Ketolides
• telithromycin
Lincomycin
• clindamycin
• lincomycin
derivatives
Macrolides
• azithromycin
• erythromycin
• erythromycin
lactobionate
• clarithromycin
• erythromycin
ethylsuccinate
• erythromycin
stearate
Miscellaneous
• aztreonam
• daptomycin
• metronidazole
antibiotics
• chloramphenicol
• erythromycin• vancomycin
sulfisoxazole
• dalfopristinquinupristin
• linezolid
Sulfamethoxazole• sulfamethoxazoletrimethoprim DS
trimethoprim
Natural penicillins
• penicillin G
• penicillin G procaine • penicillin V
benzathine-procaine
potassium
• penicillin G sodium
• penicillin G potassium
Penicillinase
• dicloxacillin
• nafcillin
• oxacillin
resistant penicillins
Quinolones
• ciprofloxacin
• levofloxacin
• Norfloxacin
• gatifloxacin
• lomefloxacin
• ofloxacin
• gemifloxacin
• moxifloxacin
• sparfloxacin
Rifamycin
• rifampin
derivatives
Second generation • cefaclor
• cefoxitin
• cefuroxime
cephalosporin
• cefotetan
• cefprozil
• loracarbef
Sulfonamides
• sulfadiazine
• sulfisoxazole
• sulfamethoxazole-trimethoprim
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DESCRIPTION
Tetracyclines
Third generation
cephalosporins
Urinary antiinfectives
OR
OR
•
•
•
•
•
•
•
doxycycline
cefdinir
cefditoren
cefixime
fosfomycin
nitrofurantoin
nitrofurantoin
macrocrystals
PRESCRIPTION
• minocycline
• tetracycline
• cefotaxime
• ceftibuten
• cefpodoxime
• ceftizoxime
• ceftazidime
• ceftriaxone
• nitrofurantoin macrocrystals-monohydrate
• trimethoprim
Antibiotic not Prescribed or Dispensed
CPT II 4124F: Antibiotic neither prescribed nor dispensed
Antibiotic Prescribed or Dispensed for Medical Reasons
Append a modifier (1P) to CPT Category II code 4120F to report documented
circumstances that appropriately exclude patients from the denominator.
4120F with 1P: Documentation of medical reason(s) for prescribing or dispensing
antibiotic
Antibiotic Prescribed or Dispensed
CPT II 4120F: Antibiotic prescribed or dispensed
DENOMINATOR:
All patients aged 18 through 64 years with a diagnosis of acute bronchitis
Denominator Criteria (Eligible Cases):
Patients aged 18 through 64 years on date of encounter
AND
Diagnosis for acute bronchitis (line-item ICD-9-CM): 466.0
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220
RATIONALE:
Antibiotics are commonly misused and overused for a number of viral respiratory conditions where
antibiotic treatment is not clinically indicated. (Scott J.G., D. Cohen, B. Dicicco-Bloom, 2001) About
80 percent of antibiotics prescribed for acute respiratory infections in adults are unnecessary,
according to CDC prevention guidelines. In adults, antibiotics are most often (65–80 percent)
prescribed for acute bronchitis, despite its viral origin. The misuse and overuse of antibiotics
contributes to antibiotic drug resistance, which is of public health concern due to the diminished
efficacy of antibiotics against bacterial infections, particularly in sick patients and the elderly.
(Austin D.J., K.G. Kristinsson, R.M. Anderson, 1999, Patterson, JE, 2001, Cohen ML, 1992,
Lipsitch M, 2001)
A HEDIS measure that highlights inappropriate antibiotic prescribing in adults for a common
respiratory condition will help to raise awareness among clinicians and patients about inappropriate
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antibiotic use. Antibiotics are most often inappropriately prescribed in adults with acute bronchitis.
This measure builds on an existing HEDIS measure targeting inappropriate antibiotic prescribing
for children with upper respiratory infection (common cold), where antibiotics are also most often
inappropriately prescribed. (Chandran R., 2001, Gonzales R., J.F. Steiner, et al., 1999)
CLINICAL RECOMMENDATION STATEMENTS:
Clinical guidelines do not support antibiotic treatment of otherwise healthy adults with acute
bronchitis due to the viral origin of acute bronchitis. Patients with chronic bronchitis, COPD or other
chronic comorbidity may be treated with antibiotics and are therefore excluded from the measure
denominator. (Gonzales R., D.C. Malone, J.H. Maselli, et al, 2001)
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Measure #117: Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 through 75 years with a diagnosis of diabetes mellitus who had a
dilated eye exam
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with diabetes
mellitus seen during the reporting period. This measure may be reported by clinicians who perform
the quality actions described in the measure based on services provided and the measure-specific
denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, G-codes, and patient demographics are used to
identify patients who are included in the measure’s denominator. CPT Category II codes are used
to report the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
reporting modifier allowed for this measure is: 8P- reason not otherwise specified. There are no
allowable performance exclusions for this measure. All measure-specific coding should be reported
ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, G-codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. The numerator options as described in
the quality-data codes are used to report the numerator of the measure. The quality-data codes
listed do not need to be submitted for registry-based submissions however these codes may be
submitted for those registries that utilize claims data. There are no allowable performance
exclusions for this measure.
NUMERATOR:
Patients who had a dilated eye exam for diabetic retinal disease at least once within 12 months
Numerator Instructions: This measure includes patients with diabetes who had one of
the following: A retinal or dilated eye exam by an eye care professional (optometrist or
ophthalmologist) during the reporting period, or a negative retinal exam (no evidence of
retinopathy) by an eye care professional in the year prior to the reporting period. For
dilated eye exams performed 12 months prior to the reporting period, an automated result
must be available.
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Dilated Eye Exam Performed by an Eye Care Professional
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OR
CPT II 2022F: Dilated retinal eye exam with interpretation by an ophthalmologist or
optometrist documented and reviewed
OR
CPT II 2024F: Seven standard field stereoscopic photos with interpretation by an
ophthalmologist or optometrist documented and reviewed
OR
CPT II 2026F: Eye imaging validated to match diagnosis from seven standard field
stereoscopic photos results documented and reviewed
OR
CPT II 3072F: Low risk for retinopathy (no evidence of retinopathy in the prior year)
Dilated Eye Exam not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 2022F or 2024F or 2026F to
report circumstances when the action described in the numerator is not performed and the
reason is not otherwise specified.
2022F or 2024F or 2026F with 8P: Dilated eye exam was not performed, reason not
otherwise specified
DENOMINATOR:
All patients aged 18 through 75 years with a diagnosis of diabetes
Denominator Criteria (Eligible Cases):
Patients aged 18 through 75 years on date of encounter
AND
Diagnosis for diabetes (line-item ICD-9-CM): 250.00, 250.01, 250.02, 250.03, 250.10,
250.11, 250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33,
250.40, 250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62,
250.63, 250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91,
250.92, 250.93, 357.2, 362.01, 362.02, 362.03, 362.04, 362.05, 362.06, 362.07, 366.41,
648.00, 648.01, 648.02, 648.03, 648.04
AND
Patient encounter during the reporting period (CPT or HCPCS): 92002, 92004, 92012,
92014, 97802, 97803, 97804, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327,
99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348,
99349, 99350, G0270, G0271
RATIONALE:
Examination of the eyes is the first step in the treatment of any existing or developing conditions
related to retinopathy and the first step in the prevention of blindness.
CLINICAL RECOMMENDATION STATEMENTS:
AACE/ACE, ADA, and American Academy of Ophthalmology (AAO): Recommend that a dilated
eye examination be performed on patients with diabetes during an initial assessment and at least
annually thereafter. (AACE/ACE, 2002; ADA, 2004; AAO, 1998; Hammond, 1998)
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American Association of Clinical Endocrinologists and American College of Endocrinology
(AACE/ACE): Recommend that the annual eye examination be performed as part of a retinal
module. The module includes test of visual acuity (Snellen chart); funduscopic examination and
intraocular pressure (IOP) test. The AACE/ACE recommends that diabetic patients should be
under the care of an ophthalmologist experienced in the management of diabetic retinopathy.
AACE/ACE further believes that a dilated eye exam should only be done by an MD/DO.
(AACE/ACE, 2002)
American Diabetes Association (ADA): Patients with type 1 diabetes should have an initial dilated
and comprehensive eye examination by an ophthalmologist or optometrist within 3-5 years after
the onset of diabetes. In general evaluation for diabetic eye disease is not necessary before 10
years of age. However, some evidence suggests that the prepubertal duration of diabetes may be
important in the development of microvascular complications; therefore, clinical judgment should
be used when applying these recommendations to individual patients. (Level of Evidence: B)
Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination by
an ophthalmologist or optometrist shortly after diabetes diagnosis. (Level of Evidence: B)
Subsequent examinations for type 1 and type 2 diabetic patients should be repeated annually by
an ophthalmologist or optometrist who is knowledgeable and experienced in diagnosing the
presence of diabetic retinopathy and is aware of its management. Examination will be required
more frequently if retinopathy is progressing. This follow-up interval is recommended recognizing
that there are limited data addressing this issue. (Level of Evidence: B)
Seven standard field stereoscopic 30° fundus photography is an accepted method for examining
diabetic retinopathy. (ADA, 2004)
American Academy of Ophthalmology (AAO): Recommends that diabetic patients should be under
the care of an ophthalmologist experienced in the management of diabetic retinopathy.
Ophthalmologists with specialized knowledge and experience in managing the disease are best
able to detect and treat serious disease. Stereoscopic photographs offer an advantage over
nonstereoscopic photographs, and the traditional “seven stereo fields” provide the most complete
coverage. (AAO, 1998; Hammond, 1996)
American Geriatrics Society (AGS): Dilated eye examinations should be performed every two years
at a minimum, and more often if there are additional risk factors for diabetic eye disease or
evidence of age-related eye disease. (CHF/AGS, 2003)
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Measure #118: Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE)
Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Patients with CAD and
Diabetes and/or Left Ventricular Systolic Dysfunction (LVSD)
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of CAD who also have diabetes
mellitus and/or LVSD (LVEF < 40%) who were prescribed ACE inhibitor or ARB therapy
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all patients with CAD
seen during the reporting period. This measure may be reported by clinicians who perform the
quality actions described in the measure based on the services provided and the measure-specific
denominator coding.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The listed numerator options are used to report
the numerator of the measure. The quality-data codes have been provided for registry only
measures for use by registries that utilize claims data. It is not necessary to submit these codes for
registry-based submissions. Do not report this measure via claims.
There are two reporting criteria for this measure:
(1) Patients who are 18 years and older with a diagnosis of CAD
OR
(2) Patients who are 18 years and older with a diagnosis of CAD who are also diabetic
The eligible professional should submit data on one of the reporting criteria, depending on
the clinical findings. If the patient has CAD (without a diagnosis of Diabetes), use
Denominator Reporting Criteria 1. If the patient has CAD and Diabetes, use Denominator
Reporting Criteria 2. If the patient has both diabetes and LVSD, the eligible professional
may report quality data for Reporting Criteria 2 and this will count as appropriate reporting
for this patient.
REPORTING CRITERIA 1: All patients with CAD (without a diagnosis of diabetes)
NUMERATOR:
Patients who were prescribed ACE inhibitor or ARB therapy
Numerator Instructions: It is necessary to determine the LVEF for the patient, either
through quantitative or qualitative assessment. Examples of a quantitative or qualitative
assessment may include an echocardiogram: 1) that provides a numerical value of LVSD
or 2) that uses descriptive terms such as moderately or severely depressed left ventricular
function.
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Definition:
Prescribed – May include prescription given to the patient for ACE inhibitor or ARB
therapy at one or more visits in the 12 month period OR patient already taking ACE
inhibitor or ARB therapy as documented in current medication list.
OR
Numerator Options:
Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB)
therapy prescribed for patients with a left ventricular ejection fraction (LVEF) <40% or
documentation of moderately or severely depressed left ventricular systolic function
(G8468)
Clinician documented that patient with a left ventricular ejection fraction (LVEF) <40% or
documentation of moderately or severely depressed left ventricular systolic function was
not an eligible candidate for angiotensin converting enzyme (ACE) inhibitor or angiotensin
receptor blocker (ARB) therapy (G8469)
OR
OR
Patient with left ventricular ejection fraction (LVEF) ≥40% or documentation as normal or
mildly depressed left ventricular systolic function (G8470)
OR
Left ventricular ejection fraction (LVEF) was not performed or documented (G8471)
Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB)
therapy not prescribed for patients with a left ventricular ejection fraction (LVEF) <40% or
documentation of moderately or severely depressed left ventricular systolic function,
reason not specified (G8472)
DENOMINATOR (REPORTING CRITERIA 1):
All patients aged 18 years and older with a diagnosis of CAD who also have a diagnosis of LVSD
(LVEF < 40%)
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for CAD (ICD-9-CM): 410.00, 410.01, 410.02, 410.10, 410.11, 410.12, 410.20,
410.21, 410.22, 410.30, 410.31, 410.32, 410.40, 410.41, 410.42, 410.50, 410.51, 410.52,
410.60, 410.61, 410.62, 410.70, 410.71, 410.72, 410.80, 410.81, 410.82, 410.90, 410.91,
410.92, 411.0, 411.1, 411.81, 411.89, 412, 413.0, 413.1, 413.9, 414.00, 414.01, 414.02,
414.03, 414.04, 414.05, 414.06, 414.07, 414.8, 414.9, V45.81, V45.82
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310,
99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343,
99344, 99345, 99347, 99348, 99349, 99350
OR
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REPORTING CRITERIA 2: Patients with CAD and diabetes
NUMERATOR:
Patients who were prescribed ACE inhibitor or ARB therapy
OR
OR
Numerator Options:
Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB)
therapy prescribed (G8473)
Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB)
therapy not prescribed for reasons documented by the clinician (G8474)
Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB)
therapy not prescribed, reason not specified (G8475)
DENOMINATOR (REPORTING CRITERIA 2):
All patients aged 18 years and older with a diagnosis of CAD who also have a diagnosis of
diabetes
Note: If a patient has both diabetes and LVSD, reporting criteria #2 will count as
appropriate reporting for this patient.
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for CAD (ICD-9-CM): 410.00, 410.01, 410.02, 410.10, 410.11, 410.12, 410.20,
410.21, 410.22, 410.30, 410.31, 410.32, 410.40, 410.41, 410.42, 410.50, 410.51, 410.52,
410.60, 410.61, 410.62, 410.70, 410.71, 410.72, 410.80, 410.81, 410.82, 410.90, 410.91,
410.92, 411.0, 411.1, 411.81, 411.89, 412, 413.0, 413.1, 413.9, 414.00, 414.01, 414.02,
414.03, 414.04, 414.05, 414.06, 414.07, 414.8, 414.9, V45.81, V45.82
AND
Diagnosis for diabetes (ICD-9-CM): 250.00, 250.01, 250.02, 250.03, 250.10, 250.11,
250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.40,
250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62, 250.63,
250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91, 250.92,
250.93, 648.00, 648.01, 648.02, 648.03, 648.04
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310,
99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343,
99344, 99345, 99347, 99348, 99349, 99350
RATIONALE:
In the absence of contraindications, ACE inhibitors or ARBs are recommended for patients with
coronary artery disease; especially those with diabetes and /or left ventricular systolic dysfunction.
ACE inhibitors and ARBs have shown to decrease morbidity and mortality, including significant
reductions in the occurrence of myocardial infarction, stroke, and diabetic complications.
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CLINICAL RECOMMENDATION STATEMENTS:
ACE inhibitor use is recommended in all patients with CAD who also have diabetes and/or left
ventricular systolic dysfunction. (ACC/AHA)
ACE inhibitor use is also recommended in patients with CAD or other vascular disease.
(ACC/AHA)
In ST elevation myocardial infarction (STEMI) patients who tolerate ACE inhibitors, an angiotensin
receptor blocker (ARB) can be useful as an alternative to ACE inhibitors in the long-term
management of STEMI patients, provided there are either clinical or radiological signs of heart
failure or LVEF less than 0.40. (ACC/AHA)
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Measure #119: Diabetes Mellitus: Urine Screening for Microalbumin or Medical Attention
for Nephropathy in Diabetic Patients
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 through 75 years with diabetes mellitus who received urine protein
screening or medical attention for nephropathy during at least one office visit within 12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all patients with
diabetes mellitus seen during the reporting period. This measure may be reported by clinicians who
perform the quality actions described in the measure based on the services provided and the
measure-specific denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT code, G-codes, and patient demographics are used to
identify patients who are included in the measure’s denominator. CPT Category II codes are used
to report the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR G-code OR the CPT Category II code with the
modifier. The reporting modifier allowed for this measure is: 8P- reason not otherwise specified.
There are no allowable performance exclusions for this measure. All measure-specific coding
should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, G-codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. The numerator options as described in
the quality-data codes are used to report the numerator of the measure. The quality-data codes
listed do not need to be submitted for registry-based submissions however these codes may be
submitted for those registries that utilize claims data. There are no allowable performance
exclusions for this measure.
NUMERATOR:
Patients who have a nephropathy screening during at least one office visit within 12 months
Numerator Instructions: This measure is looking for a nephropathy screening test or
evidence of nephropathy.
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Nephropathy Screening Performed
CPT II 3060F: Positive microalbuminuria test result documented and reviewed
OR
CPT II 3061F: Negative microalbuminuria test result documented and reviewed
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OR
OR
CPT II 3062F: Positive macroalbuminuria test result documented and reviewed
OR
CPT II 3066F: Documentation of treatment for nephropathy (eg, patient receiving dialysis,
patient being treated for ESRD, CRF, ARF, or renal insufficiency, any visit to a
nephrologist)
OR
G8506: Patient receiving angiotensin converting enzyme (ACE) inhibitor or angiotensin
receptor blocker (ARB) therapy
Nephropathy Screening not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3060F or 3061F or 3062F to
report circumstances when the action described in the numerator is not performed and the
reason is not otherwise specified.
3060F or 3061F or 3062F with 8P: Nephropathy screening was not performed, reason not
otherwise specified
DENOMINATOR:
All patients aged 18 through 75 years with the diagnosis of diabetes
Denominator Criteria (Eligible Cases):
Patients aged 18 years through 75 years on date of encounter
AND
Diagnosis for diabetes (line-item ICD-9-CM): 250.00, 250.01, 250.02, 250.03, 250.10,
250.11, 250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33,
250.40, 250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62,
250.63, 250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91,
250.92, 250.93, 357.2, 362.01, 362.02, 362.03, 362.04, 362.05, 362.06, 362.07, 366.41,
648.00, 648.01, 648.02, 648.03, 648.04
AND
Patient encounter during the reporting period (CPT or HCPCS): 97802, 97803, 97804,
99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306,
99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336,
99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0270, G0271
RATIONALE:
Nephropathy is a frequent complication of renal disease for both type 1 and type 2 diabetes and
often ends in end-stage renal disease (ESRD) (ADA, 2002). Of all people with diabetes, 10-21%
have nephropathy (ADA 2002).
CLINICAL RECOMENNDATION STATEMENTS:
American Association of Clinical Endocrinologists and American College of Endocrinology
(AACE/ACE): Recommends that the initial assessment should include a urinalysis, test for
microalbuminuria and creatinine clearance. The renal complication module should be performed
annually and includes a test for microalbuminuria and creatinine clearance (AACE/ACE, 2002).
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American Diabetes Association (ADA): A test for the presence of microalbumin should be
performed at diagnosis in patients with type 2 diabetes. Microalbuminuria rarely occurs with short
duration of type 1 diabetes; therefore, screening in individuals with type 1 diabetes should begin
after 5 years' disease duration (Level of Evidence: E). However, some evidence suggests that the
prepubertal duration of diabetes may be important in the development of microvascular
complications; therefore, clinical judgment should be exercised when individualizing these
recommendations. Because of the difficulty in precise dating of the onset of type 2 diabetes, such
screening should begin at the time of diagnosis. After the initial screening and in the absence of
previously demonstrated microalbuminuria, a test for the presence of microalbumin should be
performed annually (ADA, 2004).
Screening for microalbuminuria can be performed by three methods:
1) measurement of the albumin-to-creatinine ratio in a random spot collection
2) 24-h collection with creatinine, allowing the simultaneous measurement of creatinine
clearance
3) timed (e. g. 4-h or overnight) collection – the analysis of a spot sample for the albuminto-creatinine ratio is strongly recommended.
The role of annual microalbuminuria assessment is less clear after diagnosis of microalbuminuria
and institution of angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker
(ARB) therapy and blood pressure control. Many experts recommend continued surveillance to
assess both response to therapy and progression of disease.
National Kidney Foundation (NKF): Individuals at increased risk, but found not to have chronic
kidney disease, should be advised to follow a program of risk factor reduction, if appropriate, and
undergo repeat periodic evaluation (NKF, 2003).
A comparative analysis of recommendations and evidence in diabetes guidelines from 13 countries
(including the American Diabetes Association and Canadian Medical Association) found there was
agreement among the guidelines that ACE inhibitors should be recommended to patients with
hypertension and renal disease (Burgers, 2002).
The ADA also recommends that for the treatment of both micro- and macroalbuminuria, ARBs
should be used except during pregnancy (ADA, 2005).
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Measure #121: Chronic Kidney Disease (CKD): Laboratory Testing (Calcium,
Phosphorus, Intact Parathyroid Hormone (iPTH) and Lipid Profile)
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of advanced CKD (stage 4 or 5,
not receiving Renal Replacement Therapy [RRT]), who had the following laboratory testing ordered
within 12 months: serum levels of calcium, phosphorus and intact PTH, and lipid profile
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with advanced
CKD seen during the reporting period. It is anticipated that clinicians providing care for patients
with advanced CKD will submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II codes OR the CPT Category II code(s) with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 8P- reason not
otherwise specified. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions however these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients who had the following laboratory testing ordered at least once during the 12 month
reporting period: serum levels of calcium, phosphorus and intact PTH, and lipid profile
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Serum Levels of Calcium, Phosphorus, Intact Parathyroid Hormone (iPTH) and Lipid
Profile Ordered
CPT II 3278F: Serum levels of calcium, phosphorus, intact Parathyroid Hormone (iPTH)
and lipid profile ordered
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OR
Serum Levels of Calcium, Phosphorus, Intact Parathyroid Hormone (iPTH) and Lipid
Profile not Ordered for Medical or Patient Reasons
Append a modifier (1P or 2P) to CPT Category II code 3278F to report documented
circumstances that appropriately exclude patients from the denominator.
3278F with 1P: Documentation of medical reason(s) for not ordering serum levels of
calcium, phosphorus, intact Parathyroid Hormone (iPTH) and lipid profile
3278F with 2P: Documentation of patient reason(s) for not ordering serum levels of
calcium, phosphorus, intact Parathyroid Hormone (iPTH) and lipid profile
Serum Levels of Calcium, Phosphorus, Intact Parathyroid Hormone (iPTH) and Lipid
Profile not Ordered, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3278F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3278F with 8P: Serum levels of calcium, phosphorus, intact Parathyroid Hormone (iPTH)
and lipid profile not ordered, reason not otherwise specified
DENOMINATOR:
All patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not
receiving RRT)
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for stage 4 or 5 CKD (line-item ICD-9-CM): 585.4, 585.5
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Bone disease is a common complication of chronic kidney disease. Patients with CKD should be
monitored for calcium and phosphate imbalances and secondary hyperparathyroidism.
Disturbances in mineral and bone metabolism are prevalent in CKD and are an important cause of
morbidity, decrease in quality of life, and extraskeletal calcification that has been associated with
increased CV mortality (taken verbatim from Definition, evaluation, and classification of renal
osteodystrophy: a position statement from the Kidney Disease: Improving Global Outcomes
(KDIGO), Moe, et al, Kidney Int, 2006; 69:1945-53). Gaps: USRDS 2006 data show that less than
30% of Medicare (and less than 20% of EGHP) pts receive Ca, Phos, PTH measures within a year.
Process/goal of care to be improved: identification of abnormalities mineral and bone metabolism
that relate to increased morbidity and mortality.
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CLINICAL RECOMMENDATION STATEMENTS:
Serum levels of calcium, phosphorus, and intact plasma parathyroid hormone (PTH) should be
measured in all patients with CKD and GFR < 60 ml/min/1.73m². (Evidence) (NKF 2003)
If a patient has GFR ≤ 30 ml/min/1.73m², then s/he should have his/her serum calcium and
phosphorus measured at least every three months, and iPTH levels measured at least once.
(Grade B) (RPA 2002)
Patients with CKD should be considered in the “highest-risk” group for CVD for implementing
recommendations for pharmacological therapy, irrespective of cause of CKD. (Grade A) (NKF
2004)
All adults and adolescents with CKD should be evaluated for dyslipidemias. (Grade B) (NKF 2003)
For adults and adolescents with CKD, the assessment of dyslipidemias should include a complete
fasting lipid profile with total cholesterol, LDL, HDL, and triglycerides. (Grade B) (NKF 2003)
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Measure #122: Chronic Kidney Disease (CKD): Blood Pressure Management
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patient visits for patients aged 18 years and older with a diagnosis of advanced CKD
(stage 4 or 5, not receiving Renal Replacement Therapy [RRT]), with a blood pressure < 130/80
mmHg OR blood pressure ≥ 130/80 mmHg with a documented plan of care
INSTRUCTIONS:
This measure is to be reported at each visit for patients with a diagnosis of advanced CKD seen
during the reporting period. It is anticipated that clinicians providing care for patients with advanced
CKD will submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. G-codes and/or CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate G-code AND/OR CPT Category II code OR the CPT Category II code with the
modifier AND G-code. The reporting modifier allowed for this measure is: 8P- reason not otherwise
specified. There are no allowable performance exclusions for this measure. All measure-specific
coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions however these codes may be submitted for
those registries that utilize claims data. There are no allowable performance exclusions for this
measure.
NUMERATOR:
Patients visits with blood pressure <130/80 mmHg OR ≥130/80 mmHg with a documented plan of
care
Numerator Instructions: If multiple blood pressure measurements are taken at a single
visit, use the most recent measurement taken at that visit.
Definition:
Documented Plan of Care – Should include one or more of the following: recheck blood
pressure at specified future date; initiate or alter pharmacologic therapy; initiate or alter
non-pharmacologic therapy; documented review of patient’s home blood pressure log
which indicates that patient’s blood pressure is or is not well controlled.
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NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Patient Visits with Blood Pressure < 130/80 mmHg
(One G-code [G8476] is required on the claim form to submit this numerator option)
G8476: Most recent blood pressure has a systolic measurement of <130 mmHg and a
diastolic measurement of <80 mmHg
OR
OR
Blood Pressure Plan of Care Documented for Patient Visits with Systolic Blood
Pressure ≥ 130 mmHg and/or Diastolic Blood Pressure ≥ 80 mmHg (If either systolic
blood pressure is ≥ 130 mmHg OR diastolic blood pressure is ≥ 80 mmHg, patient
requires a plan of care)
(One G-code & one CPT II code [G8477 & 0513F] are required on the claim form to submit
this numerator option)
G8477: Most recent blood pressure has a systolic measurement of ≥130 mmHg and/or a
diastolic measurement of ≥80 mmHg
AND
CPT II 0513F: Elevated blood pressure plan of care documented
Blood Pressure Measurement not Performed, Reason not Specified
(One G-code [G8478] is required on the claim form to submit this numerator option)
G8478: Blood pressure measurement not performed or documented, reason not specified
OR
Elevated Blood Pressure Plan of Care not Documented for Patient Visits with
Systolic Blood Pressure ≥ 130 mmHg and/or Diastolic Blood Pressure ≥ 80 mmHg,
Reason not Specified
(One CPT II code & one G-code [0513F-8P & G8477] are required on the claim form to
submit this numerator option)
Append a reporting modifier (8P) to CPT Category II code 0513F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
0513F with 8P: No documentation of elevated blood pressure plan of care, reason not
otherwise specified
AND
G8477: Most recent blood pressure has a systolic measurement of ≥ 130 mmHg and/or a
diastolic measurement of ≥ 80 mmHg
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DENOMINATOR:
All visits for patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5,
not receiving RRT)
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for stage 4 or 5 CKD (line-item ICD-9-CM): 585.4, 585.5
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Identification of hypertension in patients with CKD is an essential part of management of the
disease. Hypertension is common in patients with CKD, and if hypertension is left untreated, it will
speed the progression of the disease. Recent research has shown that during office visits,
approximately 20% to 30% of CKD patients do not have their blood pressure measured.
Additionally, if the CKD patient is has an anemia/ESA visit, they are even less likely to have their
blood pressure measured. In these patients, recent research has shown that 75% do not have their
blood pressure measured at an anemia/ESA visit. Patients with CKD should have their blood
pressure measured at each office visit so that changes can be identified and treatment initiated as
soon as it is necessary. Blood pressure control is important in slowing the progression of chronic
kidney disease. By slowing the progression of the disease, quality of life is improved for the patient,
and it results in a longer period of time before a patient requires renal replacement therapy.
Patients with chronic kidney disease should have a lower target blood pressure (< 130/80) than
other patients with hypertension.
CLINICAL RECOMMENDATION STATEMENTS:
Blood pressure should be measured at each health encounter. (Grade A) (NKF 2004)
If a patient has GFR ≤ 30 ml/min/1.73m2, then his/her blood pressure should be checked with
every clinic visit. (Grade A) (RPA 2002)
If a patient has a GFR ≤ 30 ml/min/1.73m², and if blood pressure is determined to be elevated
(systolic > 130 mmHg OR diastolic > 80 mmHg), then s/he should receive intensified
antihypertensive therapy (Grade B). (RPA, 2002)
Patients with CKD should be considered in the “highest-risk” group for CVD for implementing
recommendations for pharmacological therapy, irrespective of cause of CKD (Grade A). (NKF,
2004)
Target blood pressure for CVD risk reduction in CKD and diabetic/nondiabetic kidney disease
should be < 130/80 mmHg (Grade B). (NKF, 2004)
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Measure #123: Chronic Kidney Disease (CKD): Plan of Care – Elevated Hemoglobin for
Patients Receiving Erythropoiesis-Stimulating Agents (ESA)
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of calendar months during the 12-month reporting period in which patients aged 18
years and older with a diagnosis of advanced CKD (stage 4 or 5, not receiving Renal Replacement
Therapy [RRT]), receiving ESA therapy, have a hemoglobin < 13 g/dL OR patients whose
hemoglobin is ≥ 13 g/dL and have a documented plan of care
INSTRUCTIONS:
This measure is to be reported each calendar month patients are seen with a diagnosis of
advanced CKD (stage 4 or 5) during the reporting period. The most recent quality code submitted
will be used for performance calculation. It is anticipated that clinicians providing care for patients
with advanced CKD will submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II codes OR the CPT Category II code(s) with the modifier. The
reporting modifier allowed for this measure is: 8P- reason not otherwise specified. All measurespecific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions however these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Number of calendar months during which patients with a hemoglobin level of < 13 g/dL OR patients
whose hemoglobin level is ≥ 13 g/dL have a documented plan of care
Definition:
Documented Plan of Care – Should include reducing the ESA dose and repeating
hemoglobin at a specified future date.
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
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Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Hemoglobin level < 13 g/dL
(Two CPT II codes [328xF & 4171F] are required on the claim form to submit this
numerator option)
CPT II 3281F: Hemoglobin level less than 11 g/dL
OR
CPT II 3280F: Hemoglobin level 11 g/dL to 12.9 g/dL
AND
CPT II 4171F: Patient receiving Erythropoiesis-Stimulating Agents (ESA) therapy
OR
OR
OR
Hemoglobin level ≥ 13 g/dL with a Documented Plan of Care
(Three CPT II codes [3279F & 0514F & 4171F] are required on the claim form to submit
this numerator option)
CPT II 3279F: Hemoglobin level greater than or equal to 13 g/dL
AND
CPT II 0514F: Plan of care for elevated hemoglobin level documented for patient receiving
Erythropoiesis-Stimulating Agent (ESA) therapy
AND
CPT II 4171F: Patient receiving Erythropoiesis-Stimulating Agents (ESA) therapy
If patient is not eligible for this measure because, patient was not receiving
erythropoiesis-stimulating agent (ESA) therapy, report:
(One CPT II code [4172F] is required on the claim form to submit this numerator option)
CPT II 4172F: Patient not receiving Erythropoiesis-Stimulating Agents (ESA) therapy
Hemoglobin Level Measurement not Performed, Reason not Specified
(Two CPT II codes [3281F-8P & 4171F] are required on the claim form to submit this
numerator option)
Append a reporting modifier (8P) to CPT Category II code 3281F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3281F with 8P: Hemoglobin level measurement not documented, reason not otherwise
specified
AND
CPT II 4171F: Patient receiving Erythropoiesis-Stimulating Agents (ESA) therapy
OR
Plan of Care for Elevated Hemoglobin Level not Documented for Patient Receiving
Erythropoiesis-Stimulating Agent (ESA) Therapy, Reason not Specified
(Three CPT II codes [0514F-8P & 3279F & 4171F] are required on the claim form to
submit this numerator option)
Append a reporting modifier (8P) to CPT Category II code 0514F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
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0514F with 8P: Plan of care for elevated hemoglobin level not documented for patient
receiving Erythropoiesis-Stimulating Agent (ESA) therapy, reason not
otherwise specified
AND
CPT II 3279F: Hemoglobin level greater than or equal to 13 g/dL
AND
CPT II 4171F: Patient receiving Erythropoiesis-Stimulating Agents (ESA) therapy
DENOMINATOR:
Calendar months for all patients aged 18 years and older with the diagnosis of advanced CKD
(stage 4 or 5, not receiving RRT), receiving ESA therapy
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for stage 4 or 5 CKD (line-item ICD-9-CM): 585.4, 585.5
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
The clinical recommendation regarding Hb levels for CKD patients receiving ESA therapy is that
Hb level should generally be in the range of 11.0 to 12.0 g/dL. Additionally, these patients should
also have their Hb level checked at least monthly. Given that Hb levels vary for each patient due to
numerous factors, it is necessary to monitor Hb level closely in order to make the individualized
treatment decisions required in maintaining Hb level in the target range. There is no evidence of
benefit from ESA therapy when Hb levels are maintained at greater than 13.0 g/dL. Maintaining Hb
at higher levels may result in potential harm to the patient, as well as incur unjustified cost.
Evidence linking increased risks for patients with CKD and higher Hb levels were for target Hb
levels greater than 13.0g/dL. The intention of this measure is not to suggest that the goal of ESA
treatment is to reach an achieved Hb of 13.0 g/dL. Rather, as a patient safety measures, it is to
realize that patients who reach Hb levels higher than 13.0 g/dL are at increased risk for adverse
events, and that these elevated Hb levels need to be addressed by adjusting ESA dosage.
CLINICAL RECOMMENDATION STATEMENTS:
The frequency of HB monitoring in patients treated with ESAs should be at least monthly. (Opinion)
(NKF 2006)
The Hb target is the intended aim of ESA therapy for the individual patient with CKD. In clinical
practice, achieved Hb results vary considerably from Hb target.
• Selection of the Hb target and selection of the Hb level at which ESA therapy is initiated
in the individual patient should include consideration of potential benefits (including
improvement in the quality of life and avoidance of transfusion) and potential harms
(including the risk of life-threatening adverse events). (Clinical Practice
Recommendation) (NKF 2007)
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•
•
In dialysis and nondialysis patients with CKD receiving ESA therapy, the selected Hb
target should generally be in the range of 11.0 to 12.0 g/dL. (Clinical Practice
Recommendation) (NKF 2007)
In dialysis and nondialysis patients with CKD receiving ESA therapy, the Hb target
should not be greater than 13.0 g/dL. (Clinical Practice Guideline; Moderately Strong
Evidence) (NKF, 2007)
The initial ESA dose and the ESA dose adjustments should be determined by the patient’s Hb
level, the target Hb level, the observed rate of increase in Hb level, and clinical circumstances.
(Opinion) (NKF 2006)
ESA doses should be decreased, but not necessarily held, when a downward adjustment of Hb
level is needed. (Opinion) (NKF 2006)
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Measure #124: Health Information Technology (HIT): Adoption/Use of Electronic Health
Records (EHR)
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Documents whether provider has adopted and is using health information technology. To qualify,
the provider must have adopted and be using a certified/qualified EHR
INSTRUCTIONS:
This measure is to be reported at each visit occurring during the reporting period for patients seen
during the reporting period. There is no diagnosis associated with this measure. This measure may
be reported by clinicians who have adopted and are using certified/qualified health information
technology.
Measure Reporting via Claims:
CPT codes, HCPCS (D- or G-) codes are used to identify patients who are included in the
measure’s denominator. G-codes are used to report the numerator of the measure.
When reporting the measure via claims, submit the listed CPT codes, HCPCS codes, and the
appropriate numerator G-code. There are no allowable performance exclusions for this measure.
All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
CPT codes and HCPCS (D-or G-) codes are used to identify patients who are included in the
measure’s denominator. The numerator options as described in the quality-data codes are used to
report the numerator of the measure. The quality-data codes listed do not need to be submitted for
registry-based submissions however these codes may be submitted for those registries that utilize
claims data. There are no allowable performance exclusions for this measure.
NUMERATOR:
Patient encounter documentation substantiates use of certified/qualified EHR
Definitions:
Health Information Technology (HIT) – A system that incorporates both computer
hardware and software that deals with the storage, retrieval, sharing, and use of health
care information, data, and knowledge for communication and decision making.
Basic Privacy and Security Elements – Basic privacy and security elements include the
following:
• Ability to audit the date/time and user of each time patient chart printed
• Ability to archive and retrieve health record information
CCHIT – The Certification Commission for Healthcare Information Technology – an
independent, nonprofit organization that has been recognized by the federal government
as an official certification body for electronic health record products.
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Certified/Qualified Electronic Health Record – A certified/qualified EHR can be any of
the following:
• Certification Commission for Healthcare Information Technology (CCHIT) certified
EHR at the time of measurement
• If CCHIT certification is available (in primary care or a specialty) on or before
August 1, 2008, but the system in use is not CCHIT certified, the EHR must meet
the following criteria:
o Ability to manage a medication list
o Ability to manage a problem list
o Ability to manually enter or electronically receive, store and display
laboratory results as discrete searchable data elements
o Ability to meet basic privacy and security elements
AND
the EHR (above) must be CCHIT certified on or before August 1, 2011, or
another CCHIT certified product must be in use for compliance after
August 1, 2011
• If CCHIT certification is not available for a specialty on August 1, 2008, the EHR
must have the following capabilities to be qualified:
o Ability to manage a medication list
o Ability to manage a problem list
o Ability to manually enter or electronically receive, store and display
laboratory results as discrete searchable data elements
o Ability to meet basic privacy and security elements
Note: For providers having CCHIT certified EHR products available (according to
specialty) on or before August 1, 2008, an extended time parameter has been placed in
this measure of August 1, 2011 in order to allow for a period of time for providers to
transition to a CCHIT certified product if necessary. After August 1, 2011, these providers
will no longer meet the performance requirement of the measure without a CCHIT certified
EHR in use.
Manage a Medication List – Create, maintain and display a patient specific medication
list
Manage a Problem List – Create, maintain and display a patient specific problem list
Discrete Searchable Data Elements – Laboratory data that can be recorded in
predefined fields in predefined formats within the EHR that allow for reports to be
generated, such as trends of a specific element over time. This cannot be easily done if
data is entered via a free text format or by merely scanning a report into the EHR.
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Encounter Documented Using Certified/Qualified EHR
G8447: Patient encounter was documented using a CCHIT certified EHR
OR
G8448: Patient encounter was documented using a qualified (non-CCHIT certified) EHR
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DENOMINATOR:
All patient encounters
Denominator Criteria (Eligible Cases):
Patient encounter during the reporting period (CPT or HCPCS): 90801, 90802, 90804,
90805, 90806, 90807, 90808, 90809, 92002, 92004, 92012, 92014, 92541, 92542, 92543,
92544 92548, 92552, 92553, 92555, 92557, 92561, 92562, 92563, 92564, 92565, 92567,
92568, 92570, 92571, 92572, 92575, 92576, 92577, 92579, 92582, 92584, 92585, 92586,
92587, 92588, 92601, 92602, 92603, 92604, 92620, 92621, 92625, 92626, 92627, 92640,
95920, 96150, 96151, 96152, 97001, 97002, 97003, 97004, 97750, 97802, 97803, 97804,
98940, 98941, 98942, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214,
99215, D7140, D7210, G0101, G0108, G0109, G0270, G0271
RATIONALE:
The need for clinical information systems to provide high-quality, safe care is a well recognized
fact. This need was well publicized by Dr. Ed Wagner in his “Chronic Care Model” as one of the
key elements to provide high-quality care. To quote from the Improving Chronic Care Web site,
“Effective chronic illness care is virtually impossible without information systems that assure ready
access to key data on individual patients as well as populations of patients. A comprehensive
clinical information system can enhance the care of individual patients by providing timely
reminders about needed services and summarized data to track and plan care. At the practice
population level, they identify groups of patients needing additional care, as well as facilitate
performance monitoring and quality improvement efforts.” To be able to take advantage of many of
the more advanced applications of health information technology, the facility must first implement
an EMR and use it to document patient encounters.
Although some health plans and provider incentive programs do reward facilities for EMR adoption,
our analysis did not reveal any established consensus-endorsed measure that measures adoption
of technology and defines it in the way described above.
While it is preferable to encourage adoption of CCHIT certified EMRs, it became apparent during
measure field testing that CCHIT certified EMRs are not currently available for all provider settings
and specialty groups that may report this measure. Therefore, additional numerator coding was
added to enable providers who have adopted a non-CCHIT certified product, which meets a set of
standards, to also report this measure. The following is an excerpt taken from the CCHIT website:
“The 2006 Ambulatory EHR Criteria represent basic requirements that the Commission and its
Workgroups believe are appropriate for many common ambulatory care settings. CCHIT
acknowledges that these Criteria may not be suitable for settings such as behavioral health,
emergency departments, or specialty practices and our current certification makes no
representation for these. Purchasers should not interpret a lack of CCHIT Certification as being of
significance for specialties and domains not yet addressed by CCHIT Criteria.”
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Measure #126: Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy –
Neurological Evaluation
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a
neurological examination of their lower extremities within 12 months
INSTRUCTIONS:
This measure is to reported a minimum of once per reporting period for patients with diabetes
mellitus seen during the reporting period. Evaluation of neurological status in patients with diabetes
to assign risk category and therefore have appropriate foot and ankle care to prevent ulcerations
and infections ultimately reduces the number and severity of amputations that occur. Risk
catagorization and follow up treatment plan should be done according to the following table:
Risk Categorization System:
Category
0
1
2
3
Risk Profile
Normal
Peripheral Neuropathy (LOPS)
Neuropathy, deformity, and/or PAD
Previous ulcer or amputation
Evaluation Frequency
Annual
Semi-annual
Quarterly
Monthly to quarterly
This measure may be reported by non-MD/DO clinicians who perform the quality actions described
in the measure based on the services provided and the measure-specific denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. G-codes are used to report the numerator
of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate numerator G-code. All measure-specific coding should be reported ON THE
SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions however these codes may be submitted for
those registries that utilize claims data.
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NUMERATOR:
Patients who had a lower extremity neurological exam performed at least once within 12 months
Definition:
Lower Extremity Neurological Exam – Consists of a documented evaluation of motor
and sensory abilities and may include: reflexes, vibratory, proprioception, sharp/dull and
5.07 filament detection. The components listed are consistent with the neurological
assessment recommended by the Task Force of the Foot Care Interest Group of the
American Diabetes Association. They generally recommend at least two of the listed tests
be performed when evaluating for loss of protective sensation; however the clinician
should perform all necessary tests to make the proper evaluation.
OR
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Lower Extremity Neurological Exam Performed
G8404: Lower extremity neurological exam performed and documented
Lower Extremity Neurological Exam not Performed for Documented Reasons
G8406: Clinician documented that patient was not an eligible candidate for lower extremity
neurological exam measure
Lower Extremity Neurological Exam not Performed
G8405: Lower extremity neurological exam not performed
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of diabetes mellitus
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for diabetes (line-item ICD-9-CM): 250.00, 250.01, 250.02, 250.03, 250.10,
250.11, 250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33,
250.40, 250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62,
250.63, 250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91,
250.92, 250.93
AND
Patient encounter during the reporting period (CPT): 11040, 11041, 11042, 11043,
11044, 11055, 11056, 11057, 11719, 11720, 11721, 11730, 11740, 97001, 97002, 97802,
97803, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305,
99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335,
99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350
RATIONALE:
Foot ulceration is the most common single precursor to lower extremity amputations among
persons with diabetes. Treatment of infected foot wounds accounts for up to one-quarter of all
inpatient hospital admissions for people with diabetes in the United States. Peripheral sensory
neuropathy in the absence of perceived trauma is the primary factor leading to diabetic foot
ulcerations. Approximately 45-60% of all diabetic ulcerations are purely neuropathic. Other forms of
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neuropathy may also play a role in foot ulcerations. Motor neuropathy resulting in anterior crural
muscle atrophy or intrinsic muscle wasting can lead to foot deformities such as foot drop, equinus,
and hammertoes. In people with diabetes, 22.8% have foot problems – such as amputations and
numbness – compared with 10% of nondiabetics. Over the age of 40 years old, 30% of people with
diabetes have loss of sensation in their feet.
CLINICAL RECOMMENDATION STATEMENTS:
Recognizing important risk factors and making a logical, treatment-oriented assessment of the
diabetic foot requires a consistent and thorough diagnostic approach using a common language.
Without such a method, the practitioner is more likely to overlook vital information and to pay
inordinate attention to less critical points in the evaluation. A useful examination will involve
identification of key risk factors and assignment into appropriate risk category. Only then can an
effective treatment plan be designed and implemented. (ACFAS/ACFAOM Clinical Practice
Guidelines)
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Measure #127: Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention –
Evaluation of Footwear
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were
evaluated for proper footwear and sizing
INSTRUCTIONS:
This measure is to reported a minimum of once per reporting period for patients with diabetes
mellitus seen during the reporting period. This measure may be reported by non-MD/DO clinicians
who perform the quality actions described in the measure based on the services provided and the
measure-specific denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. G-codes are used to report the numerator
of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate numerator G-code. All measure-specific coding should be reported ON THE
SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions however these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients who were evaluated for proper footwear and sizing at least once within 12 months
Definition:
Evaluation for Proper Footwear – Includes a foot examination documenting the vascular,
neurological, dermatological, and structural/biomechanical findings. The foot should be
measured using a standard measuring device and counseling on appropriate footwear
should be based on risk categorization.
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Footwear Evaluation Performed
G8410: Footwear evaluation performed and documented
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OR
Footwear Evaluation not Performed for Documented Reasons
G8416: Clinician documented that patient was not an eligible candidate for footwear
evaluation measure
Footwear Evaluation not Performed
G8415: Footwear evaluation was not performed
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of diabetes mellitus
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for diabetes (line-item ICD-9-CM): 250.00, 250.01, 250.02, 250.03, 250.10,
250.11, 250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33,
250.40, 250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62,
250.63, 250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91,
250.92, 250.93
AND
Patient encounter during the reporting period (CPT): 11040, 11041, 11042, 11043,
11044, 11055, 11056, 11057, 11719, 11720, 11721, 11730, 11740, 97001, 97002, 97802,
97803, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305,
99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335,
99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350
RATIONALE:
Foot ulceration is the most common single precursor to lower extremity amputations among
persons with diabetes. Shoe trauma, in concert with loss of protective sensation and concomitant
foot deformity, is the leading event precipitating foot ulceration in persons with diabetes. Treatment
of infected foot wounds accounts for up to one-quarter of all inpatient hospital admissions for
people with diabetes in the United States. Peripheral sensory neuropathy in the absence of
perceived trauma is the primary factor leading to diabetic foot ulcerations. Approximately 45-60%
of all diabetic ulcerations are purely neuropathic. In people with diabetes, 22.8% have foot
problems – such as amputations and numbness – compared with 10% of nondiabetics. Over the
age of 40 years old, 30% of people with diabetes have loss of sensation in their feet.
CLINICAL RECOMMENDATION STATEMENTS:
The multifactorial etiology of diabetic foot ulcers is evidenced by the numerous pathophysiologic
pathways that can potentially lead to this disorder. Among these are two common mechanisms by
which foot deformity and neuropathy may induce skin breakdown in persons with diabetes. The
first mechanism of injury refers to prolonged low pressure over a bony prominence (i.e., bunion or
hammertoe deformity). This generally causes wounds over the medial, lateral, and dorsal aspects
of the forefoot and is associated with tight or ill-fitting shoes. (ACFAS/ACFAOM Clinical Practice
Guidelines)
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Measure #128: Preventive Care and Screening: Body Mass Index (BMI) Screening and
Follow-Up
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a calculated BMI in the past six months or
during the current visit documented in the medical record AND if the most recent BMI is outside
parameters, a follow-up plan is documented
Parameters: Age 65 and older BMI ≥30 or <22
Age 18 – 64 BMI ≥25 or <18.5
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. The most recent quality code submitted will be used for performance calculation.
There is no diagnosis associated with this measure. This measure may be reported by clinicians
who perform the quality actions described in the measure based on the services provided and the
measure-specific denominator coding. BMI measured and documented in the medical record may
be reported if done in the provider’s office/facility or if BMI calculation within the past six months is
documented in outside medical records obtained by the provider. For justification of BMI
parameters for this measure please refer to the rationale and clinical recommendation statements.
The documentation of a follow up plan should be based on the most recently calculated BMI.
Measure Reporting via Claims:
CPT codes, HCPCS (D- and G-) codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. G-codes are used to report the numerator of the
measure.
When reporting the measure via claims, submit the listed CPT codes, HCPCS codes, and the
appropriate numerator G-code. All measure-specific coding should be reported ON THE SAME
CLAIM.
Measure Reporting via Registry:
CPT codes, HCPCS (D- and G-) codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions however these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients with BMI calculated within the past six months or during the current visit and a follow-up
plan documented if the BMI is outside of parameters
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Definitions:
BMI – Body Mass Index (BMI) is a number calculated from a person’s weight and height.
BMI provides a reliable indicator of body fatness for most people and is used to screen for
weight categories that may lead to health problems. BMI is calculated by dividing a
person’s weight (in kilograms) by his/her height (in meters, squared). BMI can also be
calculated by multiplying weight (in pounds) by 705, then dividing by height (in inches)
twice. A simpler method to calculate the BMI involves the use of a chart. The weight is
plotted on one axis and the height is plotted on the other axis. The BMI can then be read
where the two points intersect. Example BMI charts are widely available via the internet.
Calculated BMI – Requires that both the height and weight are actually measured. Values
merely reported by the patient cannot be used.
Follow-up Plan – Proposed outline of treatment to be conducted as a result of abnormal
BMI measurement. Such follow-up can include documentation of a future appointment,
education, referral, prescription/administration of medications/dietary supplements, etc.
Terminal Illness – Life expectancy is 6 months or less
Not Eligible/Not Appropriate for BMI Measurement – Patients can be considered not
eligible in the following situations:
• There is documentation in the medical record that the patient is over or under
weight and is being managed by another provider
• If the patient has a terminal illness
• If the patient refuses BMI measurement
• If there is any other reason documented in the medical record by the provider
explaining why BMI measurement was not appropriate
• Patient is in an urgent or emergent medical situation where time is of the essence
and to delay treatment would jeopardize the patient’s health status
OR
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
BMI Calculated, No Follow-up Plan Needed or BMI Calculated, Follow-up Plan
Documented
G8420: Calculated BMI within normal parameters and documented
OR
G8417: Calculated BMI above the upper parameter and a follow-up plan was documented
in the medical record
OR
G8418: Calculated BMI below the lower parameter and a follow-up plan was documented
in the medical record
Patient not Eligible for BMI Calculation for Documented Reasons
G8422: Patient not eligible for BMI calculation
BMI not Performed and/or Calculated BMI Outside of Normal Parameters, Follow-up
Plan not Documented, Reason not Specified
G8421: BMI not calculated
OR
G8419: Calculated BMI outside normal parameters, no follow-up plan documented in the
medical record
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DENOMINATOR:
All patients aged 18 years and older
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Patient encounter during the reporting period (CPT or HCPCS): 90801, 90802, 90804,
90805, 90806, 90807, 90808, 90809, 97001, 97003, 97802, 97803, 98960, 99201, 99202,
99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99324, 99325, 99326, 99327,
99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348,
99349, 99350, D7140, D7210, G0101, G0108, G0270
RATIONALE:
Of the Medicare population, 37 percent are overweight, and 18 percent are obese. Between 1991
and 1998, the prevalence of obesity among persons age 60-69 increased by 45 percent (American
Obesity Association).
The economic impact of obesity and its related conditions in the U.S. economy is staggering and
has been estimated at about $117 billion according to the Midcourse Review of Healthy People
2010.
A recent study predicts that by 2020 there will be an 18 percent to 22 percent increase in the
prevalence of Americans between the ages of 50 and 69 who have difficulty bathing, dressing or
walking across a room if the current rate of weight increase for this age group continues. According
to a 1998 survey, only 52 percent of adults age 50 or older reported being asked during routine
medical check-ups about physical activity or exercise. The likelihood of being asked about exercise
during a routine check-up declined with age (Center for the Advancement of Health, 2004).
Elderly patients with unintentional weight loss are at higher risk for infection, depression and death.
The leading causes of involuntary weight loss are depression (especially in residents of long-term
care facilities), cancer (lung and gastrointestinal malignancies), cardiac disorders and benign
gastrointestinal diseases. Medications that may cause nausea and vomiting, dysphagia, dysgeusia
and anorexia have been implicated. Polypharmacy can cause unintended weight loss, as can
psychotropic medication reduction (e.g., by unmasking problems such as anxiety). In one study it
was found that a BMI of less than 22 kg per m2 in women and less than 23.5 in men is associated
with increased mortality. In another study it was found that the optimal BMI in the elderly is 24 to 29
kg per m2. (Huffman, G. B., Evaluation and Treatment of Unintentional Weight Loss in the Elderly,
American Family Physician, 2002 Feb, 4:640-650.)
A tremendous gap still exists between our knowledge of malnutrition and its sequelae and our
actions in preventing and treating it. To date professionals in various disciplines have applied their
own approaches to solving the problem. Yet the causes of malnutrition are multi-factorial and the
solutions demand an integration of knowledge and expertise from the many different disciplines
involved in geriatric care. Older people have special nutritional needs due to age and disease
processes. Professionals of all disciplines need to help older individuals improve their oral health,
mental health, medication use, food choices, economic situation, functional status and medical
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condition and thereby improve both nutritional status and quality of life (American Dietetic
Association, Nutrition Screening Initiative, 2002).
A Web search of the National Quality Measures Clearinghouse on the key words of BMI, body
mass index, produced three measures, all focused on possible follow-up for overweight and
obesity for a broader age range. There were no measures that focused on underweight or a followup plan.
CLINICAL RECOMMENDATION STATEMENTS:
The USPSTF recommends that clinicians screen all adult patients for obesity and offer intensive
counseling and behavioral interventions to promote sustained weight loss for obese adults. (Level
of Evidence = B, USPSTF)
The clinical guideline for obesity recommends assessment of BMI at each encounter (National
Heart, Lung and Blood Institute).
Validated measure of nutrition status serves as an indicator of over-nourishment and undernourishment. Nutrition Screening Initiative: “Nutrition Interventions Manual for Professionals Caring
for Older Americans,” 2002 (Co-sponsored by American Dietetic Association (ADA), AAFP and
National Council on Aging, Inc.).
The NSI-suggested BMI range is 22-27 (values outside this range indicate overweight or
underweight for elderly) Nutrition Screening Initiative: “Nutrition Interventions Manual for
Professionals Caring for Older Americans,” 2002 (Co-sponsored by American Dietetic Association
(ADA), AAFP and National Council on Aging, Inc.).
Interventions can be grouped into six primary categories: Social Services, Oral Health, Mental
Health, Medication Use, Nutritional Education and Counseling, and Nutritional Support. For further
detail on any of the potential interventional strategies, see the Nutritional Interventions Manual for
Professionals Caring for Older Americans, 2002. Nutrition Screening Initiative: “Nutrition
Interventions Manual for Professionals Caring for Older Americans,” 2002 (Co-sponsored by
American Dietetic Association (ADA), AAFP and National Council on Aging, Inc.).
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Measure #130: Documentation and Verification of Current Medications in the Medical
Record
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a list of current medications with dosages
(includes prescription, over-the-counter, herbals, vitamin/mineral/dietary [nutritional] supplements)
and verification with the patient or authorized representative is documented by the provider
INSTRUCTIONS:
This measure is to be reported at each visit occurring during the reporting period for patients seen
during the reporting period. There is no diagnosis associated with this measure. This measure may
be reported by non-MD/DO clinicians who perform the quality actions described in the measure
based on the services provided and the measure-specific denominator coding.
Measure Reporting via Claims:
CPT codes, G-codes, and patient demographics are used to identify patients who are included in
the measure’s denominator. G-codes are used to report the numerator of the measure.
When reporting the measure via claims, submit the CPT codes, HCPCS codes, and the
appropriate numerator G-code. All measure-specific coding should be reported ON THE SAME
CLAIM.
Measure Reporting via Registry:
CPT codes, G-codes, and patient demographics are used to identify patients who are included in
the measure’s denominator. The numerator options as described in the quality-data codes are
used to report the numerator of the measure. The quality-data codes listed do not need to be
submitted for registry-based submissions however these codes may be submitted for those
registries that utilize claims data.
NUMERATOR:
Current medications with dosages and verification with patient or authorized representative is
documented by the provider
Definitions:
Authorized Representative – A person who is acting on the patient’s behalf and who
does not have a conflict of interest with the patient, when the patient is temporarily or
permanently unable to act for him or herself. This person should have the patient’s best
interests at heart and should be reasonably expected to act in a manner that is protective
of the person and the rights of the patient. Preferably, the patient appoints this individual.
Current Medications – All medications (includes prescription, over-the-counter, herbals,
vitamin/mineral/dietary [nutritional] supplements) a patient may be taking routinely and/or
on a PRN basis
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Verification – Documentation of acknowledgment by the patient and/or authorized
representative or provider that signifies discussion, assessment, or review to confirm
accuracy of information.
Not Eligible – A patient is not eligible if one or more of the following condition(s) exist:
• Patient refuses to participate
• Patient is in an urgent or emergent medical situation where time is of the essence
and to delay treatment would jeopardize the patient’s health status
• Patient cognitively impaired and no authorized representative available
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Current Medications with Dosages AND Verification Documented
G8427: List of current medications with dosages (includes prescription, over-the-counter,
herbals, vitamin/mineral/dietary [nutritional] supplements) and verification with the patient
or authorized representative documented by the provider
Current Medications with Dosages not Documented, Patient not Eligible
G8430: Provider documentation that patient is not eligible for medication assessment
OR
OR
Current Medications with Dosages Documented, Patient Verification not
Documented, Patient not Eligible
G8507: Provider documentation that patient is not eligible for patient verification of current
medications
Current Medications with Dosages Documented, Patient Verification not
Documented, Reason not Specified
G8428: Provider documentation of current medications with dosages (includes
prescription, over-the-counter, herbals, vitamin/mineral/dietary [nutritional] supplements)
without documented patient verification
OR
Current Medications with Dosages not Documented, Reason not Specified
G8429: Incomplete or no provider documentation that the patient’s current medications
with dosages (includes prescription, over-the-counter, herbals, vitamin/mineral/dietary
[nutritional] supplements) were assessed
DENOMINATOR:
All patients aged 18 years and older
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Patient encounter during the reporting period (CPT or HCPCS): 90801, 90802, 92002,
92004, 92012, 92014, 92541, 92542, 92543, 92544, 92545, 92547, 92548, 92557, 92567,
92568, 92570, 92585, 92588, 92626, 96116, 96150, 96152, 97001, 97002, 97003, 97004,
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97802, 97803, 98960, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214,
99215, G0101, G0108, G0270
RATIONALE:
Adverse drug events (ADEs) are one of the leading causes of hospitalizations and deaths in the
U.S. Specifically, data suggests that ADEs are an important problem among outpatients, with 13%
of events occurring in patients with a prior or documented allergy/reaction to the reactive drug.
Using a medication list in the office setting promotes patient safety and reduces medical errors,
both by improving documentation in general and, specifically, by improving communication
between patients and providers.
The need for this measure is important because no similar measure has been identified through
review of literature, the AHRQ National Quality Measures Clearinghouse, and relevant specialty
society web sites.
CLINICAL RECOMMENDATION STATEMENTS:
In addition, as part of its efforts to promote patient safety and reduce the growing incidence of
medical errors in the office setting, the Institute for Healthcare Improvement created a
recommended medication list for patients and their families to carry with them to medical
appointments to help providers reconcile medications during medical visits. [Institute for Healthcare
Improvement. Medication List For Patients and Families. Massachusetts Coalition for the
Prevention of Medical Error (in collaboration with the Massachusetts Medical Society)]
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Measure #131: Pain Assessment Prior to Initiation of Patient Therapy and Follow-Up
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with documentation of a pain assessment (if pain
is present, including location, intensity and description) through discussion with the patient
including the use of a standardized tool on each qualifying visit prior to initiation of therapy AND
documentation of a follow-up plan
INSTRUCTIONS:
This measure is to be reported for each qualifying visit occurring during the reporting period for
patients seen during the reporting period. There is no diagnosis associated with this measure. This
measure may be reported by non-MD/DO clinicians who perform the quality actions described in
the measure based on the services provided and the measure-specific denominator coding.
Measure Reporting via Claims:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. G-codes are used to report the numerator of the measure.
When reporting the measure via claims, submit the listed CPT codes, and the appropriate
numerator G-code. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. The numerator options as described in the quality-data codes are used to
report the numerator of the measure. The quality-data codes listed do not need to be submitted for
registry-based submissions however these codes may be submitted for those registries that utilize
claims data.
NUMERATOR:
Patient’s pain assessment prior to initiation of treatment is documented through discussion with the
patient including the use of a standardized tool AND a follow-up plan is documented
Definitions:
Qualifying Visit – Meets denominator criteria (age and CPT encounter codes) as listed
below.
Standardized Tool – An assessment tool that has been appropriately normalized and
validated for the population in which it is used. Examples of tools for pain assessment
include, but are not limited to, Multidimensional Pain Score and McGill Pain Questionnaire.
Follow-up Plan – Proposed outline of treatment to be conducted as a result of pain
assessment. Such follow-up must include a reassessment of pain and may include
documentation of a future appointment, education, referral, notification or primary care
provider, etc.
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Not Eligible – A patient is not eligible if the following condition(s) exist:
Pain Assessment
• Patient refuses to participate
• Severe mental and/or physical incapacity where the person is unable to express
himself/herself in a manner understood by others. For example, cases where pain
cannot be accurately assessed through use of nationally recognized standardized
pain assessment tools
• 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
•
•
OR
Follow-Up Plan
Absence of pain on assessment
Diagnosis/condition/illness if not situationally related to pain
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Pain Assessment Documented AND Follow-Up Plan Documented
G8440: Documentation of pain assessment (including location, intensity and description)
prior to initiation of treatment or documentation of the absence of pain as a result of
assessment through discussion with the patient including the use of a standardized tool
AND a follow-up plan is documented
Pain Assessment not Documented, Patient not Eligible
G8442: Documentation that patient is not eligible for a pain assessment
OR
OR
Pain Assessment Documented, Follow-up Plan not Documented, Patient not Eligible
G8508: Documentation of pain assessment (including location, intensity and description)
prior to initiation of treatment or documentation of the absence of pain as a result of
assessment through discussion with the patient including the use of a standardized tool;
no documentation of a follow-up plan, patient not eligible
Pain Assessment not Documented, Reason not Specified
G8441: No documentation of pain assessment (including location, intensity and
description) prior to initiation of treatment
OR
Pain Assessment Documented, Follow-up Plan not Documented, Reason not
Specified
G8509: Documentation of pain assessment (including location, intensity and description)
prior to initiation of treatment or documentation of the absence of pain as a result of
assessment through discussion with the patient including the use of a standardized tool;
no documentation of a follow-up plan, reason not specified
DENOMINATOR:
All patients aged 18 years and older
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Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Patient encounter during the reporting period (CPT): 90801, 90802, 96116, 96150,
97001, 97003, 98940, 98941, 98942
RATIONALE:
The multidisciplinary pain management team is the optimal method for delivery of comprehensive
treatment to patients in pain. Thus, it is essential for therapists to assess pain prior to initiation of
therapy. Pain is the most common symptom for which the general population seeks health care,
and chronic pain due to arthritis, back problems, cancer and other ailments costs the U.S.
economy $100 billion per year in lost worker productivity and health costs.
A search of the National Quality Measures Clearinghouse and relevant specialty society web sites
revealed no measures that address pain assessment prior to the initiation of therapy.
CLINICAL RECOMMENDATION STATEMENTS:
The Institute for Clinical Systems Improvement (ICSI) supports that the intensity of pain should be
assessed prior to the initiation of appropriate treatment and continually reassessed throughout the
duration of treatment.
Reducing the intensity of the pain by just 25% has been shown to achieve a 50% improvement in
functional status (Flor, Fydrich, & Turk, 1992. Evidence Grade = A).
Older adults with persistent pain commonly experience an increase in pain intensity with movement
and, as a result, will limit the activities or movements that exacerbate the pain (e.g., stair climbing
or walking) (Davis, Hiemenz, & White, 2002; Duong et al., 2005. Evidence Grade = C).
A multidisciplinary approach to diagnosis and treatment of pain is the preferred method of
delivering health care to patients with chronic pain of any etiology due to the complexity of
diagnosis and management. (International Association for the Study of Pain (IASP). Task Force on
Guidelines for Desirable Characteristics for Pain Treatment Facilities, Level N/A).
The Veterans Health Administration (VHA) and Department of Defense (DoD) in conjunction with
the VHA Office of Quality and Performance and a consultant group developed a postoperative pain
guideline which provides readily accessible information and evidence-based guidance to a variety
of providers, including physicians, dentists, nurses, pharmacists, physical therapists, and
psychologists. It highlights deficiencies in our understanding of the pain and recovery processes
and how they might guide our choices of postoperative analgesic techniques.
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Measure #134: Screening for Clinical Depression and Follow-Up Plan
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older screened for clinical depression using a
standardized tool AND follow-up plan documented
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. There is no diagnosis associated with this measure. This measure may be
reported by non-MD/DO clinicians who perform the quality actions described in the measure based
on the services provided and the measure-specific denominator coding.
Measure Reporting via Claims:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. G-codes are used to report the numerator of the measure.
When reporting the measure via claims, submit the listed CPT codes and the appropriate
numerator G-code. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. The numerator options as described in the quality-data codes are used to
report the numerator of the measure. The quality-data codes listed do not need to be submitted for
registry-based submissions however these codes may be submitted for those registries that utilize
claims data.
NUMERATOR:
Patient’s screening for clinical depression using a standardized tool AND follow-up plan is
documented
Definitions:
Screening – Testing done on people at risk of developing a certain disease, even if they
have no symptoms. Screening tests can predict the likelihood of someone having or
developing a particular disease. This measure looks for the test being done in the
practitioner’s office that is filing the code.
Standardized Tool – An assessment tool that has been appropriately normalized and
validated for the population in which it is used. Some depression screening tools include:
Patient Health Questionnaire (PHQ9), Beck Depression Inventory (BDI or BDI-II), Center
for Epidemiologic Studies Depression Scale (CES-D), Depression Scale (DEPS), Duke
Anxiety-Depression Scale (DADS), Geriatric Depression Scale (GDS), GDS – Short
Version, Hopkins Symptom Checklist (HSCL), The Zung Self-Rating Depression Scale
(SDS), and Cornell Scale Screening (this is a screening tool which is used in situations
where the patient has cognitive impairment and is administered through the caregiver).
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Follow-Up Plan – Proposed outline of treatment to be conducted as a result of clinical
depression screen. Such follow-up must include further evaluation if screen is positive and
may include documentation of a future appointment, education, additional evaluation
and/or referral to a practitioner who is qualified to diagnose and treat depression, and/or
notification of primary care provider.
Not Eligible/Not Appropriate – A patient is not eligible if one or more of the following
conditions exist:
• Patient refuses to participate
• 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
• Situations where the patient’s motivation to improve may impact the accuracy of
results of nationally recognized standardized depression assessment tools. For
example: certain court appointed cases
• Patient was referred with a diagnosis of depression
• Patient has been participating in on-going treatment with screening of clinical
depression in a preceding reporting period
• Severe mental and/or physical incapacity where the person is unable to express
himself/herself in a manner understood by others. For example: cases such as
delirium or severe cognitive impairment, where depression cannot be accurately
assessed through use of nationally recognized standardized depression
assessment tools
OR
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Positive Screen for Clinical Depression, Follow-up Plan Documented
G8431: Positive screen for clinical depression using a standardized tool and a follow-up
plan documented
OR
Negative Screen for Clinical Depression Documented, Patient not
Eligible/Appropriate for Follow-up Plan
G8510: Negative screen for clinical depression using standardized tool, patient not
eligible/appropriate for follow-up plan documented
Screening for Clinical Depression not Documented, Patient not Eligible/Appropriate
G8433: Screening for clinical depression using a standardized tool not documented,
patient not eligible/appropriate
Screening for Clinical Depression not Documented, Reason not Specified
G8432: No documentation of clinical depression screening using a standardized tool
OR
Screening for Clinical Depression Documented, Follow-Up Plan not Documented,
Reason not Specified
G8511: Screen for clinical depression using a standardized tool documented, follow-up
plan not documented, reason not specified
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DENOMINATOR:
All patients aged 18 years and older
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Patient encounter during the reporting period (CPT): 90801, 90802, 90804, 90805,
90806, 90807, 90808, 90809, 92557, 92567, 92568, 92625, 97003
RATIONALE:
The World Health Organization identified major depression as the fourth leading cause of
worldwide disease in 1990, causing more disability than either ischemic heart disease or
cerebrovascular disease. In primary care settings, the point prevalence of major depression ranges
from 5 to 9 percent among adults, and up to 50 percent of depressed patients are not recognized.
Depressive disorders are also relatively common in younger persons, with estimated prevalence of
0.8 to 2.0 percent in children and 4.5 percent in adolescents.
U.S. Preventive Services Task Force compared the effects of integrated recognition and
management depression screening programs with “usual care” in community primary care
practices. Results showed significantly improved patient outcomes.
The National Center for Policy Analysis and the U.S. Surgeons General, among others, estimate
the direct and indirect costs of depression to American businesses ranging from $36.2 billion to
$80 billion annually.
Major depression is “ ranked second only to ischemic heart disease in magnitude of disease
burden in established market economies” and “is the leading cause of disability (measured by the
number of years lived with a disabling condition) worldwide among persons age 5 and
older.” Murray CJL, Lopez AD, eds. The Global Burden Of Disease And Injury Series, Volume 1: A
Comprehensive Assessment Of Mortality And Disability From Diseases, Injuries, And Risk Factors
In 1990 And Projected To 2020. Cambridge, MA: Published by the Harvard School of Public Health
on behalf of the World Health Organization and the World Bank, Harvard University Press, 1996.
A search of the literature in PubMed concerning social workers and depression screening showed
nothing to indicate that these practitioners are routinely screening their patients for depression.
A search of the National Quality Measures Clearinghouse database found no depression screening
measures that address Medicare eligible patients and there was only one measure from the
Physician Consortium for Performance Improvement addressing screening for patients aged 18
years and older with suspected major depressive disorder.
CLINICAL RECOMMENDATION STATEMENTS:
USPSTF recommends screening adults for depression in clinical practices that have systems in
place to assure accurate diagnosis, effective treatment, and follow-up. Small benefits have been
observed in studies that simply feed back screening results to clinicians. Larger benefits have been
observed in studies in which the communication of screening results is coordinated with effective
follow-up and treatment. (Evidence: B)
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The Canadian Task Force on Preventive Health Care used the rigorous USPSTF 2002 systematic
review to update their recommendations regarding depression screening. The Canadian task force
arrived at the same practice recommendations as USPSTF.
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Measure #135: Chronic Kidney Disease (CKD): Influenza Immunization
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of advanced CKD (stage 4 or 5,
not receiving Renal Replacement Therapy [RRT]) who received the influenza immunization during
the flu season (September through February)
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for advanced CKD patients
seen during the reporting period. This measure is intended to determine whether or not CKD
patients received or had an order for an influenza immunization during the flu season (September
through February). It is anticipated that clinicians providing care for patients with advanced CKD
will submit this measure.
•
•
If reporting this measure between January 1, 2010 and August 31, 2010, CPT Category II
code 4037F should be reported when the influenza vaccination is ordered or administered
to the patient during the months of September, October, November, December of 2009 or
January and February of 2010 for the flu season ending February 28, 2010.
If reporting this measure between September 1, 2010 and December 31, 2010, CPT
Category II code 4037F should be reported when the influenza vaccination is ordered or
administered to the patient during the months of September, October, November, and
December of 2010 for the flu season ending February 28, 2011.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis code, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 3P- system
reasons, 8P- reason not otherwise specified. All measure-specific coding should be reported ON
THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions however these codes may be submitted for
those registries that utilize claims data.
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NUMERATOR:
Patients who received the influenza immunization during the flu season (September through
February)
OR
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Influenza Immunization Ordered or Administered
CPT II 4037F: Influenza immunization ordered or administered
Influenza Immunization not Ordered or Administered for Medical, Patient, or System
Reasons
Append a modifier (1P, 2P or 3P) to CPT Category II code 4037F to report documented
circumstances that appropriately exclude patients from the denominator.
4037F with 1P: Documentation of medical reason(s) for patient not receiving the influenza
immunization
4037F with 2P: Documentation of patient reason(s) for patient not receiving the influenza
immunization
4037F with 3P: Documentation of system reason(s) for patient not receiving the influenza
immunization
Influenza Immunization not Ordered or Administered, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4037F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4037F with 8P: Influenza immunization not ordered or administered, reason not otherwise
specified
DENOMINATOR:
All patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not
receiving RRT)
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for stage 4 or 5 CKD (line-item ICD-9-CM): 585.4, 585.5
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
USRDS data shows that Medicare patients with CKD are more likely to receive a flu vaccine versus
employer group health plan patients with CKD (0.43 versus 0.08 respectively). Additionally, it is
estimated that fewer than 20% of all patients in high risk groups receive a flu vaccine each year.
Patients with CKD need to be vaccinated yearly in order to decrease morbidity and mortality
related to influenza and its complications.
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CLINICAL RECOMMENDATION STATEMENTS:
Vaccination with TIV (trivalent inactivated flu vaccine) is recommended for the following persons
who are at increased risk for severe complications from influenza, or at higher risk for influenzaassociated clinic, emergency department, or hospital visits: adults and children who have chronic
pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, hematological,
or metabolic disorders (including diabetes mellitus). (CDC, 2007)
In any given year, the optimal time to vaccinate patients cannot be determined because influenza
seasons vary in their timing, and more than one outbreak might occur in a single community in a
single year. (CDC, 2007)
In general, health-care providers should begin offering vaccination soon after vaccine becomes
available and if possible, by October. (CDC, 2007)
Vaccine efforts should continue throughout the season, because the duration of the influenza
season varies, and influenza might not occur in certain communities until February or March.
The majority of adults have antibody protection against influenza within 2 weeks after vaccination.
(CDC, 2007)
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Measure #136: Melanoma: Follow-Up Aspects of Care
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients, regardless of age, with a new diagnosis of melanoma or a history of
melanoma who received all of the following aspects of care within 12 months: (1) patient was
asked specifically if he/she had any new or changing moles; AND (2) a complete physical skin
examination was performed and the morphology, size, and location of new or changing pigmented
lesions were noted; AND (3) patient was counseled to perform a monthly self skin examination
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for melanoma patients
seen during the reporting period. It is anticipated that clinicians providing care for patients with
melanoma or a history of melanoma will submit this measure.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes and CPT codes are used to identify patients who are included in the
measure’s denominator. The listed numerator options are used to report the numerator of the
measure. The listed numerator options are used to report the numerator of the measure. The
quality-data codes have been provided for registry only measures for use by registries that utilize
claims data. It is not necessary to submit these codes for registry-based submissions. Do not
report this measure via claims.
NUMERATOR:
Patients who received all aspects of care at least once within 12 months
Numerator Instructions: A complete physical skin exam includes: head (including the
face), neck, chest (including the axillae), abdomen, back, and extremities. The genitalia
(including the groin and buttocks) may also be examined (optional).
Definition:
Follow-up Aspects of Care – Include all of the following (1) patient was asked specifically
if he/she had any new or changing moles; AND (2) a complete physical skin examination
was performed and the morphology, size, and location of new or changing pigmented
lesions were noted; AND (3) patient was counseled to perform a monthly self skin
examination.
OR
OR
Numerator Options:
Melanoma follow-up completed (0015F)
Documentation of system reason(s) for not performing the follow-up service (eg, another
physician performed this service) (0015F with 3P)
Melanoma follow-up not performed, reason not otherwise specified (0015F with 8P)
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DENOMINATOR:
All patients, regardless of age, with a new diagnosis of melanoma or a history of melanoma
Denominator Criteria (Eligible Cases):
Diagnosis for melanoma or history of melanoma (ICD-9-CM): 172.0, 172.1, 172.2,
172.3, 172.4, 172.5, 172.6, 172.7, 172.8, 172.9, V10.82
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Early detection of an additional or secondary primary melanoma is an important goal of follow-up
care. The majority of additional primary melanomas are discovered by the patient or family
member. Educating patients to perform self-examinations will lead to earlier detection of secondary
primary sites of melanoma. Only 60% of physicians routinely performed full-body examinations with
their high-risk patients.
CLINICAL RECOMMENDATION STATEMENTS:
Skin examination and surveillance at least once a year for life is recommended for all melanoma
patients, including those with stage 0 in situ-melanoma. Frequency of dermatologic surveillance
should be determined individually, based on risk factors, including skin type, family history,
presence of dysplastic nevi, and history of non-melanoma skin cancers. Clinicians should also
consider educating patients about monthly self-exam of their skin and lymph nodes. (NCCN)
For patients with stage IA melanoma, a comprehensive H&P (with specific emphasis on the
regional nodes and skin) should be performed every 3 to 12 months as clinically indicated. For
patients with stage IB-III melanomas, a comprehensive H&P (with emphasis on the regional nodes
and skin) should be performed every 3 to 6 months for 3 years; then every 4 to 12 months for 2
years; and annually (at least) thereafter, as clinically indicated. (NCCN) (Level of Evidence –
Category 2A)
A structured follow-up program could permit the earlier detection of recurrent disease at a time
when it might be more amenable to potentially curative surgical resection. This follow-up would be
particularly appropriate for patients at risk for regional nodal recurrence who have not yet
undergone sentinel node biopsy or elective lymph node dissection. (NCCN)
All patients should be taught self-examination because many recurrences are found by patients
themselves at home rather than by clinicians in the clinic. (BAD)
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Measure #137: Melanoma: Continuity of Care – Recall System
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of
melanoma whose information was entered, at least once within a 12 month period, into a recall
system that includes:
• A target date for the next complete physical skin exam, AND
• A process to follow up with patients who either did not make an appointment within the
specified timeframe or who missed a scheduled appointment
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for melanoma patients
seen during the reporting period. It is anticipated that clinicians providing care for patients with
melanoma or a history of melanoma will submit this measure.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes and CPT codes are used to identify patients who are included in the
measure’s denominator. The listed numerator options are used to report the numerator of the
measure. The quality-data codes have been provided for registry only measures for use by
registries that utilize claims data. It is not necessary to submit these codes for registry-based
submissions. Do not report this measure via claims.
NUMERATOR:
Patients whose information is entered, at least once within a 12 month period, into a recall system
that includes:
• A target date for the next complete physical skin exam AND
• A process to follow up with patients who either did not make an appointment within the
specified timeframe or who missed a scheduled appointment
Numerator Instructions: To satisfy this measure, the recall system must be linked to a
process to notify patients when their next physical exam is due and to follow up with
patients who either did not make an appointment within the specified timeframe or who
missed a scheduled appointment and must include the following elements at a minimum:
patient identifier, patient contact information, cancer diagnosis(es), dates(s) of initial
cancer diagnosis (if known), and the target date for the next complete physical exam.
OR
Numerator Options:
Patient information entered into a recall system that includes target date for the next exam
specified AND a process to follow up with patients regarding missed or unscheduled
appointments (7010F)
Documentation of system reason(s) for not entering patient’s information into a recall
system (eg, melanoma being monitored by another physician provider) (7010F with 3P)
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OR
Recall system not utilized, reason not otherwise specified (7010F with 8P)
DENOMINATOR:
All patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma
Denominator Criteria (Eligible Cases):
Diagnosis for melanoma or history of melanoma (ICD-9-CM): 172.0, 172.1, 172.2,
172.3, 172.4, 172.5, 172.6, 172.7, 172.8, 172.9, V10.82
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Lack of follow-up with providers noted in the Institute of Medicine (IOM) report on patient errors.
Follow-up for skin examination and surveillance is an important aspect in the management of
patients with a current diagnosis or a history of melanoma. The presence of a recall system,
whether it is electronic or paper based, enables providers to ensure that patients receive follow-up
appointments in accordance with their individual needs.
CLINICAL RECOMMENDATION STATEMENTS:
Skin examination and surveillance at least once a year for life is recommended for all melanoma
patients, including those with stage 0 in situ-melanoma. Frequency of dermatologic surveillance
should be determined individually, based on risk factors, including skin type, family history,
presence of dysplastic nevi, and history of non-melanoma skin cancers. Clinicians should also
consider educating patients about monthly self-exam of their skin and lymph nodes. (NCCN)
For patients with stage IA melanoma, a comprehensive H&P (with specific emphasis on the
regional nodes and skin) should be performed every 3 to 12 months as clinically indicated. For
patients with stage IB-III melanomas, a comprehensive H&P (with emphasis on the regional nodes
and skin) should be performed every 3 to 6 months for 3 years; then every 4 to 12 months for 2
years; and annually (at least) thereafter, as clinically indicated. (NCCN) (Level of Evidence Category 2A)
Each local skin cancer multi-disciplinary team (LSMDT) and specialist skin cancer multi-disciplinary
team (SSMDT) should have at least one skin cancer clinical nurse specialist (CNS) who will play a
leading role in supporting patients and carers. There should be equity of access to information and
support regardless of where the care is delivered. A checklist may be used by healthcare
professionals to remind them to give patients and carers the information they need in an
appropriate format for pre-diagnosis, diagnosis, treatment, follow-up, and palliative care. This may
also include a copy of the letter confirming the diagnosis and treatment plan sent by the consultant
to the general practitioner (GP).
• Provide a rapid referral service for patients who require specialist management
through the LSMDT/SSMDT.
• Be responsible for the provision of information, advice, and support for patients
managed in primary care and their care givers.
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•
•
•
•
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Maintain a register of all patients treated, whose care should be part of a regular audit
presented to the LSMDT/SSMDT.
Liaise and communicate with all members of the skin cancer site-specific network
group.
Ensure that referring GPs are given prompt and full information about their patients’
diagnosis or treatment in line with national standards on communication to GPs of
cancer diagnoses.
Collect data for network-wide audit. (NICE)
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Measure #138: Melanoma: Coordination of Care
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patient visits, regardless of patient age, with a new occurrence of melanoma who
have a treatment plan documented in the chart that was communicated to the physician(s)
providing continuing care within one month of diagnosis
INSTRUCTIONS:
This measure is to be reported at each visit occurring during the reporting period for melanoma
patients seen during the reporting period. It is anticipated that clinicians providing care for patients
with melanoma will submit this measure.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes and CPT codes are used to identify patients who are included in the
measure’s denominator. The listed numerator options are used to report the numerator of the
measure. The quality-data codes have been provided for registry only measures for use by
registries that utilize claims data. It is not necessary to submit these codes for registry-based
submissions. Do not report this measure via claims.
NUMERATOR:
Patient visits with a treatment plan documented in the chart that was communicated to the
physician(s) providing continuing care within one month of diagnosis
Definition: Communication may include: documentation in the medical record that the
physician(s) treating the melanoma communicated (eg, verbally, by letter, copy of
treatment plan sent) with the physician(s) providing the continuing care OR a copy of a
letter in the medical record outlying whether the patient was or should be treated for
melanoma.
Numerator Instructions: A treatment plan should include the following elements:
diagnosis, tumor thickness, and plan for surgery or alternate care.
OR
OR
Numerator Options:
Treatment plan communicated to provider(s) managing continuing care within one month
of diagnosis (5050F)
Documentation of patient reason(s) for not communicating treatment plan (e.g., patients
asks that treatment plan not be communicated to the physician(s) providing continuing
care) (5050F with 2P)
OR
Documentation of system reason(s) for not communicating treatment plan (e.g., patient
does not have a primary care physician or referring physician) (5050F with 3P)
Treatment plan not communicated, reason not otherwise specified (5050F with 8P)
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DENOMINATOR:
All visits for patients, regardless of age, diagnosed with a new occurrence of melanoma
Eligible cases are determined, and must be reported, if either of the following conditions are
met:
Option 1 - Denominator Criteria (eligible Cases):
Diagnosis for melanoma (ICD-9-CM): 172.0, 172.1, 172.2, 172.3, 172.4, 172.5, 172.6,
172.7, 172.8, 172.9
AND
CPT codes for excision of malignant melanoma: 11600, 11601, 11602, 11603, 11604,
11606, 11620, 11621, 11622, 11623, 11624, 11626, 11640, 11641, 11642, 11643, 11644,
11646, 14000, 14001, 14020, 14021, 14040, 14041, 14060, 14061, 14301, 14302, 17311,
17313
OR
Option 2 - Denominator Criteria (Eligible Cases):
Diagnosis for melanoma (ICD-9-CM): 172.0, 172.1, 172.2, 172.3, 172.4, 172.5, 172.6,
172.7, 172.8, 172.9
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Perceived lack of follow-up with primary care providers which is reinforced in the Institute of
Medicine (IOM) report on patient errors. The intention of this measure is to enable the primary care
provider to support, facilitate, and coordinate the care of the patient.
CLINICAL RECOMMENDATION STATEMENTS:
Each local skin cancer multi-disciplinary team (LSMDT) and specialist skin cancer multi-disciplinary
team (SSMDT) should have at least one skin cancer clinical nurse specialist (CNS) who will play a
leading role in supporting patients and carers. There should be equity of access to information and
support regardless of where the care is delivered. A checklist may be used by healthcare
professionals to remind them to give patients and carers the information they need in an
appropriate format for pre-diagnosis, diagnosis, treatment, follow-up, and palliative care. This may
also include a copy of the letter confirming the diagnosis and treatment plan sent by the consultant
to the general practitioner (GP).
• Provide a rapid referral service for patients who require specialist management
through the LSMDT/SSMDT.
• Be responsible for the provision of information, advice, and support for patients
managed in primary care and their care givers.
• Maintain a register of all patients treated, whose care should be part of a regular audit
presented to the LSMDT/SSMDT.
• Liaise and communicate with all members of the skin cancer site-specific network
group.
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diagnosis or treatment in line with national standards on communication to GPs of
cancer diagnoses.
Collect data for network-wide audit. (NICE)
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Measure #139: Cataracts: Comprehensive Preoperative Assessment for Cataract Surgery
with Intraocular Lens (IOL) Placement
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a procedure of cataract surgery with IOL
placement who received a comprehensive preoperative assessment of 1) dilated fundus
examination; 2) axial length, corneal keratometry measurement, and method of IOL power
calculation reviewed; and 3) functional or medical indication(s) for surgery prior to the cataract
surgery with IOL placement within 12 months prior to cataract surgery
INSTRUCTIONS:
This measure is to be reported each time a cataract surgery with IOL placement is performed
during the reporting period. There is no diagnosis associated with this measure. It is anticipated
that clinicians who perform the cataract procedure will submit this measure.
Measure Reporting via Claims:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. CPT Category II codes are used to report the numerator of the measure.
When reporting the measure via claims, submit the appropriate CPT code and the appropriate CPT
Category II code OR the CPT Category II code with the modifier. The reporting modifier allowed
for this measure is: 8P- reason not otherwise specified. There are no allowable performance
exclusions for this measure. All measure-specific coding should be reported ON THE SAME
CLAIM.
Measure Reporting via Registry:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. The numerator options as described in the quality-data codes are used to
report the numerator of the measure. The quality-data codes listed do not need to be submitted for
registry-based submissions however these codes may be submitted for those registries that utilize
claims data. There are no allowable performance exclusions for this measure.
NUMERATOR:
Patients who received a comprehensive preoperative assessment within 12 months prior to
cataract surgery
Definition:
Comprehensive Preoperative Assessment – 1) dilated fundus examination; 2) axial
length, corneal keratometry measurement, and method of IOL power calculation reviewed;
and 3) functional or medical indication(s) for surgery prior to the cataract surgery with IOL
placement
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NUMERATOR NOTE: “Axial length, corneal keratometry measurement, and method of
IOL power calculation” should have been reviewed at least 12 months prior to cataract
surgery.
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Comprehensive Preoperative Assessment Performed
CPT II 0014F: Comprehensive preoperative assessment performed for cataract surgery
with intraocular lens (IOL) placement
Comprehensive Preoperative Assessment not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 0014F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
0014F with 8P: Comprehensive preoperative assessment not performed for cataract
surgery with intraocular lens (IOL) placement, reason not otherwise
specified
DENOMINATOR:
All patients aged 18 years and older who had cataract surgery with IOL placement
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Patient encounter during the reporting period (CPT): 66982, 66983, 66984
RATIONALE:
1. Scientific basis for comprehensive preoperative assessment
In order to ensure that cataract surgery is APPROPRIATE and SAFE to perform, the operating
surgeon is obligated to ensure that there is 1) a patient-centered problem that cataract surgery will
address and improve (i.e., that there is likely to be an appropriate outcome of surgery); 2) that the
safety of the procedure is maximized through appropriate IOL choice to reduce “wrong power IOL”
surgery; and 3) that there are no other conditions that would impact either the appropriateness or
the safety of surgery through a comprehensive eye examination, including dilation.
The purpose of the comprehensive evaluation of a patient whose chief complaint might be related
to a cataract is to determine the presence of a cataract, confirm that a cataract is a significant
factor related to the visual impairment and symptoms described by the patient, and exclude or
identify other ocular or systemic conditions that might contribute to visual impairment or affect the
cataract surgical plan or ultimate outcome.
During the preoperative evaluation, other ocular conditions could be found in the course of fundus
evaluation that would lead to identification of possible contraindications for surgery:
Surgery for a visually impairing cataract should not be performed under the following
circumstances:
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•
•
•
•
Eyeglasses or visual aids provide vision that meets the patient’s needs.
Surgery will not improve visual function.
The patient cannot safely undergo surgery because of co-existing medical or ocular
conditions.
Appropriate postoperative care cannot be arranged.
The surgeon should consider the patient’s individual desires and needs in selecting an appropriate
postoperative refractive target. The axial length can be measured by A-scan ultrasonography using
either an applanation (contact) or an immersion (non-contact) technique. Biometry measurement
for both eyes is advisable, even if surgery is not planned for the other eye. Formulas for calculating
IOL power rely on keratometry to determine the net refractive contribution of the cornea. These
measurements can be obtained through either manual or automated keratometry, or through
corneal topography. Latest generation lens calculation formulas should be used in the IOL
selection process.
2. Evidence of gap in care.
Results from the Cataract Appropriateness Project from RAND and additional studies for AHCPR
at RAND suggest that the gap for a comprehensive preoperative assessment range from 10 to
30+%.
CLINICAL RECOMMENDATION STATEMENTS:
The initial physical examination should include visual acuity, refraction, ocular alignment and
motility, pupil reactivity and function, IOP measurement, external examination, slit-lamp
biomicroscopy, evaluation of the fundus through dilated pupil, assessment of general and mental
health (Level A:III Recommendation).
Achieving the targeted postoperative refraction requires measuring axial length accurately,
determining corneal power, and using the most appropriate IOL power formula.
The primary indication for surgery is visual function that no longer meets the patient’s needs and
for which cataract surgery provides a reasonable likelihood of improved vision. Functional
indications for surgery include documentation that a patient is experiencing difficulty with activities
of daily living, such as reading, walking, driving, and performing other visual tasks. This may also
include symptoms of anisometropia, glare, starbursts, or color vision abnormalities.
Medical indications for surgery include documentation that the presence of the cataract is
contributing to disease (such as primary angle closure) or that removal is necessary for adequate
visualization of the fundus. Such medical conditions for a cataract removal include the following:
• Clinically significant anisometropia in the presence of a cataract.
• The lens opacity interferes with optimal diagnosis or management of posterior
segment conditions.
• The lens causes inflammation (phacolysis, phacoanaphylaxis).
• The lens induces angle closure (phacomorphic or phacotopic).
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Measure #140: Age-Related Macular Degeneration (AMD): Counseling on Antioxidant
Supplement
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 50 years and older with a diagnosis of AMD and/or their caregiver(s)
who were counseled within 12 months on the benefits and/or risks of the Age-Related Eye Disease
Study (AREDS) formulation for preventing progression of AMD
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for AMD patients seen
during the reporting period. It is anticipated that clinicians who provide the primary management of
patients with AMD will submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the appropriate ICD-9-CM diagnosis code, CPT
codes, and the appropriate CPT Category II code OR the CPT Category II code with the modifier.
The reporting modifier allowed for this measure is: 8P- reason not otherwise specified. There are
no allowable performance exclusions for this measure. All measure-specific coding should be
reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions however these codes may be submitted for
those registries that utilize claims data. There are no allowable performance exclusions for this
measure.
NUMERATOR:
Patients and/or their caregiver(s) who were counseled within 12 months on the benefits and/or
risks of the AREDS formulation for preventing progression of AMD
Numerator Instructions: Counseling can be discussed with all patients with AMD, even
those who do not meet the criteria for the AREDS formulation, patients who are smokers
(beta-carotene can increase the risk for cancer in these patients) or other reasons why the
patient would not meet criteria for AREDS formulation as outlined in the AREDS. The
ophthalmologist or optometrist can explain why these supplements are not appropriate for
their particular situation. Also, given the purported risks associated with antioxidant use,
patients would be informed of the risks and benefits and make their choice based on
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valuation of vision loss vs. other risks. As such, the measure seeks to educate patients
about overuse as well as appropriate use.
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
AREDS Counseling Performed
CPT II 4177F: Counseling about the benefits and/or risks of the Age-Related Eye Disease
Study (AREDS) formulation for preventing progression of age-related macular
degeneration (AMD) provided to patient and/or caregiver(s)
AREDS Counseling not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4177F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4177F with 8P: AREDS counseling not performed, reason not otherwise specified
DENOMINATOR:
All patients aged 50 years and older with a diagnosis of AMD
Denominator Criteria (Eligible Cases):
Patients aged ≥ 50 years on date of encounter
AND
Diagnosis for AMD (line-item ICD-9-CM): 362.50, 362.51, 362.52
AND
Patient encounter during the reporting period (CPT): 92002, 92004, 92012, 92014,
99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99307, 99308, 99309,
99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337
RATIONALE:
1. Scientific basis for counseling regarding use of AREDS formulation for patients with AMD
Antioxidant vitamins and mineral supplements help to reduce the rate of progression to advanced
AMD for those patients with intermediate or advanced AMD in one eye. From the same AREDS
study, there is no evidence that the use of antioxidant vitamin and mineral supplements for patients
with mild AMD alters the natural history of mild AMD.
At the same time, published meta analyses have raised an issue as to the presence of an elevated
mortality risk among patients taking elements similar to parts of the AREDS formulation (and
elevated risk among smokers). As such, patients need to know of their individualized risk profile for
taking the AREDS formula AND the potential benefits, so that they can make their OWN individual
decision as to whether or not to take the AREDS formulation.
This indicator thus seeks to directly enhance the provider-patient relationship to apply the results of
level 1 randomized controlled trials (RCTs) in a manner that accommodates the needs of each
individual patient in a patient-centered manner, rather than a paternalistic approach of either
recommending or withholding treatment.
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2. Evidence of gap in care.
Antioxidant vitamins and mineral supplements help to reduce the rate of progression to advanced
AMD for those patients with intermediate or advanced AMD in one eye. From the same AREDS
study, there is no evidence that the use of antioxidant vitamin and mineral supplements for patients
with mild AMD alters the natural history of mild AMD.
CLINICAL RECOMMENDATION STATEMENTS:
Patients with intermediate AMD or advanced AMD in one eye should be counseled on the use of
antioxidant vitamin and mineral supplements as recommended in the Age-related Eye Disease
Study (AREDS) reports. (Level A:I Recommendation) (AAO)
TABLE 1
Antioxidant Vitamin and Mineral Supplements Used in the AREDS
Supplement
Daily Dose (See note below)
Vitamin C
500 mg
Vitamin E
400 IU
Beta-carotene
15 mg (25,000 IU)
Zinc oxide
80 mg
Cupric oxide
2 mg
Note: These doses are not those listed on the commercially available vitamin/mineral supplements
because of a change in labeling rules by the U.S. Food and Drug Administration that specifies that
the doses must reflect the amounts available at the end of the shelf life.
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Measure #141: Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure
(IOP) by 15% OR Documentation of a Plan of Care
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of POAG whose glaucoma
treatment has not failed (the most recent IOP was reduced by at least 15% from the preintervention level) OR if the most recent IOP was not reduced by at least 15% from the preintervention level, a plan of care was documented within 12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for glaucoma patients seen
during the reporting period. It is anticipated that clinicians who provide the primary management of
patients with POAG will submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the appropriate ICD-9-CM diagnosis code, CPT
codes, and the appropriate CPT Category II code(s) OR the CPT Category II code with the
modifier. The reporting modifier allowed for this measure is: 8P- reason not otherwise specified.
There are no allowable performance exclusions for this measure. All measure-specific coding
should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions however these codes may be submitted for
those registries that utilize claims data. There are no allowable performance exclusions for this
measure.
NUMERATOR:
Patients whose glaucoma treatment has not failed (the most recent IOP was reduced by at least
15% from the pre-intervention level) OR if the most recent IOP was not reduced by at least 15%
from the pre-intervention level a plan of care was documented within 12 months
Definition:
Plan of Care – May include: recheck of IOP at specified time, change in therapy, perform
additional diagnostic evaluations, monitoring per patient decisions or unable to achieve
due to health system reasons, and/or referral to a specialist
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NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Intraocular Pressure (IOP) Reduced Greater than or Equal to 15% Pre-intervention
Level
(One CPT II code [3284F] is required on the claim form to submit this numerator option)
CPT II 3284F: Intraocular pressure (IOP) reduced by a value of greater than or equal to
15% from the pre-intervention level
OR
OR
Intraocular Pressure (IOP) Reduced Less than 15% Pre-intervention Level with Plan
of Care
(Two CPT II codes [0517F & 3285F] are required on the claim form to submit this
numerator option)
CPT II 0517F: Glaucoma plan of care documented
AND
CPT II 3285F: Intraocular pressure (IOP) reduced by a value less than 15% from the preintervention level
Glaucoma Plan of Care not Documented, Reason not Specified
(Two CPT II codes [0517F-8P & 3285F] are required on the claim form to submit this
numerator option)
Append a reporting modifier (8P) to CPT Category II code 0517F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
0517F with 8P: Glaucoma plan of care not documented, reason not otherwise specified
AND
CPT II 3285F: Intraocular pressure (IOP) reduced by a value less than 15% from the preintervention level (3285F)
OR
Intraocular Pressure (IOP) Measurement not Documented, Reason not Specified
(One CPT II code [3284F-8P] is required on the claim form to submit this numerator
option)
Append a reporting modifier (8P) to CPT Category II code 3284F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3284F with 8P: IOP measurement not documented, reason not otherwise specified
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of POAG
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Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for POAG (ICD-9-CM): 365.10, 365.11, 365.12, 365.15
AND
Patient encounter during the reporting period (CPT): 92002, 92004, 92012, 92014,
99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99307, 99308, 99309,
99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337
RATIONALE:
1. Scientific basis for intraocular pressure (IOP) control as outcomes measure (intermediate)
Analyses of results of several randomized clinical trials all demonstrate that reduction of IOP of at
least 18% (EMGT, CIGTS, AGIS, CNTGS) reduces the rate of worsening of visual fields by at least
40%. The various studies, however, achieved different levels of mean IOP lowering in realizing
their benefit in patient outcomes, ranging from 18% in the “normal pressure” subpopulation of
EMGT to 42% in the CIGTS study. (Level I studies) As such, an appropriate “failure” indicator is to
NOT achieve at least a 15% IOP reduction. The rationales for a failure indicator are that 1) the
results of different studies can lead experienced clinicians to believe that different levels of IOP
reduction are appropriate; 2) to minimize the impact of adverse selection for those patients whose
IOPs are more difficult to control; and 3) because each patient’s clinical course may require IOP
reduction that may vary from 18 to 40+%.
In addition, “…[s]several population based studies have demonstrated that the prevalence of
POAG as well as the incidence of POAG, increases as the level of IOP increases. These studies
provide strong evidence that IOP plays an important role in the neuropathy of POAG. Furthermore,
studies have demonstrated that reduction in the level of IOP lessens the risk of visual field
progression in open-angle glaucoma. In addition, treated eyes that have a greater IOP fluctuation
are at increased risk of progression.
Intraocular pressure is the intermediate outcome of therapy used by the FDA for approval of new
drugs and devices and, as noted above, has been shown to be directly related to ultimate patient
outcomes of vision loss. As such, failure to achieve minimal pressure lowering, absent an
appropriate plan of care to address the situation, would constitute performance whose
improvement would directly benefit patients with POAG.
2. Evidence for gap in care
Based on studies in the literature reviewing documentation of IOP achieved under care, the gap
could be as great as 50% or more in the community of ophthalmologists and optometrists treating
patients with primary open-angle glaucoma. Based on loose criteria for control, IOP was controlled
in 66% of follow-up visits for patients with mild glaucoma and 52% of visits for patients with
moderate to severe glaucoma. Another study of a single comprehensive insurance plan suggested
that a large proportion of individuals felt to require treatment for glaucoma or suspect glaucoma are
falling out of care and are being monitored at rates lower than expected from recommendations of
published guidelines.
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CLINICAL RECOMMENDATION STATEMENTS:
The initial target pressure selected should be at least 20% lower than the pretreatment IOP,
depending upon the clinical findings. Further reduction of the target IOP is often also justified by
the severity of existing optic nerve damage, the level of the measured pretreatment IOP, the
rapidity with which the damage occurred, and other risk factors. In general, the more advanced the
damage, the lower the initial pressure should be (Level A: III Recommendation).
Please note that the American Optometric Association’s (AOA) 2002 guideline on Open-angle
Glaucoma was not reviewed during the development of this measure prior to the public comment
period and therefore is not presented here verbatim. Review of the AOA guideline subsequent to
initial measure development indicates that the recommendations in the AOA guideline are
consistent with the intent of the measure. As such, the intent of this measure is to have this
indicator apply to both optometrists and ophthalmologists (and any other physician who provides
glaucoma care); the use of “ophthalmologists” only in the preceding verbatim section reflects the
wording in the American Academy of Ophthalmology Preferred Practice pattern.
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Measure #142: Osteoarthritis (OA): Assessment for Use of Anti-Inflammatory or
Analgesic Over-the-Counter (OTC) Medications
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patient visits for patients aged 21 years and older with a diagnosis of OA with an
assessment for use of anti-inflammatory or analgesic OTC medications
INSTRUCTIONS:
This measure is to be reported at each visit occurring during the reporting period for OA patients
seen during the reporting period. This measure may be reported by clinicians who perform the
quality actions described in the measure based on the services provided and the measure-specific
denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis code, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
reporting modifier allowed for this measure is: 8P- reason not otherwise specified. There are no
allowable performance exclusions for this measure. All measure-specific coding should be reported
ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions however these codes may be submitted for
those registries that utilize claims data. There are no allowable performance exclusions for this
measure.
NUMERATOR:
Patient visits with assessment for use of anti-inflammatory or analgesic OTC medications
documented
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Assessment for Anti-inflammatory or Analgesic OTC Medications Performed
CPT II 1007F: Use of anti-inflammatory or analgesic over-the-counter (OTC) medications
for symptom relief assessed
Assessment for Anti-inflammatory or Analgesic OTC Medications not Performed,
Reason not Specified
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Append a reporting modifier (8P) to CPT Category II code 1007F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
1007F with 8P: Use of anti-inflammatory or analgesic OTC medications not assessed,
reason not otherwise specified
DENOMINATOR:
All visits for patients aged 21 years and older with OA
Denominator Criteria (Eligible Cases):
Patients aged ≥ 21 years on date of encounter
AND
Diagnosis for OA (line-item ICD-9-CM): 715.00, 715.04, 715.09, 715.10, 715.11, 715.12,
715.13, 715.14, 715.15, 715.16, 715.17, 715.18, 715.20, 715.21, 715.22, 715.23, 715.24,
715.25, 715.26, 715.27, 715.28, 715.30, 715.31, 715.32, 715.33, 715.34, 715.35, 715.36,
715.37, 715.38, 715.80, 715.89, 715.90, 715.91, 715.92, 715.93, 715.94, 715.95, 715.96,
715.97, 715.98
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Management of pain in patients with osteoarthritis is an important aspect of care. Patients who are
able to have their pain controlled are more likely to be able to function at their desired level, which
leads to improved quality of life.
CLINICAL RECOMMENDATION STATEMENTS:
Initial treatment should include activity modification and trial of analgesic or non-steroidal antiinflammatory medication (NSAID). (AAOS; A Recommendation)
Acetaminophen has been shown to be as effective a pain reliever as NSAIDs in patients with OA of
the knee. (AAOS, A Recommendation)
Analgesic and anti-inflammatory medications are important in arthritis pain management, but
should be used concurrently with nutritional, physical, educational, and cognitive-behavioral
interventions. (APS; A Recommendation)
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Measure #143: Oncology: Medical and Radiation – Pain Intensity Quantified
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
This is a two-part measure which is paired with Measure #144: Oncology: Medical and
Radiation: Plan of Care for Pain. If pain is present, Measure #144 should also be reported.
DESCRIPTION:
Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently
receiving chemotherapy or radiation therapy in which pain intensity is quantified
INSTRUCTIONS:
This measure is to be reported at each visit occurring during the reporting period for patients with a
diagnosis of cancer who are seen during the reporting period. It is anticipated that clinicians
providing care for patients with cancer will submit this measure.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes and CPT codes are used to identify patients who are included in the
measure’s denominator. There are no allowable performance exclusions for this measure. The
listed numerator options are used to report the numerator of the measure. The quality-data codes
have been provided for registry only measures for use by registries that utilize claims data. It is not
necessary to submit these codes for registry-based submissions. There are no allowable
performance exclusions for this measure. There are no allowable performance exclusions for this
measure. Do not report this measure via claims.
NUMERATOR:
Patient visits in which pain intensity was quantified
Numerator Instructions: Pain intensity should be quantified using a standard instrument,
such as a 0-10 numeric rating scale, a categorical scale, or the pictorial scale.
OR
Numerator Options:
Pain severity quantified; pain present (1125F)
OR
Pain severity quantified; no pain present (1126F)
Pain severity not documented, reason not otherwise specified (1125F with 8P)
DENOMINATOR:
All patient visits, regardless of patient age, with a diagnosis of cancer currently receiving
chemotherapy or radiation therapy
Denominator Criteria (Eligible Cases):
Diagnosis for cancer (ICD-9-CM): 140.0, 140.1, 140.3, 140.4, 140.5, 140.6, 140.8, 140.9,
141.0, 141.1, 141.2, 141.3, 141.4, 141.5, 141.6, 141.8, 141.9, 142.0, 142.1, 142.2, 142.8,
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142.9, 143.0, 143.1, 143.8, 143.9, 144.0, 144.1, 144.8, 144.9, 145.0, 145.1, 145.2, 145.3,
145.4, 145.5, 145.6, 145.8, 145.9, 146.0, 146.1, 146.2, 146.3, 146.4, 146.5, 146.6, 146.7,
146.8, 146.9, 147.0, 147.1, 147.2, 147.3, 147.8, 147.9, 148.0, 148.1, 148.2, 148.3, 148.8,
148.9, 149.0, 149.1, 149.8, 149.9, 150.0, 150.1, 150.2, 150.3, 150.4, 150.5, 150.8, 150.9,
151.0, 151.1, 151.2, 151.3, 151.4, 151.5, 151.6, 151.8, 151.9, 152.0, 152.1, 152.2, 152.3,
152.8, 152.9, 153.0, 153.1, 153.2, 153.3, 153.4, 153.5, 153.6, 153.7, 153.8, 153.9, 154.0,
154.1, 154.2, 154.3, 154.8, 155.0, 155.1, 155.2, 156.0, 156.1, 156.2, 156.8, 156.9, 157.0,
157.1, 157.2, 157.3, 157.4, 157.8, 157.9, 158.0, 158.8, 158.9, 159.0, 159.1, 159.8,
159.9,160.0, 160.1, 160.2, 160.3, 160.4, 160.5, 160.8, 160.9, 161.0, 161.1, 161.2, 161.3,
161.8, 161.9, 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9, 163.0, 163.1, 163.8, 163.9,
164.0, 164.1, 164.2, 164.3, 164.8, 164.9, 165.0, 165.8, 165.9, 170.0, 170.1, 170.2, 170.3,
170.4, 170.5, 170.6, 170.7, 170.8, 170.9, 171.0, 171.2, 171.3, 171.4, 171.5, 171.6, 171.7,
171.8, 171.9, 172.0, 172.1, 172.2, 172.3, 172.4, 172.5, 172.6, 172.7, 172.8, 172.9, 173.0,
173.1, 173.2, 173.3, 173.4, 173.5, 173.6, 173.7, 173.8, 173.9, 174.0, 174.1, 174.2, 174.3,
174.4, 174.5, 174.6, 174.8, 174.9, 175.0, 175.9, 176.0, 176.1, 176.2, 176.3, 176.4, 176.5,
176.8, 176.9, 179, 180.0, 180.1, 180.8, 180.9, 181, 182.0, 182.1, 182.8, 183.0, 183.2,
183.3, 183.4, 183.5, 183.8, 183.9, 184.0, 184.1, 184.2, 184.3, 184.4, 184.8, 184.9, 185,
186.0, 186.9, 187.1, 187.2, 187.3, 187.4, 187.5, 187.6, 187.7, 187.8, 187.9, 188.0, 188.1,
188.2, 188.3, 188.4, 188.5, 188.6, 188.7, 188.8, 188.9, 189.0, 189.1, 189.2, 189.3, 189.4,
189.8, 189.9, 190.0, 190.1, 190.2, 190.3, 190.4, 190.5, 190.6, 190.7, 190.8, 190.9, 191.0,
191.1, 191.2, 191.3, 191.4, 191.5, 191.6, 191.7, 191.8, 191.9, 192.0, 192.1, 192.2, 192.3,
192.8, 192.9, 193, 194.0, 194.1, 194.3, 194.4, 194.5, 194.6, 194.8, 194.9, 195.0, 195.1,
195.2, 195.3, 195.4, 195.5, 195.8, 196.0, 196.1, 196.2, 196.3, 196.5, 196.6, 196.8, 196.9,
197.0, 197.1, 197.2, 197.3, 197.4, 197.5, 197.6, 197.7, 197.8, 198.0, 198.1, 198.2, 198.3,
198.4, 198.5, 198.6, 198.7, 198.81, 198.82, 198.89, 199.0, 199.1, 199.2, 200.00, 200.01,
200.02, 200.03, 200.04, 200.05, 200.06, 200.07, 200.08, 200.10, 200.11, 200.12, 200.13,
200.14, 200.15, 200.16, 200.17, 200.18, 200.20, 200.21, 200.22, 200.23, 200.24, 200.25,
200.26, 200.27, 200.28, 200.30, 200.31, 200.32, 200.33, 200.34, 200.35, 200.36, 200.37,
200.38, 200.40, 200.41, 200.42, 200.43, 200.44, 200.45, 200.46, 200.47, 200.48; 200.50,
200.51, 200.52, 200.53, 200.54, 200.55, 200.56, 200.57, 200.58, 200.60, 200.61, 200.62,
200.63, 200.64, 200.65, 200.66, 200.67, 200.68, 200.70, 200.71, 200.72, 200.73, 200.74,
200.75, 200.76, 200.77, 200.78, 200.80, 200.81, 200.82, 200.83, 200.84, 200.85, 200.86,
200.87, 200.88, 201.00, 201.01, 201.02, 201.03, 201.04, 201.05, 201.06, 201.07, 201.08,
201.10, 201.11, 201.12, 201.13, 201.14, 201.15, 201.16, 201.17, 201.18, 201.20, 201.21,
201.22, 201.23, 201.24, 201.25, 201.26, 201.27, 201.28, 201.40, 201.41, 201.42, 201.43,
201.44, 201.45, 201.46, 201.47, 201.48, 201.50, 201.51, 201.52, 201.53, 201.54, 201.55,
201.56, 201.57, 201.58, 201.60, 201.61, 201.62, 201.63, 201.64, 201.65, 201.66, 201.67,
201.68, 201.70, 201.71, 201.72, 201.73, 201.74, 201.75, 201.76, 201.77, 201.78, 201.90,
201.91, 201.92, 201.93, 201.94, 201.95, 201.96, 201.97, 201.98, 202.00, 202.01, 202.02,
202.03, 202.04, 202.05, 202.06, 202.07, 202.08, 202.10, 202.11, 202.12, 202.13, 202.14,
202.15, 202.16, 202.17, 202.18, 202.20, 202.21, 202.22, 202.23, 202.24, 202.25, 202.26,
202.27, 202.28, 202.30, 202.31, 202.32, 202.33, 202.34, 202.35, 202.36, 202.37, 202.38,
202.40, 202.41, 202.42, 202.43, 202.44, 202.45, 202.46, 202.47, 202.48, 202.50, 202.51,
202.52, 202.53, 202.54, 202.55, 202.56, 202.57, 202.58, 202.60, 202.61, 202.62, 202.63,
202.64, 202.65, 202.66, 202.67, 202.68, 202.70, 202.71, 202.72, 202.73, 202.74, 202.75,
202.76, 202.77, 202.78, 202.80, 202.81, 202.82, 202.83, 202.84, 202.85, 202.86, 202.87,
202.88, 202.90, 202.91, 202.92, 202.93, 202.94, 202.95, 202.96, 202.97, 202.98, 203.00,
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203.01, 203.02, 203.10, 203.11, 203.12, 203.80, 203.81, 203.82, 204.00, 204.01, 204.02,
204.10, 204.11, 204.12, 204.20, 204.21, 204.22, 204.80, 204.81, 204.82, 204.90, 204.91,
204.92, 205.00, 205.01, 205.02, 205.10, 205.11, 205.12, 205.20, 205.21, 205.22, 205.30,
205.31, 205.32, 205.80, 205.81, 205.82, 205.90, 205.91, 205.92, 206.00, 206.01, 206.02,
206.10, 206.11, 206.12, 206.20, 206.21, 206.22, 206.80, 206.81, 206.82, 206.90, 206.91,
206.92, 207.00, 207.01, 207.02, 207.10, 207.11, 207.12, 207.20, 207.21, 207.22, 207.80,
207.81, 207.82, 208.00, 208.01, 208.02, 208.10, 208.11, 208.12, 208.20, 208.21, 208.22,
208.80, 208.81, 208.82, 208.90, 208.91, 208.92, 209.00, 209.01, 209.02, 209.03, 209.10,
209.11, 209.12, 209.13, 209.14, 209.15, 209.16, 209.17, 209.20, 209.21, 209.22, 209.23,
209.24, 209.25, 209.26, 209.27, 209.29, 209.30, 209.31, 209.32, 209.33, 209.34, 209.35,
209.36, 209.70, 209.71, 209.72, 209.73, 209.74, 209.75, 209.79, 235.0, 235.1, 235.2,
235.3, 235.4, 235.5, 235.6, 235.7, 235.8, 235.9, 236.0, 236.1, 236.2, 236.3, 236.4, 236.5,
236.6, 236.7, 236.90, 236.91, 236.99, 237.0, 237.1, 237.2, 237.3, 237.4, 237.5, 237.6,
237.70, 237.71, 237.72, 237.9, 238.0, 238.1, 238.2, 238.3, 238.4, 238.5, 238.6, 238.71,
238.72, 238.73, 238.74, 238.75, 238.76, 238.77, 238.8, 238.9, 239.0, 239.1, 239.2, 239.3,
239.4, 239.5, 239.6, 239.7, 239.81, 239.89, 239.9
AND EITHER:
Patient encounter during the reporting period (CPT) - Procedure codes: 77427,
77431, 77432, 77435, 77470
OR
Patient encounter during the reporting period (CPT) - Service codes: 99201, 99202,
99203, 99204, 99205, 99212, 99213, 99214, 99215
AND
Patient encounter during the reporting period (CPT) - Procedure codes: 51720,
96401, 96402, 96405, 96406, 96409, 96411, 96413, 96415, 96416, 96417, 96420, 96422,
96423, 96425, 96440, 96445, 96450, 96521, 96522, 96523, 96542, 96549
RATIONALE:
Inadequate cancer pain management is widely prevalent, harmful to the patient, and costly.
CLINICAL RECOMMENDATION STATEMENTS:
All patients with cancer should be screened during the initial evaluation, at regular intervals, and
whenever new therapy is initiated. The standard means for determining how much pain a patient is
experiencing relies on a patient's self-report. Severity should be quantified using a 0-10 numerical
rating scale, a categorical scale, or the pictorial scale (Wong-Baker Faces Pain Rating Scale).
Faces can be used with patients who have difficulty with the above scales, eg, children, the elderly,
and patients with language or cultural differences or other communication barriers (Category 2A).
(NCCN)
Pain intensity must be quantified, as the algorithm bases therapeutic decisions on a numerical
value assigned to the severity of pain. Opioid naïve patients experiencing severe or increasing pain
should receive rapid escalating doses of short-acting opioids, a bowel regimen, and Nonopioid
analgesics as indicated. Psychosocial support is needed to ensure that patients encountering
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common barriers to appropriate pain control (eg, fear of addiction or side effects, inability to
purchase opioids) or needing additional assistance (eg, depression, rapidly declining functional
status) receive appropriate aid. Although pain intensity ratings will be obtained frequently to judge
opioid dose increases, a formal reassessment is mandated in 24 hours for severe pain (Category
2A). (NCCN)
Regular, on-going assessment of pain, non-pain symptoms (including but not limited to shortness
of breath, nausea, fatigue and weakness, anorexia, insomnia, anxiety, depression, confusion, and
constipation), treatment side effects, and functional capacities are documented. Validated
instruments, where available, should be used. (NCP)
All patients should be routinely screened for pain, and when it is present, pain intensity should be
recorded in highly visible ways that facilitate regular review by health care providers. A standard for
pain assessment and documentation should be established in each setting to ensure that pain is
recognized, documented, and treated promptly. (APS)
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Measure #144: Oncology: Medical and Radiation – Plan of Care for Pain
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
This is a two-part measure which is paired with Measure #143: Oncology: Medical and
Radiation: Pain Intensity Quantified. This measure should be reported if patient reports pain
for Measure #143.
DESCRIPTION:
Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently
receiving chemotherapy or radiation therapy who report having pain with a documented plan of
care to address pain
INSTRUCTIONS:
This measure is to be reported at each visit occurring during the reporting period for patients with a
diagnosis of cancer and in which pain is present who are seen during the reporting period. It is
anticipated that clinicians providing care for patients with cancer will submit this measure.
Measure Reporting via Registry:
All eligible instances when patient reports pain for Measure #143 make up the denominator for this
measure.The listed numerator options are used to report the numerator of the measure. The
quality-data codes have been provided for registry only measures for use by registries that utilize
claims data. It is not necessary to submit these codes for registry-based submissions. There are no
allowable performance exclusions for this measure. Do not report this measure via claims.
NUMERATOR:
Patient visits that included a documented plan of care to address pain
Numerator Instructions: A documented plan of care may include: use of opioids, nonopioid analgesics, psychological support, patient and/or family education, referral to a pain
clinic, or reassessment of pain at an appropriate time interval.
OR
Numerator Options:
Plan of care to address pain documented (0521F)
Plan of care for pain not documented, reason not otherwise specified (0521F with 8P)
DENOMINATOR:
All patient visits, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or
radiation therapy who report having pain
Denominator Criteria (Eligible Cases):
All eligible instances when pain severity quantified; pain present (1125F) is reported in the
numerator for Measure #143
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RATIONALE:
Inadequate cancer pain management is widely prevalent, harmful to the patient, and costly.
CLINICAL RECOMMENDATION STATEMENTS:
All patients with cancer should be screened during the initial evaluation, at regular intervals, and
whenever new therapy is initiated. The standard means for determining how much pain a patient is
experiencing relies on a patient's self-report. Severity should be quantified using a 0-10 numerical
rating scale, a categorical scale, or the pictorial scale (Wong-Baker Faces Pain Rating Scale).
Faces can be used with patients who have difficulty with the above scales, eg, children, the elderly,
and patients with language or cultural differences or other communication barriers (Category 2A).
(NCCN)
Pain intensity must be quantified, as the algorithm bases therapeutic decisions on a numerical
value assigned to the severity of pain. Opioid naïve patients experiencing severe or increasing pain
should receive rapid escalating doses of short-acting opioids, a bowel regimen, and Nonopioid
analgesics as indicated. Psychosocial support is needed to ensure that patients encountering
common barriers to appropriate pain control (eg, fear of addiction or side effects, inability to
purchase opioids) or needing additional assistance (eg, depression, rapidly declining functional
status) receive appropriate aid. Although pain intensity ratings will be obtained frequently to judge
opioid dose increases, a formal reassessment is mandated in 24 hours for severe pain (Category
2A). (NCCN)
For patients whose pain is less than 7 at presentation, the pathways are similar. The main
differences include the option to perform the formal pain intensity reassessment less frequently
(24-48 hours) and to consider beginning with slower titration of short-acting opioids for patients with
moderate pain intensity rating 4-6 or with NSAID or acetaminophen if the patient has mild pain
intensity rating from 1 to 0 and is opioid and NSAID-naïve (Category 2A). (NCCN)
Regular, on-going assessment of pain, non-pain symptoms (including but not limited to shortness
of breath, nausea, fatigue and weakness, anorexia, insomnia, anxiety, depression, confusion, and
constipation), treatment side effects, and functional capacities are documented. Validated
instruments, where available, should be used. (NCP)
All patients should be routinely screened for pain, and when it is present, pain intensity should be
recorded in highly visible ways that facilitate regular review by health care providers. A standard for
pain assessment and documentation should be established in each setting to ensure that pain is
recognized, documented, and treated promptly. (APS)
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Measure #145: Radiology: Exposure Time Reported for Procedures Using Fluoroscopy
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of final reports for procedures using fluoroscopy that include documentation of
radiation exposure or exposure time
INSTRUCTIONS:
This measure is to be reported each time fluoroscopy is performed in a hospital or outpatient
setting during the reporting period. There is no diagnosis associated with this measure. It is
anticipated that clinicians providing the services for procedures using fluoroscopy will submit this
measure.
Measure Reporting via Claims:
CPT codes and G-codes are used to identify patients who are included in the measure’s
denominator. CPT Category II codes are used to report the numerator of the measure.
When reporting the measure via claims, submit the listed CPT codes, G-codes, and the
appropriate CPT Category II code OR the CPT Category II code with the modifier. The reporting
modifier allowed for this measure is: 8P- reason not otherwise specified. There are no allowable
performance exclusions for this measure. All measure-specific coding should be reported ON THE
SAME CLAIM.
Measure Reporting via Registry:
CPT codes and G-codes are used to identify patients who are included in the measure’s
denominator. The numerator options as described in the quality-data codes are used to report the
numerator of the measure. The quality-data codes listed do not need to be submitted for registrybased submissions however these codes may be submitted for those registries that utilize claims
data. There are no allowable performance exclusions for this measure.
NUMERATOR:
Final reports for procedures using fluoroscopy that include documentation of radiation exposure or
exposure time
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Radiation Exposure or Exposure Time Documented in Fluoroscopy Report
CPT II 6045F: Radiation exposure or exposure time in final report for procedure using
fluoroscopy, documented
Radiation Exposure or Exposure Time not Documented in Fluoroscopy Report,
Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 6045F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
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6045F with 8P: Final fluoroscopy report does not include documentation of radiation
exposure or exposure time, reason not otherwise specified
DENOMINATOR:
All final reports for procedures using fluoroscopy
Denominator Criteria (Eligible Cases):
Patient encounter during the reporting period (CPT or HCPCS) 0075T, 0080T, 24516,
25606, 25651, 26608, 26650, 26676, 26706, 26727, 27235, 27244, 27245, 27506, 27509,
27756, 27759, 28406, 28436, 28456, 28476, 36147, 36598, 37182, 37183, 37184, 37187,
37188, 37210, 43260, 43261, 43262, 43263, 43264, 43265, 43267, 43268, 43269, 43271,
43272, 43752, 44500, 49440, 49441, 49442, 49446, 49450, 49451, 49452, 49460, 49465,
50382, 50384, 50385, 50386, 50387, 50389, 50590, 61623, 62263, 62264, 62280, 62281,
62282, 62318, 62319, 63610, 64530, 64561, 64605, 64610, 64620, 64680, 64681, 70010,
70015, 70170, 70332, 70370, 70371, 70373, 70390, 71023, 71034, 71040, 71060, 71090,
72240, 72255, 72265, 72270, 72275, 72285, 72291, 72295, 73040, 73085, 73115, 73525,
73542, 73580, 73615, 74190, 74210, 74220, 74230, 74235, 74240, 74241, 74245, 74246,
74247, 74249, 74250, 74251, 74260, 74270, 74280, 74283, 74290, 74291, 74300, 74305,
74320, 74327, 74328, 74329, 74330, 74340, 74355, 74360, 74363, 74425, 74430, 74440,
74445, 74450, 74455, 74470, 74475, 74480, 74485, 74740, 74742, 75600, 75605, 75625,
75630, 75650, 75658, 75660, 75662, 75665, 75671, 75676, 75680, 75685, 75705, 75710,
75716, 75722, 75724, 75726, 75731, 75733, 75736, 75741, 75743, 75746, 75756, 75791,
75801, 75803, 75805, 75807, 75809, 75810, 75825, 75827, 75831, 75833, 75840, 75842,
75860, 75870, 75872, 75880, 75885, 75887, 75889, 75891, 75893, 75894, 75896, 75898,
75900, 75901, 75902, 75940, 75952, 75953, 75954, 75956, 75957, 75958, 75959, 75960,
75961, 75962, 75966, 75970, 75978, 75980, 75982, 75984, 75992, 75994, 75995, 76000,
76001, 76080, 76120, 76496, 77001, 77002, 77003, 92611, 93555, 93556, G0106, G0120,
G0275, G0278
RATIONALE:
Data suggests that the lifetime risk for cancer can be increased, albeit by a small amount, with
frequent or repeated exposure to ionizing radiation, including procedures using fluoroscopy. (NCI,
2002) The BEIR report concluded that “the linear no-threshold model (LNT) provided the most
reasonable description of the relation between low-dose exposure to ionizing radiation and the
incidence of solid cancers that are induced by ionizing radiation.” (NRC, 2006) In order to monitor
these long-term effects, the exposure time or radiation dose that a patient receives as a result of
the procedure should be measured and recorded in the patient’s record.
CLINICAL RECOMMENDATION STATEMENTS:
Radiation dose related information provided by automated dosimetry systems should be recorded
in the patient’s permanent record for procedures involving more than 10 minutes of fluoroscopic
exposure. If automated dosimetry data is not available, fluoroscopic exposure times should be
recorded in the patient’s medical record for such procedures. (ACR, 2003)
[ACR] should now encourage practices to record actual fluoroscopy time for all fluoroscopic
procedures. The fluoroscopy time for various procedures (e.g., upper gastrointestinal, pediatric
voiding cystourethrography, diagnostic angiography) should then be compared with benchmark
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figures…More complete patient radiation dose data should be recorded for all high-dose
interventional procedures, such as embolizations, transjugular intrahepatic portosystemic shunts,
and arterial angioplasty or stent placement anywhere in the abdomen and pelvis. (Amis et al.,
ACR, 2007)
Measure & record patient radiation dose:
• Record fluoroscopy time
• Record available measures – DAP (dose area product), cumulative dose, skin dose
(NCI, 2005)
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Measure #146: Radiology: Inappropriate Use of “Probably Benign” Assessment
Category in Mammography Screening
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of final reports for screening mammograms that are classified as “probably benign”
INSTRUCTIONS:
This measure is to be reported each time a screening mammogram is performed during the
reporting period. It is anticipated that clinicians who provide the physician component of diagnostic
imaging studies for screening mammograms will submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM codes, CPT codes, and G-codes are used to identify patients who are
included in the measure’s denominator. CPT Category II codes are used to report the numerator of
the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
G-codes, and the appropriate CPT Category II codes. There are no allowable performance
exclusions for this measure. All measure-specific coding should be reported ON THE SAME
CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and G-codes are used to identify patients who are
included in the measure’s denominator. The numerator options as described in the quality-data
codes are used to report the numerator of the measure. The quality-data codes listed do not need
to be submitted for registry-based submissions however these codes may be submitted for those
registries that utilize claims data. There are no allowable performance exclusions for this measure.
NUMERATOR:
Final reports classified as “probably benign”
Numerator Instructions: For performance, a lower percentage, with a definitional target
approaching 0%, indicates appropriate assessment of screening mammograms (eg, the
proportion of screening mammograms that are classified as “probably benign”).
The mammogram assessment category (and corresponding CPT Category II [33xxF]
code) to be reported is the single overall final assessment for the mammographic study.
Separate breast assessment categories should not be reported for this measure.
Definition:
“Probably Benign” Classification – MQSA assessment category of “probably benign”;
BI-RADS® category 3; or FDA-approved equivalent assessment category
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OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Mammogram Assessment Category of “Probably Benign” Documented
CPT II 3343F: Mammogram assessment category of “probably benign”, documented
CPT II 3340F: Mammogram assessment category of “incomplete: need additional imaging
evaluation,” documented
OR
CPT II 3341F: Mammogram assessment category of “negative”, documented
OR
CPT II 3342F: Mammogram assessment category of “benign”, documented
OR
CPT II 3344F: Mammogram assessment category of “suspicious”, documented
OR
CPT II 3345F: Mammogram assessment category “highly suggestive of malignancy”,
documented
OR
CPT II 3350F: Mammogram assessment category of “known biopsy proven malignancy”,
documented
DENOMINATOR
All final reports for screening mammograms
Denominator Criteria (Eligible Cases):
Diagnosis for screening mammogram (line-item ICD-9-CM): V76.11, V76.12
AND
Patient encounter during the reporting period (CPT or HCPCS): 77057, G0202
RATIONALE:
Although a mammogram assessment category of “probably benign” is not recommended for use in
interpreting screening mammograms, it is associated with up to 11% of screening mammograms
and accounts for over 40%–50% of abnormal screening mammograms. (Yasmeen et al., 2003A)
Mammogram assessment category of “probably benign” is coupled with a recommendation for
short-interval follow-up (typically 6 months), resulting in economic and emotional consequences for
the women that receive them.
CLINICAL RECOMMENDATION STATEMENTS:
Do not use Category 3 in interpreting screening examinations. (ACR, 2003)
All the published studies emphasize the need to conduct a complete diagnostic imaging evaluation
before making a probably benign (Category 3) assessment; hence it is inadvisable to render such
an assessment when interpreting a screening examination. (ACR, 2003)
The use of Category 3, probably benign, is reserved for findings that are almost certainly benign. It
must be emphasized that this is NOT an indeterminate category for malignancy, but one that, for
mammography, has a less than 2% chance of malignancy (i.e. is almost certainly benign). (ACR,
2003)
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Such findings are generally identified on baseline screening or on screening for which previous
examinations are unavailable for comparison. Immediate evaluation with additional mammographic
views and/or ultrasound is required to render a Category 3, probably benign assessment. (ACR,
2003)
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Measure #147: Nuclear Medicine: Correlation with Existing Imaging Studies for All
Patients Undergoing Bone Scintigraphy
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of final reports for all patients, regardless of age, undergoing bone scintigraphy that
include physician documentation of correlation with existing relevant imaging studies (eg, x-ray,
MRI, CT, etc.) that were performed
INSTRUCTIONS:
This measure is to be reported each time bone scintigraphy is performed during the reporting
period. There is no diagnosis associated with this measure. It is anticipated clinicians performing
the bone scintigraphy study will report on this measure.
Measure Reporting via Claims:
CPT codes are used to identify patients who are included in the measure’s denominator. CPT
Category II codes are used to report the numerator of the measure.
When reporting the measure via claims, submit the listed CPT codes, and the appropriate CPT
Category II code OR the CPT Category II code with the modifier. The modifiers allowed for this
measure are: 3P- system reason, 8P- reason not otherwise specified. All measure-specific coding
should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
CPT codes are used to identify patients who are included in the measure’s denominator. The
numerator options as described in the quality-data codes are used to report the numerator of the
measure. The quality-data codes listed do not need to be submitted for registry-based submissions
however these codes may be submitted for those registries that utilize claims data.
NUMERATOR:
Final reports that include physician documentation of correlation with existing relevant imaging
studies (eg, x-ray, MRI, CT, etc.)
Definition:
Relevant Imaging Studies – Studies that correspond to the same anatomical region in
question.
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Bone Scintigraphy Report Correlated with Existing Studies
CPT II 3570F: Final report for bone scintigraphy study includes correlation with existing
relevant imaging studies (eg., x-ray, MRI, CT) corresponding to the same anatomical
region in question
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OR
Bone Scintigraphy Report not correlated for System Reasons
Append a modifier (3P) to CPT Category II code 3570F to report documented
circumstances that appropriately exclude patients from the denominator.
3570F with 3P: Documentation of system reason(s) for not documenting correlation with
existing relevant imaging studies in final report (eg no existing relevant
imaging study available, patient did not have a previous relevant imaging
study)
Note: Correlative studies are considered to be unavailable if relevant
studies (reports and/or actual examination material) from other imaging
modalities exist but could not be obtained after reasonable efforts to
retrieve the studies are made by the interpreting physician prior to the
finalization of the bone scintigraphy report.
Bone Scintigraphy Report not Correlated, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3570F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3570F with 8P: Bone scintigraphy report not correlated, reason not otherwise specified
DENOMINATOR:
All final reports for patients, regardless of age, undergoing bone scintigraphy
Denominator Criteria (Eligible Cases):
Patient encounter during the reporting period (CPT): 78300, 78305, 78306, 78315,
78320
RATIONALE:
Radionuclide bone imaging plays an integral part in tumor staging and management; the majority
of bone scans are performed in patients with a diagnosis of malignancy, especially carcinoma of
the breast, prostate gland, and lung. This modality is extremely sensitive for detecting skeletal
abnormalities, and numerous studies have confirmed that it is considerably more sensitive than
conventional radiography for this purpose. However, the specificity of bone scan abnormalities can
be low since many other conditions may mimic tumor; therefore, it is important that radionuclide
bone scans are correlated with available, relevant imaging studies. Existing imaging studies that
are available can help inform the diagnosis and treatment for the patient. Furthermore, correlation
with existing radiographs is considered essential to insure that benign conditions are not
interpreted as tumor. While there are no formal studies on variations in care in how often
correlation with existing studies is not performed, there is significant anecdotal information from
physicians practicing in the field that there is a gap in care and that correlation is not occurring
frequently when images are available.
Literature suggests that as many as 30% of Radiology reports contain errors, regardless of the
imaging modality, Radiologists experience, or time spent in interpretation. Evidence has also
suggested that Radiology reports are largely non-standardized and commonly incomplete, vague,
untimely, and error-prone and may not serve the needs of referring physicians. Therefore, it is
imperative that existing imaging reports be correlated with the Nuclear Medicine bone scintigraphy
procedure to ensure proper diagnosis and appropriate patient treatment.
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CLINICAL RECOMMENDATION STATEMENTS:
Bone scintigraphic abnormalities should be correlated with appropriate physical examination and
imaging studies to ascertain that osseous or soft-tissue abnormalities, which might cause cord or
other nerve compression or pathologic fracture in an extremity, are not present. (SNM, 2003)
Relevant radiographs and/or MR imaging of painful sites to exclude cord compression or severe
lytic lesions which carry an increased risk of pathologic fracture should be examined by the
physician. (SNM, 2003)
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Measure #153: Chronic Kidney Disease (CKD): Referral for Arteriovenous (AV) Fistula
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5,
not receiving Renal Replacement Therapy [RRT]), who were referred for AV fistula at least once
during the 12-month reporting period
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with a
diagnosis of advanced CKD seen during the reporting period. It is anticipated that clinicians
providing care for patients with advanced CKD will submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 8P- reason not
otherwise specified. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes and patient demographics are used to identify patients who
are included in the measure’s denominator. The numerator options as described in the quality-data
codes are used to report the numerator of the measure. The quality-data codes listed do not need
to be submitted for registry-based submissions however these codes may be submitted for those
registries that utilize claims data.
NUMERATOR:
Patients who were referred for AV fistula at least once during the 12 month reporting period
OR
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
AV Fistula Referred
CPT II 4051F: Referred for an arteriovenous (AV) fistula
AV Fistula not Referred for Medical or Patient Reasons
Append a modifier (1P or 2P) to CPT Category II code 4051F to report documented
circumstances that appropriately exclude patients from the denominator.
4051F with 1P: Documentation of medical reason(s) for not referring for an AV fistula
4051F with 2P: Documentation of patient reason(s) for not referring for an AV fistula
AV Fistula not Referred, Reason not Specified
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Append a reporting modifier (8P) to CPT Category II code 4051F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4051F with 8P: AV fistula not referred, reason not otherwise specified
DENOMINATOR:
All patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not
receiving RRT)
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for stage 4 or 5 CKD (line-item ICD-9-CM): 585.4, 585.5
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
For patients who will require dialysis, an AV fistula is the preferred permanent vascular access.
Patients who have an AV fistula as their permanent vascular access for dialysis have fewer
complications, such as infection. However USRDS data shows that only 35% of male and 15% of
female hemodialysis patients have an AV fistula compared to 50% of male and 60% of female
hemodialysis patients that have a long-term catheter as their vascular access. By improving the
rate of which AV fistulas are used, morbidity and mortality due to complications of other types of
permanent vascular access will decrease.
CLINICAL RECOMMENDATION STATEMENTS:
1.3 Patients should have a functional permanent access at the initiation of dialysis therapy.
• 1.3.1 A fistula should be placed at least 6 months before the anticipated start of HD
treatments. This timing allows for access evaluation and additional time for revision to
ensure a working fistula is available at initiation of dialysis therapy. (NKF 2006)
2.1 The order of preference for placement of fistulae in patients with kidney failure who choose HD
as their initial mode of KRT should be (in descending order of preference):
• 2.1.1 Preferred: Fistulae (NKF 2006)
o 2.1.1.1 A wrist (radiocephalic) primary fistula (NKF 2006)
o 2.1.1.2 An elbow (brachiocephalic) primary fistula (NKF 2006)
o 2.1.1.3 A transposed brachial basilic vein fistula (NKF 2006)
• 2.1.2 Acceptable: AVG of synthetic or biological material, such as: (NKF 2006)
o 2.1.2.1 A forearm loop graft, preferable to a straight configuration
o 2.1.2.2 Upper-arm graft
o 2.1.2.3 Chest wall or “necklace” prosthetic graft or lower-extremity fistula or graft;
all upper-arm sites should be exhausted
• 2.1.3 Avoid if possible: Long-term catheters. (NKF 2006)
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o 2.1.3.1 Short-term catheters should be used for acute dialysis and for a limited
duration in hospitalized patients. Noncuffed femoral catheters should be used in
bed-bound patients only (NKF 2006)
o 2.1.3.2 Long-term catheters or dialysis port catheter systems should be used in
conjunction with a plan for permanent access. Catheters capable of rapid flow
rates are preferred. Catheter choice should be based on local experience, goals
for use, and cost (NKF 2006)
o 2.1.3.3 Long-term catheters should not be placed on the same side as a maturing
AV access, if possible (NKF 2006)
o 2.1.4 Patients should be considered for construction of a primary fistula after
failure of every dialysis AV access (NKF 2006)
8.1.2 The goals for permanent HD access placement should include:
• 8.1.2.1 Prevalent functional AVF placement rate of greater than 65% of patients. (NKF
2006)
• 8.1.2.2 Cuffed catheter for permanent dialysis access (e.g., not as a bridge) in less than
10% of patients. Long-term catheter access is defined as the use of dialysis catheter for
more than three months in the absence of a maturing permanent access – graft of fistula.
(NKF 2006)
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Measure # 154: Falls: Risk Assessment
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
This is a two-part measure which is paired with Measure #155: Falls: Plan of Care. If the falls
risk assessment indicates the patient has documentation of two or more falls in the past
year or any fall with injury in the past year (CPT II code 1100F is submitted), #155 should
also be reported.
DESCRIPTION:
Percentage of patients aged 65 years and older with a history of falls who had a risk assessment
for falls completed within 12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. There is no diagnosis associated with this measure. This measure is appropriate
for use in all non-acute settings (excludes emergency departments and acute care hospitals). This
measure may be reported by clinicians who perform the quality actions described in the measure
based on the services provided and the measure-specific denominator coding.
Measure Reporting via Claims:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. CPT Category II codes are used to report the numerator of the measure.
When reporting the measure via claims, submit the listed CPT codes, and the appropriate CPT
Category II codes OR the CPT Category II code(s) with the modifier. The modifiers allowed for this
measure are: 1P- medical reasons, 8P- reason not otherwise specified. All measure-specific
coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. The numerator options as described in the quality-data codes are used to
report the numerator of the measure. The quality-data codes listed do not need to be submitted for
registry-based submissions however these codes may be submitted for those registries that utilize
claims data.
NUMERATOR:
Patients who had a risk assessment for falls completed within 12 months
Numerator Instructions: All components do not need to be completed during one patient
visit, but should be documented in the medical record as having been performed within the
past 12 months.
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Definitions:
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, or overwhelming external force.
Risk Assessment – Comprised of balance/gait AND one or more of the following: postural
blood pressure, vision, home fall hazards, and documentation on whether medications are
a contributing factor or not to falls within the past 12 months.
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Risk Assessment for Falls Completed
(Two CPT II codes [3288F & 1100F] are required on the claim form to submit this
numerator option)
CPT II 3288F: Falls risk assessment documented
AND
CPT II 1100F: Patient screened for future fall risk; documentation of two or more falls in
the past year or any fall with injury in the past year
Risk Assessment for Falls not Completed for Medical Reasons
(Two CPT II codes [3288F-1P & 1100F] are required on the claim form to submit this
numerator option)
Append a modifier (1P) to CPT Category II code 3288F to report documented
circumstances that appropriately exclude patients from the denominator.
3288F with 1P: Documentation of medical reason(s) for not completing a risk assessment
for falls
AND
CPT II 1100F: Patient screened for future fall risk; documentation of two or more falls in
the past year or any fall with injury in the past year
OR
If patient is not eligible for this measure because patient has documentation of no
falls or only one fall without injury the past year, report:
Patient not at Risk for Falls
(One CPT II code [1101F] is required on the claim form to submit this numerator option)
CPT II 1101F: Patient screened for future fall risk; documentation of no falls in the past
year or only one fall without injury in the past year
OR
If patient is not eligible for this measure because falls status is not documented,
report:
Falls Status not Documented
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OR
(One CPT II code [1101F-8P] is required on the claim form to submit this numerator
option)
Append a reporting modifier (8P) to CPT Category II code 1101F to report circumstances
when the patient is not eligible for the measure.
1101F with 8P: No documentation of falls status
Risk Assessment for Falls not Completed, Reason not Specified
(Two CPT II codes [3288F-8P & 1100F] are required on the claim form to submit this
numerator option)
Append a reporting modifier (8P) to CPT Category II code 3288F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3288F with 8P: Falls risk assessment not completed, reason not otherwise specified
AND
CPT II 1100F: Patient screened for future fall risk; documentation of two or more falls in
the past year or any fall with injury in the past year
DENOMINATOR:
All patients aged 65 years and older who have a history of falls
Denominator Criteria (Eligible Cases):
Patients aged ≥ 65 years on date of encounter
AND
Patient encounter during the reporting period (CPT): 97001, 97002, 97003, 97004,
99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306,
99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336,
99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350
RATIONALE:
Screening for specific medical conditions may direct the therapy. Although the clinical guidelines
and supporting evidence calls for an evaluation of many factors, it was felt that for the purposes of
measuring performance and facilitating implementation this initial measure must be limited in
scope. For this reason, the work group defined an evaluation of balance and gait as a core
component that must be completed on all patients with a history of falls as well as four additional
evaluations – at least one of which must be completed within the 12 month period. Data elements
required for the measure can be captured and the measure is actionable by the physician.
CLINICAL RECOMMENDATION STATEMENTS:
Older people who present for medical attention because of a fall, or report recurrent falls in the past
year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls
risk assessment. This assessment should be performed by a health care professional with
appropriate skills and experience, normally in the setting of a specialist falls service. This
assessment should be part of an individualized, multifactorial intervention. (NICE) (Grade C)
Multifactorial assessment may include the following:
• identification of falls history
• assessment of gait, balance and mobility, and muscle weakness
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•
assessment of osteoporosis risk
assessment of the older person’s perceived functional ability and fear relating to falling
assessment of visual impairment
assessment of cognitive impairment and neurological examination
assessment of urinary incontinence
assessment of home hazards
cardiovascular examination and medication review (NICE) (Grade C)
A falls risk assessment should be performed for older persons who present for medical attention
because of a fall, report recurrent falls in the past year, report difficulties in walking or balance or
fear of falling, or demonstrate unsteadiness or difficulty performing a gait and balance test.
The falls risk evaluation should be performed by a clinician with appropriate skills and
experience. [C]
A falls risk assessment is a clinical evaluation that should include the following, but are not
limited to:
• a history of fall circumstances
• review of all medications and doses
• evaluation of gait and balance, mobility levels and lower extremity joint function
• examination of vision
• examination of neurological function, muscle strength, proprioception, reflexes, and tests of
cortical, extrapyramidal, and cerebellar function
• cognitive evaluation
• screening for depression
• assessment of postural blood pressure
• assessment of heart rate and rhythm
• assessment of heart rate and rhythm, and blood pressure responses to carotid sinus
stimulation if appropriate
• assessment of home environment
The falls risks assessment should be followed by direct intervention on the identified risk. [A] (AGS)
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Measure #155: Falls: Plan of Care
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
This is a two-part measure which is paired with Measure #154: Falls: Risk Assessment.
This measure should be reported if CPT II code 1100F “Patient screened for future falls risk;
documentation of two or more falls in the past year or any fall with injury in the past year” is
submitted for Measure #154.
DESCRIPTION:
Percentage of patients aged 65 years and older with a history of falls who had a plan of care for
falls documented within 12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. There is no diagnosis associated with this measure. This measure is appropriate
for use in all non-acute settings (excludes emergency departments and acute care hospitals). This
measure may be reported by clinicians who perform the quality actions described in the measure
based on the services provided and the measure-specific denominator coding.
Measure Reporting via Claims:
All eligible instances when CPT II code 1100F (Patient screened for future falls risk; documentation
of two or more falls in the past year or any fall with injury in the past year) is reported in the
numerator for Measure #154 make up the denominator for this measure. CPT Category II codes
are used to report the numerator of the measure.
When CPT II code 1100F is reported with Measure #154, add the appropriate CPT Category II
codes OR the CPT Category II code(s) with the modifier. The modifiers allowed for this measure
are: 1P- medical reasons, 8P- reason not otherwise specified. All measure-specific coding should
be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
All eligible instances when patient is reported in the numerator for Measure #154 as screened for
future falls risk; documentation of two or more falls in the past year or any fall with injury in the past
year are included in the measure’s denominator. The numerator options as described in the
quality-data codes are used to report the numerator of the measure. The quality-data codes listed
do not need to be submitted for registry-based submissions however these codes may be
submitted for those registries that utilize claims data.
NUMERATOR:
Patients with a plan of care for falls documented within 12 months
Numerator Instructions: All components do not need to be completed during one patient
visit, but should be documented in the medical record as having been performed within the
past 12 months.
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Definitions:
Plan of Care – Must include: 1) consideration of appropriate assistance device AND 2)
balance, strength, and gait training.
Consideration of Appropriate Assistance Device – Medical record must include:
documentation that an assistive device was provided or considered OR referral for
evaluation for an appropriate assistance device
Balance, Strength, and Gait Training – Medical record must include: documentation that
balance, strength, and gait training/instructions were provided OR referral to an exercise
program, which includes at least one of the three components: balance, strength or gait
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, or overwhelming external force
OR
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Plan of Care Documented
CPT II 0518F: Falls plan of care documented
Plan of Care not Documented for Medical Reasons
Append a modifier (1P) to CPT Category II code 0518F to report documented
circumstances that appropriately exclude patients from the denominator.
0518F with 1P: Documentation of medical reason(s) for no plan of care for falls
Plan of Care not Documented, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 0518F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
0518F with 8P: Plan of care not documented, reason not otherwise specified
DENOMINATOR:
All patients aged 65 years and older with a history of falls (history of falls is defined as 2 or more
falls in the past year or any fall with injury in the past year)
Denominator Criteria (Eligible Cases):
All eligible instances when CPT II code 1100F (Patient screened for future fall risk;
documentation of two or more falls in the past year or any fall with injury in the past year) is
reported in the numerator for Measure #154.
RATIONALE:
Interventions to prevent future falls should be documented for the patient with 2 or more falls or
injurious falls.
CLINICAL RECOMMENDATION STATEMENTS:
Among community-dwelling older persons (i.e., those living in their own homes), multifactorial
interventions should include:
• gait training and advice on the appropriate use of assistive devices (Grade B)
• review and modification of medication, especially psychotropic medication (Grade B)
• exercise programs, with balance training as one of the components (Grade B)
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•
•
•
treatment of postural hypotension (Grade B)
modification of environmental hazards (Grade C)
treatment for cardiovascular disorders (Grade D) (AGS/BGS/AAOS)
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Measure #156: Oncology: Radiation Dose Limits to Normal Tissues
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients, regardless of age, with a diagnosis of pancreatic or lung cancer receiving
3D conformal radiation therapy with documentation in medical record that radiation dose limits to
normal tissues were established prior to the initiation of a course of 3D conformal radiation for a
minimum of two tissues
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with a
diagnosis of cancer receiving 3D conformal radiation therapy seen during the reporting period. It is
anticipated that clinicians providing radiation therapy for patients with cancer will submit this
measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes and CPT codes are used to identify patients who are included
in the measure’s denominator. CPT Category II code(s) are used to report the numerator of the
measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
reporting modifier allowed for this measure is: 8P- reason not otherwise specified. There are no
allowable performance exclusions for this measure. All measure-specific coding should be reported
ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes and CPT codes are used to identify patients who are included in the
measure’s denominator. The numerator options as described in the quality-data codes are used to
report the numerator of the measure. The quality-data codes listed do not need to be submitted for
registry-based submissions however these codes may be submitted for those registries that utilize
claims data. There are no allowable performance exclusions for this measure.
NUMERATOR:
Patients who had documentation in medical record that radiation dose limits to normal tissues were
established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Radiation Dose Limits to Normal Tissues Established
CPT II 0520F: Radiation dose limits to normal tissues established prior to the initiation of a
course of 3D conformal radiation for a minimum of two tissues/organs
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Radiation Dose Limits to Normal Tissues not Established, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 0520F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
0520F with 8P: Radiation dose limits to normal tissues not established prior to the
initiation of a course of 3D conformal radiation for a minimum of two
tissues/organs, reason not otherwise specified
DENOMINATOR:
All patients, regardless of age, with a diagnosis of pancreatic or lung cancer who receive 3D
conformal radiation therapy
Denominator Criteria (Eligible Cases):
Diagnosis for pancreatic or lung cancer (line-item ICD-9-CM): 157.0, 157.1, 157.2,
157.3, 157.4, 157.8, 157.9, 162.0, 162.2, 162.3, 162.4, 162.5, 162.8, 162.9
AND
Patient encounter during the reporting period (CPT): 77295
RATIONALE:
Identifying radiation dose limits to normal tissues is an important step in the process of care for
patients receiving radiation therapy treatments. Although no specific data is available, in its practice
accreditation reviews, the American College of Radiation Oncology has found that radiation dose
limits to normal tissues are included in the patient chart less frequently than reviewers expected.
While dose constraint specification is an integral part of IMRT, it is not required for 3D conformal
radiation therapy. Patients treated with 3D conformal radiation therapy are often subjected to dose
levels that exceed normal tissue tolerance, and precise specification of maximum doses to be
received by normal tissues represent both an intellectual process for the physician during radiation
treatment planning, and a fail-safe point for the treating therapists. In most circumstances where
facilities require specification of radiation dose limits to normal tissues prior to initiation of therapy,
policies and procedures exist that prohibit exceeding those limits in the absence of written
physician approval.
CLINICAL RECOMMENDATION STATEMENTS:
“The cognitive process of treatment planning requires the radiation oncologist to have knowledge
of the natural history of the tumor to be treated and to determine the tumor site, its extent, and its
relationship with adjacent normal tissues. This process is based on consideration of the history,
physician examination, endoscopy, diagnostic imaging, findings at surgery, and histology. When
ionizing radiation is to be used, the radiation oncologist must select beam characteristics and/or
radionuclide sources, method of delivery, doses, and sequencing with other treatments. The
sequencing with other treatments should be coordinated in collaboration with medical and surgical
oncologists. The radiation oncologist determines the dose to be delivered to the tumor, limiting
doses to critical structures (emphasis added), and the fractionation desired.” (ACR 2004)
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Measure #157: Thoracic Surgery: Recording of Clinical Stage for Lung Cancer and
Esophageal Cancer Resection
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of surgical patients aged 18 years and older undergoing resection for lung or
esophageal cancer who had clinical TNM staging provided prior to surgery
INSTRUCTIONS:
This measure is to be reported each time a major cancer resection of the lung or esophagus is
performed. This measure is intended to reflect the quality of services provided for patients
undergoing resection for lung or esophageal cancer. The clinical staging of lung and esophageal
cancer patients guides the decision-making process when choosing optimal treatment modality
which may or may not include surgery. It is anticipated that clinicians who perform the listed
surgical procedures with a diagnosis of lung or esophageal cancer will submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II code(s) are used to
report the numerator of the measure.
When reporting the measure via claims submit the listed CPT codes and the appropriate CPT
Category II code OR the CPT Category II code with the modifier. The modifiers allowed for this
measure are: 1P- medical reasons, 8P- reason not otherwise specified. All measure-specific
coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions however these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients undergoing resection for lung and esophageal cancer who had clinical TNM staging
provided prior to surgery
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Clinical TNM Staging Provided
CPTII 3323F: Clinical tumor, node and metastases (TNM) staging documented and
reviewed prior to surgery
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OR
Clinical TNM Staging not Provided for Medical Reasons
Append a modifier (1P) to CPT Category II code 3323F to report documented
circumstances that appropriately exclude patients from the denominator.
3323F with 1P: Documentation of medical reason(s) for clinical tumor, node and
metastases (TNM) staging not documented and reviewed prior to surgery
Clinical TNM Staging not Provided, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3323F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3323F with 8P: Clinical tumor, node and metastases (TNM) staging not documented and
reviewed prior to surgery, reason not otherwise specified
DENOMINATOR:
All patients aged 18 years and older undergoing resection for lung or esophageal cancer
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for lung or esophageal cancer (line-item ICD-9-CM): 150.3, 150.4, 150.5,
162.2, 162.3, 162.4, 162.5
AND
Patient encounter during the reporting period (CPT): 32440, 32442, 32445, 32480,
32482, 32484, 32486, 32488, 32500, 32503, 32504, 32657, 32663, 43107, 43108, 43112,
43113, 43117, 43118, 43121, 43122, 43123
RATIONALE:
Evaluation of patients with suspected lung cancer and esophageal cancer includes both diagnosis
of the primary tumor and evaluation of the extent of disease. The current system for staging lung
and esophageal cancer is based on the AJCC TNM classification. The clinical staging of lung and
esophageal cancer patients guides the decision-making process when choosing optimal treatment
modality which may or may not include surgery. Review of the 5000 lobectomies recorded in the
current STS General Thoracic Database identified a significant gap with respect to recording of
clinical stage; it was reported in only 80% of patients undergoing resection for lung cancer.
Remediation of this process gap should improve quality by reducing inappropriate selection of
treatment modalities including surgery.
CLINICAL RECOMMENDATION STATEMENTS:
BTS Guidelines on the selection of patients with lung cancer for surgery, Thorax 2001;56,89108(February), and National Cancer Institute Web site: Non-Small Cell Lung Cancer PDQ®:
Treatment. Available for download at the following address as of 11/3/08 http://www.cancer.gov/cancertopics/pdq/treatment/non-small-cell-lung/HealthProfessional, page3,
and Surgical treatment of esophageal cancer. Manchester (MA): Society for Surgery of the
Alimentary Tract (SSAT); 2002. 3 p.ASSESSMENT OF OPERABILITY (Clinical Staging
Importance in Lung Cancer)
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“Assuming satisfactory performance status, operability in patients with lung cancer depends on the
clinical assessment of tumor stage. Preoperative clinical staging (cTNM), as accurately as possible
given the limitations of the investigations available, is therefore crucial.
Recommendations
1. All patients being considered for surgery should have a plain chest radiograph and a
computed tomographic (CT) scan of the thorax including the liver and adrenal glands. [B]
2. Confirmatory diagnostic percutaneous needle biopsy in patients presenting with
peripheral lesions is not mandatory in patients who are otherwise fit, particularly if there
are previous chest radiographs showing no evidence of a lesion. [B]
3. Patients with mediastinal nodes greater than 1 cm in short axis diameter on the CT scan
should undergo biopsy by staging mediastinoscopy, anterior mediastinotomy, or needle
biopsy as appropriate. [B]
On the basis of these investigations, cTNM staging should be possible and appropriate surgery
undertaken in the light of current knowledge of results.”
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Measure #158: Carotid Endarterectomy: Use of Patch During Conventional Carotid
Endarterectomy
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older undergoing conventional (non-eversion) carotid
endarterectomy who undergo patch closure of the arteriotomy
INSTRUCTIONS:
This measure is to be reported each time a patient undergoes a carotid endarterectomy procedure
during the reporting period. It is anticipated that clinicians who perform the listed surgical procedure
as specified in the denominator coding will submit this measure.
Measure Reporting via Claims:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. G-codes are used to report the numerator of the measure.
When reporting the measure via claims, submit the listed CPT codes, and the appropriate
numerator G-code. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. The numerator options as described in the quality-data codes are used to
report the numerator of the measure. The quality-data codes listed do not need to be submitted for
registry-based submissions however these codes may be submitted for those registries that utilize
claims data.
NUMERATOR:
Patients undergoing an elective, conventional CEA who undergo patch closure of the arteriotomy
site
Definitions:
Non-Eversion, Conventional CEA – Involves a longitudinal arteriotomy incision with
plaque extraction requiring closure of the arteriotomy with or without a patch (vein or
synthetic).
Eversion Carotid Endarterectomy – Involves the complete transection of the internal
carotid artery at its origin and the removal of the atheroma circumferentially is performed
followed by re-implantation of the vessel.
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Conventional CEA with Patch
G8524: Patch closure used for patient undergoing conventional CEA
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OR
OR
If patient is not eligible for this measure because a conventional CEA was not
performed, report:
G8525: Clinician documented that endarterectomy patient did not receive conventional
CEA
Conventional CEA Performed without Patch
G8526: Patch closure not used for patient undergoing conventional CEA, reason not
specified
DENOMINATOR:
Patients aged 18 years and older undergoing CEA requiring patch arteriotomy (vein or synthetic)
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Patient encounter during the reporting period (CPT): 35301
RATIONALE:
Carotid endarterectomy (CEA) can be performed in the conventional manner, in which a
longitudinal arteriotomy is used to expose the plaque for subsequent endarterectomy, or with the
eversion technique, in which the artery is transected and everted for plaque removal. With
conventional endarterectomy, multiple randomized trials have demonstrated the benefit of patching
to reduce postoperative stroke and prevent recurrent stenosis. With conventional endarterectomy,
multiple randomized trials have demonstrated the benefit of patching to reduce postoperative
stroke and prevent recurrent stenosis (Ref 1-10). In a systematic review of this question, Bond et al
concluded that patch angioplasty was associated with a reduction of stroke risk (P=.004), ipsilateral
stroke (P=.001), stroke or death postoperatively (P=.007) and both perioperative occlusion
(P=.0001) and recurrent stenosis during long-term follow-up (P<.0001) (Ref 11). This report
concluded that patching should be performed during conventional CEA. There does not appear to
be any difference or advantage among various types of patches (autogenous vein, polyester,
polytetrafluoroethylene, or bovine pericardium).
Because eversion CEA involves a transverse closure, it does not require patching. In fact a
Cochrane review based on multiple randomized studies have shown that eversion CEA is
comparable in outcome to conventional CEA with patching in terms of stroke, death, and recurrent
stenosis.
CLINICAL RECOMMENDATION STATEMENTS:
There are no current practice guidelines concerning use of patch during conventional CEA, but
such guidelines are currently being prepared by the Society for Vascular Surgery. The VSGNNE
uses carotid patching during conventional CEA as a quality indicator in its reports to regional
centers. A 2007 analysis of nearly 3000 conventional CEAs performed in VSGNNE showed that
the use of patching varied from 60% to 100% (mean 90%) among 11 hospitals. This demonstrates
potential for improvement even for a group of surgeons where this result is known.
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Measure #159: HIV/AIDS: CD4+ Cell Count or CD4+ Percentage
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 6 months and older with a diagnosis of HIV/AIDS for whom a CD4+
cell count or CD4+ cell percentage was performed at least once every 6 months
INSTRUCTIONS:
This measure is to be reported either once or twice per reporting period for patients with HIV/AIDS.
If the patient is seen during both the first and second halves of the year, we would expect 2 QDCs:
once during the first half of the year and once in the second half of the year. However, if the two
visits both occurred in either the first or second half of the year, only 1 QDC needs to be reported.
This measure is intended to reflect the quality of services provided for the primary management of
patients with HIV/AIDS.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The listed numerator options are used to report
the numerator of the measure. The quality-data codes have been provided for registry only
measures for use by registries that utilize claims data. It is not necessary to submit these codes for
registry-based submissions. There are no allowable performance exclusions for this measure. Do
not report this measure via claims.
NUMERATOR:
Patients with CD4+ cell count or CD4+ cell percentage performed at least once every 6 months
OR
Numerator Options:
CD4+ cell count or CD4+ cell percentage documented as performed (3500F)
CD4+ cell count or percentage not documented as performed, reason not specified (3500F
with 8P)
DENOMINATOR:
Patients aged 6 months and older with a diagnosis of HIV/AIDS who had at least two medical visits
during the measurement year, with at least 60 days between each visit
Denominator Criteria (Eligible Cases):
Patients aged ≥ 6 months on date of encounter
AND
Diagnosis for HIV/AIDS (ICD-9-CM): 042, 079.53, V08
AND
Patient encounters during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
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RATIONALE:
CD4+ cell counts help to establish monitoring frequency, and are taken into account when
establishing a patient’s disease stage.
CLINICAL RECOMMENDATION STATEMENTS:
Asymptomatic patients with normal CD4 cell counts and low virus loads can be monitored
infrequently, repeating virus load measurements every 3-4 months and CD4 cell counts every 3-6
months. (Level of Evidence: B) (IDSA)
CD4 percentage or count should be measured at the time of diagnosis of HIV infection and at least
every 3-4 months thereafter. (DHHS)
Clinicians should measure CD4 cell counts at the time of diagnosis of HIV infection and every 3 to
4 months thereafter. (NYSDOH)
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Measure #160: HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 6 years and older with a diagnosis of HIV/AIDS and CD4+ cell count
<200 cells/mm3 who were prescribed PCP prophylaxis within 3 months of low CD4+ cell count
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with HIV/AIDS
seen during the reporting period. Only patients who had at least two visits during the reporting
period, with at least 60 days between each visit will be counted in the denominator for this
measure. This measure is intended to reflect the quality of services provided for the primary
management of patients with HIV/AIDS.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The listed numerator options are used to report
the numerator of the measure. The quality-data codes have been provided for registry only
measures for use by registries that utilize claims data. It is not necessary to submit these codes for
registry-based submissions. Do not report this measure via claims.
NUMERATOR:
Patients who were prescribed PCP prophylaxis within 3 months of low CD4+ cell count
Definition:
Prescribed – May include prescription given to the patient for PCP prophylaxis therapy at
one or more visits in the 12-month period OR patient already taking PCP prophylaxis
therapy as documented in current medication list
OR
Numerator Options:
Pneumocystis jiroveci pneumonia prophylaxis prescribed within 3 months of low CD4+ cell
count or percentage (4280F)
AND
CD4+ cell count <200 cells/mm3 (3494F)
Pneumocystis jiroveci pneumonia prophylaxis not prescribed within 3 months of low CD4+
cell count or percentage for medical reason (4280F with 1P)
(i.e., patient’s CD4+ cell count above threshold within 3 months after CD4+ cell count
below threshold, indicating that the patient’s CD4+ levels are within an acceptable range
and the patient does not require PCP prophylaxis)
AND
CD4+ cell count <200 cells/mm3 (3494F)
OR
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OR
CD4+ cell count 200 – 499 cells/mm3 (3495F)
OR
CD4+ cell count ≥500 cells/mm3 (3496F)
CD4+ cell count not performed, reason not specified (3494F with 8P)
OR
PCP prophylaxis was not prescribed within 3 months of low CD4+ cell count, reason not
specified (4280F with 8P)
AND
CD4+ cell count <200 cells/mm3 (3494F)
DENOMINATOR:
Patients aged 6 years and older with a diagnosis of HIV/AIDS whose CD4+ cell count < 200
cells/mm3, and who had at least two medical visits during the measurement year, with at least 60
days between each visit
Denominator Criteria (Eligible Cases):
Patients aged ≥ 6 years on date of encounter
AND
Diagnosis for HIV/AIDS (ICD-9-CM): 042, 079.53, V08
AND
Patient encounters during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Although advances in the management of HIV and AIDS diseases have been made, Pneumocystis
carinii pneumonia (PCP) remains an important complication and cause of morbidity. Without PCP
prophylaxis, patients with HIV/AIDS are at increased risk of developing PCP, especially when CD4
cell counts fall 200 cells/mm3 to 250 cells/mm3 (Kaplan, 1998; Phair, 1990). PCP prophylaxis is
very effective and has been demonstrated to prolong life.
CLINICAL RECOMMENDATION STATEMENTS:
HIV-infected adults and adolescents, including pregnant women and those on HAART, should
receive chemoprophylaxis against PCP if they have a CD4+T lymphocyte count of <200/mL or a
history of oropharyngeal candidiasis. (USPH/IDSA, 2002)
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Measure #161: HIV/AIDS: Adolescent and Adult Patients with HIV/AIDS Who Are
Prescribed Potent Antiretroviral Therapy
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients with a diagnosis of HIV/AIDS aged 13 years and older: who have a history
of a nadir CD4+ cell count below 350/mm3 or who have a history of an AIDS-defining condition,
regardless of CD4+ cell count; or who are pregnant, regardless of CD4+ cell count or age, who
were prescribed potent antiretroviral therapy
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with HIV/AIDS
seen during the reporting period. Only patients who had at least two visits during the reporting
period, with at least 60 days between each visit will be counted in the denominator for this
measure. This measure is intended to reflect the quality of services provided for the primary
management of patients with HIV/AIDS.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The listed numerator options are used to report
the numerator of the measure. The quality-data codes have been provided for registry only
measures for use by registries that utilize claims data. It is not necessary to submit these codes for
registry-based submissions. Do not report this measure via claims.
There are two reporting criteria for this measure:
(1) Patients who are aged 13 years and older with a diagnosis of HIV/AIDS who have a
history of a nadir CD4+ cell count below 350/mm3 or who have a history of an AIDS-defining
condition, regardless of CD4+ cell count.
OR
(2) Patients with a diagnosis of HIV/AIDS and who are pregnant, regardless of CD4+ cell
count or age
Eligible professionals should submit data on one set of reporting criteria, depending on the
clinical findings. If patient has HIV/AIDS (without a diagnosis of pregnancy) and a history of
a nadir CD4+ cell count below 350/mm3 or a history of AIDS-defining condition, use
Denominator Reporting Criteria 1. If the patient has HIV/AIDS and pregnant, use
Denominator Reporting Criteria 2. If the patient can be included in both criteria, the eligible
professional may report quality data for either reporting criteria and this will count as
appropriate reporting for this patient.
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REPORTING CRITERIA 1: For all patients with HIV/AIDS (without a diagnosis of pregnancy)
NUMERATOR:
Patients who were prescribed potent antiretroviral therapy
Numerator Instructions: Nadir (lowest ever) CD4+ cell count may be the present count
Definitions:
Potent Antiretroviral Therapy – Potent antiretroviral therapy is described as any
antiretroviral therapy that has demonstrated optimal efficacy and results in durable
suppression of HIV as shown by prior clinical trials. For potent antiretroviral therapy
recommendations, refer to current DHHS guidelines available for download at the following
address as of 11/3/08 - http://www.aids.gov.
AIDS-defining Condition – Conditions included in the 1993 AIDS surveillance case
definition:
• Candidiasis of bronchi, trachea, or lungs;
• Candidiasis, esophageal;
• Cervical cancer, invasive;
• Coccidiodomycosis, disseminated or extrapulmonary;
• Cryptococcosis, extrapulmonary;
• Crytosporidiosis, chronic intestinal (greater than 1 month’s duration);
• Cytomegalovirus disease (other than liver, spleen, or nodes);
• Cytomegalovirus retinitis (with loss of vision);
• Encephalopathy, HIV-related;
• Herpes simplex: chronic ulcer(s) (greater than 1 month’s duration);
• Bronchitis, pneumonitis, or esophagitis;
• Histoplasmosis, disseminated or extrapulmonary;
• Isosporiasis, chronic intestinal (greater than 1 month’s duration);
• Kaposi’s sarcoma;
• Lymphoma, Burkitt’s (or equivalent term);
• Lymphoma, immunoblastic (or equivalent term);
• Lymphoma, primary, of brain;
• Mycobacterium avium complex or M. kansasii, disseminated or extrapulmonary;
• Mycobacterium tuberculosis, any site (pulmonary or extrapulmonary);
• Mycobacterium, other species or unidentified species, disseminated or
extrapulmonary;
• Pneumocystis carinii pneumonia;
• Pneumonia, recurrent;
• Progressive multifocal leukoencephalopathy;
• Salmonella septicemia, recurrent;
• Toxoplasmosis of brain;
• Wasting syndrome due to HIV. (NYSDOH, 2007)
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Prescribed – May include prescription given to the patient for potent antiretroviral therapy
at one or more visits in the 12-month period OR patient already taking potent antiretroviral
therapy as documented in current medication list.
Numerator Options:
Potent antiretroviral therapy prescribed (4276F)
AND
OR
OR
History of nadir CD4+ cell count <350 cells/mm3 (3492F)
OR
History of AIDS-defining condition (3490F)
No history of nadir CD4+ cell count <350 cells/mm3 AND no history of AIDS-defining
condition (3493F)
Potent antiretroviral therapy not prescribed, reason not specified (4276F with 8P)
AND
History of nadir CD4+ cell count < 350 cells/mm3 (3492F)
OR
History of AIDS-defining condition (3490F)
DENOMINATOR (REPORTING CRITERIA 1):
Patients aged 13 years or older with a diagnosis of HIV/AIDS who have a history of nadir CD4+ cell
count below 350/mm3 or who have a history of an AIDS-defining condition, regardless of CD4+ cell
count who had at least two medical visits during the measurement year, with at least 60 days
between each visit
Denominator Criteria (Eligible Cases):
Patients aged ≥ 13 years on date of encounter
AND
Diagnosis for HIV/AIDS (ICD-9-CM): 042, 079.53, V08
AND
Patient encounters during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
OR
REPORTING CRITERIA 2: For patients with HIV/AIDS who are pregnant
NUMERATOR:
Patients who were prescribed potent antiretroviral therapy
Definition:
Potent Antiretroviral Therapy – Potent antiretroviral therapy is described as any
antiretroviral therapy that has demonstrated optimal efficacy and results in durable
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suppression of HIV as shown by prior clinical trials. For potent antiretroviral therapy
recommendations, refer to current DHHS guidelines available for download at the following
address as of 11/3/08 - http://www.aids.gov.
Prescribed – May include prescription given to the patient for potent antiretroviral therapy
at one or more visits in the 12-month period OR patient already taking potent antiretroviral
therapy as documented in current medication list.
OR
Numerator Options:
Potent antiretroviral therapy prescribed (4276F)
Potent antiretroviral therapy not prescribed, reason not specified (4276F with 8P)
DENOMINATOR (REPORTING CRITERIA 2):
Patients with a diagnosis of HIV/AIDS who are pregnant, regardless of CD4+ cell count or age who
had at least two medical visits during the measurement year, with at least 60 days between each
visit
Denominator Criteria (Eligible Cases):
Diagnosis for HIV/AIDS (ICD-9-CM): 042, V08, 079.53
AND
Diagnosis for pregnancy (ICD-9-CM): V22.0, V22.1, V22.2, V23.0, V23.1, V23.2, V23.3,
V23.41, V23.49, V23.5, V23.7, V23.81, V23.82, V23.83, V23.84, V23.89, V23.9
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Potent antiretroviral therapy slows disease progression, extends survival, and results in maintained
quality of life by suppressing HIV RNA viral load.
CLINICAL RECOMMENDATION STATEMENTS:
Antiretroviral therapy should be initiated in patients with a history of an AIDS-defining illness (AI) or
with a CD4 T-cell count < 350 cells/mm3. The data supporting this recommendation are stronger for
those with a CD4 T-cell count < 200 cells/mm3 and with a history of AIDS (AI) than for those with
CD4 T-cell counts between 200 and 350 cells/mm3 (AII). Antiretroviral therapy should also be
initiated in the following groups of patients regardless of CD4 T-cell count: a) pregnant women (AI);
b) patients with HIV-associated nephropathy (AI); and c) patients coinfected with HBV when
treatment for HBV infection is indicated (BIII). (DHHS)
Clinicians should prescribe a HAART regimen that is best able to delay disease progression,
prolong survival, and maintain quality of life through maximal viral suppression. (NYSDOH)
Initiation of HAART is recommended for patients who:
are symptomatic* from HIV, OR
have an AIDS-defining condition,** including those with CD4 counts < 200 cells/mm3, or
are asymptomatic with two successive measurements of CD4 counts < 350 cells/mm3 and
patient-related barriers to adherence are minimized.
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*Signs and symptoms include but are not limited to oropharyngeal candidiasis (thrush);
vulvovaginal candidiasis that is frequent or responds poorly to therapy; cervical dysplasia
(moderate or severe)/cervical carcinoma in situ; HIV nephropathy in the setting of worsening serum
creatinine; severe seborrheic dermatitis, constitutional symptoms, such as fever or diarrhea lasting
>1 months; oral hairy leukoplakia; herpes zoster (shingles) involving at least two distinct episodes
or more than one dermatome; thrombocytopenia; listeriosis; pelvic inflammatory disease,
particularly if complicated by tubo-ovarian abscess; peripheral neuropathy; bacillary angiomatosis;
or any conditions included in the CDC-defined AIDS definition.
**All HIV-infected persons with CD4+ T-lymphocyte counts of less than 200 cells/uL or a CD4+
percentage of less than 14. Conditions included in the 1993 AIDS surveillance case definition:
Candidiasis of bronchi, trachea, or lungs; candidiasis, esophageal; cervical cancer, invasive;
coccidiodomycosis, disseminated or extrapulmonary; cryptococcosis, extrapulmonary;
crytosporidiosis, chronic intestinal (greater than 1 month’s duration); cytomegalovirus disease
(other than liver, spleen, or nodes); cytomegalovirus retinitis (with loss of vision); encephalopathy,
HIV-related; herpes simplex: chronic ulcer(s) (greater than 1 month’s duration); or bronchitis,
pneumonitis, or esophagitis; histoplasmosis, disseminated or extrapulmonary; isosporiasis, chronic
intestinal (greater than 1 month’s duration); Kaposi’s sarcoma; lymphoma, Burkitt’s (or equivalent
term); lymphoma, immunoblastic (or equivalent term); lymphoma, primary, of brain; mycobacterium
avium complex or M. kansasii, disseminated or extrapulmonary; mycobacterium tuberculosis, any
site (pulmonary or extrapulmonary); mycobacterium, other species or unidentified species,
disseminated or extrapulmonary; pneumocystis carinii pneumonia; pneumonia, recurrent;
progressive multifocal leukoencephalopathy; salmonella septicemia, recurrent; toxoplasmosis of
brain; wasting syndrome due to HIV. (NYSDOH).
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Measure #162: HIV/AIDS: HIV RNA Control After Six Months of Potent Antiretroviral
Therapy
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS who are receiving
potent antiretroviral therapy, who have a viral load below limits of quantification after at least 6
months of potent antiretroviral therapy or patients whose viral load is not below limits of
quantification after at least 6 months of potent antiretroviral therapy and have documentation of a
plan of care
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with HIV/AIDS
who are receiving potent antiretroviral therapy during the reporting period. Only patients who had at
least two visits during the reporting period, with at least 60 days between each visit will be counted
in the denominator for this measure. This measure is intended to reflect the quality of services
provided for the primary management of patients with HIV/AIDS.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The listed numerator options are used to report
the numerator of the measure. The quality-data codes have been provided for registry only
measures for use by registries that utilize claims data. It is not necessary to submit these codes for
registry-based submissions. Do not report this measure via claims.
NUMERATOR:
Patients with viral load below limits of quantification or patients with viral load not below limits of
quantification who have a documented plan of care
Numerator Instructions: Viral load below limits of quantification is determined using
laboratory cutoff levels for reference laboratory used by clinic or provider
Definitions:
Potent Antiretroviral Therapy – Potent antiretroviral therapy is described as any
antiretroviral therapy that has demonstrated optimal efficacy and results in durable
suppression of HIV as shown by prior clinical trials. For potent antiretroviral therapy
recommendations, refer to current DHHS guidelines available for download at the following
address as of 11/3/08 - http://www.aids.gov.
Plan of Care – May include altering the therapy regimen, reaffirming to the patient the
importance of high adherence to the regimen, or reassessment of viral load at a specified
future date
Numerator Options:
HIV RNA viral load below limits of quantification (3502F)
AND
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Patient receiving potent antiretroviral therapy for 6 months or longer (4270F)
OR
OR
OR
HIV RNA viral load not below limits of quantification (3503F)
AND
HIV RNA control plan of care, documented (0575F)
AND
Patient receiving potent antiretroviral therapy for 6 months or longer (4270F)
Patient receiving potent antiretroviral therapy for less than 6 months or not receiving potent
antiretroviral therapy (4271F)
Viral load not performed or documented, reason not specified (3502F with 8P)
AND
Patient receiving potent antiretroviral therapy for 6 months or longer (4270F)
OR
Plan of care for viral load not below limits of quantification was not documented, reason
not specified (0575F with 8P)
AND
HIV RNA viral load not below limits of quantification (3503F)
AND
Patient receiving potent antiretroviral therapy for 6 months or longer (4270F)
DENOMINATOR:
All patients aged 13 years and older with a diagnosis of HIV/AIDS who had at least two medical
visits during the measurement year, with at least 60 days between each visit, who have received
potent antiretroviral therapy for at least 6 months
Denominator Criteria (Eligible Cases):
Patients aged ≥ 13 years on date of encounter
AND
Diagnosis for HIV/AIDS (ICD-9-CM): 042, 079.53, V08
AND
Patient encounters during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
The goal of potent antiretroviral therapy is to establish HIV RNA viral load below limits of
quantification.
CLINICAL RECOMMENDATION STATEMENTS:
The goal of treatment for patients with prior drug exposure and drug resistance is to re-establish
maximal virologic suppression, HIV RNA <50 copies/ml (AI). (DHHS)
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Clinicians should prescribe a HAART regimen that is best able to delay disease progression,
prolong survival, and maintain quality of life through maximal viral suppression. (NYSDOH)
Initiation of HAART is recommended for patients who:
are symptomatic* from HIV, OR
have an AIDS-defining condition,** including those with CD4 counts <200 cells/mm3, or
are asymptomatic with two successive measurements of CD4 counts <350 cells/mm3 and
patient-related barriers to adherence are minimized.
*Signs and symptoms include but are not limited to oropharyngeal candidiasis (thrush);
vulvovaginal candidiasis that is frequent or responds poorly to therapy; cervical dysplasia
(moderate or severe)/cervical carcinoma in situ; HIV nephropathy in the setting of worsening serum
creatinine; severe seborrheic dermatitis, constitutional symptoms, such as fever or diarrhea lasting
>1 months; oral hairy leukoplakia; herpes zoster (shingles) involving at least two distinct episodes
or more than one dermatome; thrombocytopenia; listeriosis; pelvic inflammatory disease,
particularly if complicated by tubo-ovarian abscess; peripheral neuropathy; bacillary angiomatosis;
or any conditions included in the CDC-defined AIDS definition.
**All HIV-infected persons with CD4+ T-lymphocyte counts of less than 200 cells/uL or a CD4+
percentage of less than 14. Conditions included in the 1993 AIDS surveillance case definition:
Candidiasis of bronchi, trachea, or lungs; candidiasis, esophageal; cervical cancer, invasive;
coccidiodomycosis, disseminated or extrapulmonary; cryptococcosis, extrapulmonary;
crytosporidiosis, chronic intestinal (greater than 1 month’s duration); cytomegalovirus disease
(other than liver, spleen, or nodes); cytomegalovirus retinitis (with loss of vision); encephalopathy,
HIV-related; herpes simplex: chronic ulcer(s) (greater than 1 month’s duration); or bronchitis,
pneumonitis, or esophagitis; histoplasmosis, disseminated or extrapulmonary; isosporiasis, chronic
intestinal (greater than 1 month’s duration); Kaposi’s sarcoma; lymphoma, Burkitt’s (or equivalent
term); lymphoma, immunoblastic (or equivalent term); lymphoma, primary, of brain; mycobacterium
avium complex or M. kansasii, disseminated or extrapulmonary; mycobacterium tuberculosis, any
site (pulmonary or extrapulmonary); mycobacterium, other species or unidentified species,
disseminated or extrapulmonary; pneumocystis carinii pneumonia; pneumonia, recurrent;
progressive multifocal leukoencephalopathy; salmonella septicemia, recurrent; toxoplasmosis of
brain; wasting syndrome due to HIV. (NYSDOH)
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Measure #163: Diabetes Mellitus: Foot Exam
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
The percentage of patients aged 18 through 75 years with diabetes who had a foot examination
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with diabetes
mellitus seen during the reporting period. The performance period for this measure is 12 months.
This measure may be reported by clinicians who perform the quality actions described in the
measure based on the services provided and the measure-specific denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, G-codes, and patient demographics are used to
identify patients who are included in the measure’s denominator. CPT Category II codes are used
to report the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
G-codes, and the appropriate CPT Category II code OR the CPT Category II code with the
modifier. The modifiers allowed for this measure are: 1P- medical reasons, 8P- reason not
otherwise specified. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, G-codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. The numerator options as described in
the quality-data codes are used to report the numerator of the measure. The quality-data codes
listed do not need to be submitted for registry-based submissions however these codes may be
submitted for those registries that utilize claims data.
NUMERATOR:
Patients who received a foot exam (visual inspection, sensory exam with monofilament, or pulse
exam)
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Foot Exam Performed
CPT II 2028F: Foot examination performed (includes examination through visual
inspection, sensory exam with monofilament, and pulse exam – report when any of the
three components are completed)
Foot Exam not Performed for Medical Reason
Append a modifier (1P) to CPT Category II code 2028F to report documented
circumstances that appropriately exclude patients from the denominator.
2028F with 1P: Documentation of medical reason for not performing foot exam (i.e.,
patient with bilateral foot/leg amputation)
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OR
Foot Exam not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 2028F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
2028F with 8P: Foot exam was not performed, reason not otherwise specified
DENOMINATOR:
Patients aged 18 through 75 years with a diagnosis of diabetes
Denominator Criteria (Eligible Cases):
Patients aged 18 through 75 years on date of encounter
AND
Diagnosis for diabetes (line-item ICD-9-CM): 250.00, 250.01, 250.02, 250.03, 250.10,
250.11, 250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33,
250.40, 250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62,
250.63, 250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91,
250.92, 250.93, 357.2, 362.01, 362.02, 362.03, 362.04, 362.05, 362.06, 362.07, 366.41,
648.00, 648.01, 648.02, 648.03, 648.04
AND
Patient encounter during the reporting period (CPT or HCPCS): 97802, 97803, 97804,
99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306,
99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336,
99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0270, G0271
RATIONALE:
The most common consequences of diabetic neuropathy are amputation and foot ulceration (ADA,
2006). In developed countries, up to five percent of diabetic patients have foot ulcers (IDF, 2005).
One in every six diabetics will have an ulcer during their lifetime (IDF, 2005). Amputation and foot
ulceration are also major causes of morbidity and mortality. One half to 80% of all amputations are
diabetes-related (Mayfield, 1998; Reiber, 1995; ADA, 2001; Unwin, 2000).The risk of ulcers or
amputations increases the longer someone has diabetes. Early recognition and management of
risk factors can prevent or delay adverse outcomes (ADA, 2006).
CLINICAL RECOMMENDATION STATEMENTS:
American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE)
and American Diabetes Association (ADA) recommend that a foot examination (visual inspection,
sensory exam, and pulse exam) be performed during an initial assessment.
AACE/ACE (2002) recommends that a foot examination be a part of every follow-up assessment
visit, which should occur quarterly.
ADA (2004) recommends that all individuals with diabetes should receive an annual foot
examination to identify high-risk foot conditions. This examination should include assessment of
protective sensation, foot structure and biomechanics, vascular status, and skin integrity.
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The ADA (2004) recommends that people with one or more high-risk foot conditions should be
evaluated more frequently for the development of additional risk factors. People with neuropathy
should have a visual inspection of their feet at every contact with a health care professional.
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Measure #164: Coronary Artery Bypass Graft (CABG): Prolonged Intubation
(Ventilation)
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require
intubation > 24 hours
INSTRUCTIONS:
This measure is to be reported each time an isolated CABG procedure is performed during the
reporting period. It is anticipated that clinicians who provide services for isolated CABG will submit
this measure. This measure is intended to reflect the quality of the surgical services provided for
isolated CABG patients. Isolated CABG refers to CABG using arterial and/or venous grafts only.
This measure does not include patients undergoing repeat CABG procedures.
Measure Reporting via Registry:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. The listed numerator options are used to report the numerator of the
measure. The quality-data codes have been provided for registry only measures for use by
registries that utilize claims data. It is not necessary to submit these codes for registry-based
submissions. There are no allowable performance exclusions for this measure. Do not report this
measure via claims.
NUMERATOR:
Patients undergoing isolated CABG who require intubation > 24 hours
Numerator Instructions: For performance, a lower rate indicates better performance.
OR
Numerator Options:
Prolonged intubation (> 24 hrs) required (G8569)
Prolonged intubation (> 24 hrs) not required (G8570)
DENOMINATOR:
All patients undergoing isolated CABG surgery
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Patient encounter during the reporting period (CPT): 33510, 33511, 33512, 33513,
33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536
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RATIONALE:
Based on the STS coronary artery bypass graft (CABG) study population, the morbidity rate
associated with prolonged intubation following CABG is 5.96%. Also, prolonged ventilation (defined
as >24 hours) was an independent predictor for readmission to the ICU following CABG surgery
(OR=10.53; CI: 6.18 to 17.91). Shorter ventilation times are linked to high quality of care ( i.e.,
reduced in-hospital and operative mortality, as well as better long-term outcomes as compared to
prolonged ventilation).
CLINICAL RECOMMENDATION STATEMENTS:
Extubation greater than (>) 24 hours is considered a “pulmonary complication.” Patients who were
extubated after 24 hours had a longer duration of hospital stay and a greater incidence of
postoperative complications.
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Measure #165: Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection
Rate
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who developed
deep sternal wound infection (involving muscle, bone, and/or mediastinum requiring operative
intervention) within 30 days postoperatively
INSTRUCTIONS:
This measure is to be reported each time an isolated CABG procedure is performed during the
reporting period. It is anticipated that clinicians who provide services for isolated CABG will submit
this measure. This measure is intended to reflect the quality of the surgical services provided for
isolated CABG patients. Isolated CABG refers to CABG using arterial and/or venous grafts only.
This measure does not include patients undergoing repeat CABG procedures.
Measure Reporting via Registry:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. The listed numerator options are used to report the numerator of the
measure. The quality-data codes have been provided for registry only measures for use by
registries that utilize claims data. It is not necessary to submit these codes for registry-based
submissions. There are no allowable performance exclusions for this measure. Do not report this
measure via claims.
NUMERATOR:
Patients who developed a deep sternal wound infection within 30 days postoperatively (must have
ALL of the following conditions: wound opened with excision of tissue [incision and drainage] or reexploration of mediastinum, positive culture and treatment with antibiotics)
Numerator Instructions: For performance, a lower rate indicates better performance.
OR
Numerator Options:
Development of deep sternal wound infection within 30 days postoperatively (G8571)
No deep sternal wound infection (G8572)
DENOMINATOR:
All patients undergoing isolated CABG surgery
Denominator Criteria (Eligible Cases):
All patients aged ≥ 18 years on date of encounter
AND
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Patient encounter during the reporting period (CPT): 33510, 33511, 33512, 33513,
33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536
RATIONALE:
The most serious hospital-acquired infection associated with coronary artery bypass graft (CABG)
surgery is deep sternal wound or deep surgical site infection. The most common bacteria involved
are S. aureus including increasingly more common methicillin resistant Staph (MRS). For CABG
only outcomes 1997-1999 the STS dataset reported 0.63% deep sternal wound infection rate in
503,478 records. A report from an academic hospital reported 1.9% deep surgical site infections
(Centers for Disease Control and Prevention National Nosocomial Infection Surveillance [CDC
NNIS] criteria) in 1,980 patients undergoing isolated CABG or CABG+ procedures from 1996-1999.
The Northern New England Cardiovascular Disease Study Group reported an incidence rate for
mediastinitis of 1.25% and noted a marked increase in mortality during the first year post-CABG
and a threefold increase during a 4-year follow-up period.
CLINICAL RECOMMENDATION STATEMENTS:
Several risk factors for sternal wound infection have been identified that can be optimized with
good care practices: prophylactic antibiotics within 1 hour before incision time (odds ratio 5.3) [see
antibiotic timing process measure] and avoiding elevated blood glucose levels (odds ratio 10.2).
Surveillance for surgical site infections is a critical hospital function to monitor infection control
practices and direct improvement activity.
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Measure #166: Coronary Artery Bypass Graft (CABG): Stroke/Cerebrovascular Accident
(CVA)
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who had a
stroke/CVA within 24 hours postoperatively
INSTRUCTIONS:
This measure is to be reported each time an isolated CABG procedure is performed during the
reporting period. It is anticipated that clinicians who provide services for isolated CABG will submit
this measure. This measure is intended to reflect the quality of the surgical services provided for
isolated CABG patients. Isolated CABG refers to CABG using arterial and/or venous grafts only.
This measure does not include patients undergoing repeat CABG procedures.
Measure Reporting via Registry:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. The listed numerator options are used to report the numerator of the
measure. The quality-data codes have been provided for registry only measures for use by
registries that utilize claims data. It is not necessary to submit these codes for registry-based
submissions. There are no allowable performance exclusions for this measure. Do not report this
measure via claims.
NUMERATOR:
Patients who have a stroke/CVA within 24 hours postoperatively
Numerator Instructions: For performance, a lower rate indicates better performance.
OR
Numerator Options:
Stroke/CVA following isolated CABG surgery (G8573)
No stroke/CVA following isolated CABG surgery (G8574)
DENOMINATOR:
All patients undergoing isolated CABG surgery, excluding patients with a prior CVA
Denominator Criteria (Eligible Cases):
All patients aged ≥ 18 years on date of encounter
AND
Patient encounter during the reporting period (CPT): 33510, 33511, 33512, 33513,
33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536
WITHOUT
History of prior CVA
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RATIONALE:
Stroke is a devastating complication after coronary bypass surgery. The 1999 American College of
Cardiology/American Heart Association (ACC/AHA) guidelines indicate that adverse cerebral
outcomes are observed in ~6% of patients after bypass surgery equally divided between 2 types:
1) associated with major, focal neurological defects, stupor or coma and 2) evidence of
deterioration in intellectual function. Type 1 deficits occur in ~3% of patients and is responsible for
21% mortality.
Reports in the literature on postoperative stroke incidence are difficult to compare because the
conditions included in the term “stroke” vary. A standardized definition of stoke will provide
common language to compare stroke incidence and evaluate management strategies for reducing
this devastating complication.
Reported rates of postoperative cerebral dysfunction range from 0.4% to 13.8% following coronary
operations. Complications for patients undergoing emergent CABG or valve surgery were greater
than the complication rate for patients undergoing elective CABG or valve surgery. As bypass
times increased, so did the incidence of stroke. When bypass time was 90 to 113 minutes,
OR=1.59, p=0.022 and when bypass time was >114 minutes, the OR was 2.59, p<0.001.
Outcomes are better when patient age is younger and with beating-heart surgery rather than onpump surgery.
CLINICAL RECOMMENDATION STATEMENTS:
The 1999 ACC/AHA guidelines describe strategies for reducing the risk of postoperative stroke
such as an aggressive approach to the management of patients with severely diseased ascending
aortas identified by intraoperative echocardiographic imaging, prevention or aggressive
management of postoperative atrial fibrillation, delay of bypass surgery in the case of a left
ventricular mural thrombus or a recent, preoperative CVA and preoperative carotid screening.
Patients should carefully be screened for cerebrovascular disease to help prevent stroke and its
associated morbidities.
Use of beta-adrenergic antagonists was associated with a lower incidence of stroke in patients
undergoing elective CABG (OR=0.45; 95% CI 0.23 to 0.83; p=0.016). Use of antiplatelet agents
within 48 hours of surgery is associated with a decreased risk of stroke (OR=0.51, p=0.01).
Increased use of beating-heart surgery without cardiopulmonary bypass may lead to a lower
prevalence of stroke following cardiac surgery and thus improve patient outcomes.
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Measure #167: Coronary Artery Bypass Graft (CABG): Postoperative Renal Insufficiency
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who develop
postoperative renal insufficiency or require dialysis
INSTRUCTIONS:
This measure is to be reported each time an isolated CABG procedure is performed during the
reporting period. It is anticipated that clinicians who provide services for isolated CABG will submit
this measure. This measure is intended to reflect the quality of the surgical services provided for
isolated CABG patients. Isolated CABG refers to CABG using arterial and/or venous grafts only.
This measure does not include patients undergoing repeat CABG procedures.
Measure Reporting via Registry:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. The listed numerator options are used to report the numerator of the
measure. The quality-data codes have been provided for registry only measures for use by
registries that utilize claims data. It is not necessary to submit these codes for registry-based
submissions. There are no allowable performance exclusions for this measure. Do not report this
measure via claims.
NUMERATOR:
Patients who develop postop renal insufficiency or require dialysis (indicate whether the patient
had acute or worsening renal insufficiency resulting in one or more of the following: 1) increase of
serum creatinine to > 2.0, and 2x most recent preoperative creatinine level; 2) a new requirement
for dialysis postoperatively)
Numerator Instructions: For performance, a lower rate indicates better performance.
OR
Numerator Options:
Developed postoperative renal insufficiency or required dialysis (G8575)
No postoperative renal insufficiency/dialysis not required (G8576)
DENOMINATOR:
All patients undergoing isolated CABG surgery, excluding patients with either a documented history
of renal insufficiency or baseline serum creatinine > 2.0
Denominator Criteria (Eligible Cases):
All patients aged ≥ 18 years on date of encounter
AND
Patient encounter during the reporting period (CPT): 33510, 33511, 33512, 33513,
33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536
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WITHOUT
History of renal insufficiency or baseline serum creatinine > 2.0
RATIONALE:
In 2000, coronary artery bypass graft (CABG) surgery was performed on more than 350,000
patients at a cost of close to $20 billion. Some degree of Acute Renal Dysfunction (ARD) occurs in
about 8% of patients following CABG, and dialysis-dependent renal failure occurs in 0.7% to 3.5%
of patients receiving CABG. The latter is associated with substantial increases in morbidity, length
of stay, and mortality (odds ratios for mortality range from 15 to 27). ARD is associated with
increased morbidity, mortality and length of stay in an ICU following surgery. In addition, Acute
Renal Failure occurs in 1.5% of patients undergoing any type of cardiac surgery. There has been a
substantial increase in postoperative morbidity, mortality, and cost associated with this relatively
common complication, regardless of whether or not this incidence varies much between providers,
and there are implications of even a modest decrease in its incidence.
CLINICAL RECOMMENDATION STATEMENTS:
Acute renal failure following CABG is an intermediate outcome measure for mortality since this
complication is independently associated (OR=27) with early mortality following cardiac surgery,
even after adjustment for comorbidity and postoperative complications.
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Measure #168: Coronary Artery Bypass Graft (CABG): Surgical Re-exploration
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require a
return to the operating room (OR) for mediastinal bleeding/tamponade, graft occlusion (due to
acute closure, thrombosis, technical or embolic origin), or other cardiac reason
INSTRUCTIONS:
This measure is to be reported each time an isolated CABG procedure is performed during the
reporting period. It is anticipated that clinicians who provide services for isolated CABG will submit
this measure. This measure is intended to reflect the quality of the surgical services provided for
isolated CABG patients. Isolated CABG refers to CABG using arterial and/or venous grafts only.
This measure does not include patients undergoing repeat CABG procedures.
Measure Reporting via Registry:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. The listed numerator options are used to report the numerator of the
measure. The quality-data codes have been provided for registry only measures for use by
registries that utilize claims data. It is not necessary to submit these codes for registry-based
submissions. There are no allowable performance exclusions for this measure. Do not report this
measure via claims.
NUMERATOR:
Patients who require a return to the OR for bleeding/tamponade, graft occlusion, or other cardiac
reason
Numerator Instructions: For performance, a lower rate indicates better performance.
OR
Numerator Options:
Reoperation required due to bleeding/tamponade, graft occlusion or other cardiac reason
(G8577)
Reoperation not required due to bleeding/tamponade, graft occlusion or other cardiac
reason (G8578)
DENOMINATOR:
All patients undergoing isolated CABG surgery
Denominator Criteria (Eligible Cases):
All patients aged ≥ 18 years on date of encounter
AND
Patient encounter during the reporting period (CPT): 33510, 33511, 33512, 33513,
33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536
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RATIONALE:
In 2000, coronary artery bypass graft (CABG) surgery was performed on more than 350,000
patients at a cost of close to $20 billion. Re-exploration after surgery is a serious complication that
impacts length of stay, efficient use of resources, and increases risk for additional complications
and death. As one of several major complications of cardiac surgery, repeat surgery is particularly
worrisome for consumers and is an inefficient use of resources.
CLINICAL RECOMMENDATION STATEMENTS:
Re-exploration after surgery is a serious complication that impacts length of stay, efficient use of
resources, and increases risk for additional complications and death. This measure is currently in
use by approx. 65% of providers in the United States who perform cardiac surgery and report data
to the STS National Database.
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Measure #169: Coronary Artery Bypass Graft (CABG): Antiplatelet Medications at
Discharge
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who have
antiplatelet medication at discharge
INSTRUCTIONS:
This measure is to be reported each time an isolated CABG procedure is performed during the
reporting period. It is anticipated that clinicians who provide services for isolated CABG will submit
this measure. This measure is intended to reflect the quality of the surgical services provided for
isolated CABG patients. Isolated CABG refers to CABG using arterial and/or venous grafts only.
This measure does not include patients undergoing repeat CABG procedures.
Measure reporting via Registry:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. The listed numerator options are used to report the numerator of the
measure. The quality-data codes have been provided for registry only measures for use by
registries that utilize claims data. It is not necessary to submit these codes for registry-based
submissions. Do not report this measure via claims.
NUMERATOR:
Patients who were discharged on antiplatelet medication
OR
OR
Numerator Options:
Antiplatelet medication at discharge (G8579)
Antiplatelet medication contraindicated/not indicated (G8580)
No antiplatelet medication at discharge (G8581)
DENOMINATOR:
All patients undergoing isolated CABG surgery, who did not have in-hospital mortality.
Denominator Criteria (Eligible Cases):
All patients aged ≥ 18 years on date of encounter
AND
Patient encounter during the reporting period (CPT): 33510, 33511, 33512, 33513,
33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536
AND
Patient not deceased prior to discharge
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RATIONALE:
Use of aspirin soon after coronary artery bypass graft (CABG) is associated with reduced risk of
death and ischemic complications involving the heart, brain, kidneys, and gastrointestinal tract.
High-risk patients now represent the majority of patients who undergo bypass surgery, giving rise
to rates of 15% or higher for complications affecting heart, brain, kidneys, and intestines.
Guidelines from the American College of Chest Physicians recommend the administration of
aspirin soon after CABG, specifically 325 mg per day starting six hours after surgery.
CLINICAL RECOMMENDATION STATEMENTS:
Evidence-based discharge therapies are underutilized in older patients who underwent CABG
during hospitalization for AMI.
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Measure #170: Coronary Artery Bypass Graft (CABG): Beta-Blockers Administered at
Discharge
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who were
discharged on beta-blockers
INSTRUCTIONS:
This measure is to be reported each time an isolated CABG procedure is performed during the
reporting period. It is anticipated that clinicians who provide services for isolated CABG will submit
this measure. This measure is intended to reflect the quality of the surgical services provided for
isolated CABG patients. Isolated CABG refers to CABG using arterial and/or venous grafts only.
This measure does not include patients undergoing repeat CABG procedures.
Measure Reporting via Registry:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. The listed numerator options are used to report the numerator of the
measure. The quality-data codes have been provided for registry only measures for use by
registries that utilize claims data. It is not necessary to submit these codes for registry-based
submissions. Do not report this measure via claims.
NUMERATOR:
Patients who were discharged on beta-blockers
OR
OR
Numerator Options:
Beta-blocker at discharge (G8582)
Beta-blocker contraindicated/not indicated (G8583)
No beta-blocker at discharge (G8584)
DENOMINATOR:
All patients undergoing isolated CABG surgery who did not have in-hospital mortality.
Denominator Criteria (Eligible Cases):
All patients aged ≥ 18 years on date of encounter
AND
Patient encounter during the reporting period (CPT): 33510, 33511, 33512, 33513,
33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536
AND
Patient not deceased prior to discharge
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RATIONALE:
Upwards of 70% of patients who undergo revascularization procedures have had a myocardial
infarction (MI). Cumulative evidence and randomized trials indicate that patients with a previous MI
live longer if they are on beta blockers. For many years, patients were taken off beta-blocker
medications in preparations for surgery. Evidence from the STS National Database demonstrated
that beta blocker use is safe and effective in many CABG patients previously thought to be at high
risk for adverse events of beta blocker therapy (women, elderly, diabetes, congestive heart failure).
The Society of Thoracic Surgeons National Database reported an increase in use of preoperative
beta blockers during the time period 1996 (50% use) and 1999 (60% use).
CLINICAL RECOMMENDATION STATEMENTS:
Beta blockade reduces atrial fibrillation complications following CABG. At four to five years, survival
was approximately 13% worse in patients who developed postoperative atrial fibrillation (p <0.001).
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Measure #171: Coronary Artery Bypass Graft (CABG): Lipid Management and
Counseling
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 18 years and older undergoing isolated CABG surgery who have antilipid treatment at discharge
INSTRUCTIONS:
This measure is to be reported each time an isolated CABG procedure is performed during the
reporting period. It is anticipated that clinicians who provide services for isolated CABG will submit
this measure. This measure is intended to reflect the quality of the surgical services provided for
isolated CABG patients. Isolated CABG refers to CABG using arterial and/or venous grafts only.
This measure does not include patients undergoing repeat CABG procedures.
Measure Reporting via Registry:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. The listed numerator options are used to report the numerator of the
measure. The quality-data codes have been provided for registry only measures for use by
registries that utilize claims data. It is not necessary to submit these codes for registry-based
submissions. Do not report this measure via claims.
NUMERATOR:
Patients with an anti-lipid treatment at discharge
OR
OR
Numerator Options:
Anti-lipid treatment at discharge (G8585)
Anti-lipid treatment contraindicated/not indicated (G8586)
No anti-lipid treatment at discharge (G8587)
DENOMINATOR:
All patients undergoing isolated CABG surgery, who did not have in-hospital mortality
Denominator Criteria (Eligible Cases):
All patients aged ≥ 18 years on date of encounter
AND
Patient encounter during the reporting period (CPT): 33510, 33511, 33512, 33513,
33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536
AND
Patient not deceased prior to discharge
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RATIONALE:
Atherosclerosis is a chronic disease. Events such as acute myocardial infarction (MI) and coronary
artery bypass graft (CABG) surgery identify patients with the disease, but acute therapy is not
sufficient for optimal long-term outcomes. In post-bypass patients, atherosclerosis continues to
progress in the native circulation and develops at an accelerated rate in saphenous vein bypass
grafts. Management of the chronic disease is critically important in patients with atherosclerosis,
such as those undergoing CABG.
The advantages of adherence to the American College of Cardiology/American Heart Association
“Get with the Guidelines” program are discussed in a recent article, which also demonstrates both
variation in quality and opportunity for improvement (38% compliance with guidelines before
program implementation, 98.4% compliance thereafter). The article also discusses educational and
process measures used by a major medical center to achieve compliance.
CLINICAL RECOMMENDATION STATEMENTS:
Compliance rates for patients receiving personalized follow- up for lipid management over two
years were significantly better than in the control group. Lipid lowering in coronary heart disease
has been demonstrated distinctively through three trials (CLAS, post-CABG, and CARE) to delay
the progression of atherosclerosis and/or reduce deaths, and non- fatal MI following bypass
surgery. Aggressive (low-density lipoprotein [LDL]) cholesterol-lowering treatment (target <85
mg/d) was correlated to a slower rate of disease progression (31%) after 4-5 years in comparison
to the control group, which was comprised of patients receiving moderate lipid- lowering treatment
(target <130 to 140 mg/dl).
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Measure #172: Hemodialysis Vascular Access Decision-Making by Surgeon to Maximize
Placement of Autogenous Arterial Venous (AV) Fistula
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of advanced Chronic Kidney
Disease (CKD) (stage 4 or 5) or End Stage Renal Disease (ESRD) requiring hemodialysis vascular
access documented by surgeon to have received autogenous AV fistula
INSTRUCTIONS:
This measure is to be reported each time a procedure for hemodialysis access is performed during
the reporting period. It is anticipated that clinicians who perform the listed surgical procedures as
specified in the denominator coding will submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. G-codes are used to report the numerator
of the measure.
When reporting the measure via claims, submit the listed CPT codes, and the appropriate
numerator G-code. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions however these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients diagnosed with advanced CKD or ESRD requiring hemodialysis vascular access as
documented by the surgeon
OR
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Autogenous AV Fistula Performed
G8530: Autogenous AV fistula received
Autogenous AV Fistula not Performed for Documented Reasons
G8531: Clinician documented that patient was not an eligible candidate for autogenous AV
fistula
Autogenous AV Fistula not Performed, Reason not Specified
G8532: Clinician documented that patient received vascular access other than autogenous
AV fistula, reason not specified
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DENOMINATOR:
All patients with advanced CKD or ESRD who undergo open surgical placement of permanent
hemodialysis access
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for stage 4 or 5 CKD or ESRD (line-item ICD-9-CM): 585.4, 585.5, 585.6,
996.73
AND
Patient encounter during the reporting period (CPT): 36818, 36819, 36820, 36821,
36825, 36830
RATIONALE:
AV access complications account for more than 15% of hospital admissions among hemodialysis
patients. As the number of patients in need of chronic hemodialysis increases—estimated at 10%
per year starting at a base population of 345,000 in 2000 – the cost to the health care system of
dialysis access-related complications will increase proportionally.
CLINICAL RECOMMENDATION STATEMENTS:
For the surgeon, the most directly measurable performance parameter is the percentage of
autogenous accesses placed as a proportion of the total number of accesses, (autogenous and
prosthetic) placed by the particular surgeon.
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Measure #173: Preventive Care and Screening: Unhealthy Alcohol Use – Screening
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use
using a systematic screening method within 24 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. This measure is intended to determine whether or not all patients aged 18 years
and older were screened for unhealthy alcohol use during the reporting period. There is no
diagnosis associated with this measure. This measure may be reported by clinicians who perform
the quality actions described in the measure based on the services provided and the measurespecific denominator coding.
Measure Reporting via Claims:
CPT codes, G-codes, and patient demographics are used to identify patients who are included in
the measure’s denominator. CPT Category II codes are used to report the numerator of the
measure.
When reporting the measure via claims, submit the listed CPT codes and the appropriate CPT
Category II code OR the CPT Category II code(s) with the modifier. The modifiers allowed for this
measure are: 1P- medical reason, 8P- reason not otherwise specified. All measure-specific coding
should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
CPT codes, G-codes, and patient demographics are used to identify patients who are included in
the measure’s denominator. The numerator options as described in the quality-data codes are
used to report the numerator of the measure. The quality-data codes listed do not need to be
submitted for registry-based submissions however these codes may be submitted for those
registries that utilize claims data.
NUMERATOR:
Patients who were screened for unhealthy alcohol use using a systematic screening method within
24 months
Definition:
Unhealthy Alcohol Use – Covers a spectrum that is associated with varying degrees of
risk to health. Categories representing unhealthy alcohol use include risky use, problem
drinking, harmful use, and alcohol abuse, and the less common but more severe
alcoholism and alcohol dependence. Risky use is defined as > 7 standard drinks per week
or > 3 drinks per occasion for women and persons > 65 years of age; > 14 standard drinks
per week or > 4 drinks per occasion for men ≤ 65 years of age.
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OR
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Unhealthy Alcohol Use Screening Performed
CPT II 3016F: Patient screened for unhealthy alcohol use using a systematic screening
method
Unhealthy Alcohol Use Screening not Performed, for Medical Reasons
Append a modifier (1P) to CPT Category II code 3016F to report documented
circumstances that appropriately exclude patients from the denominator.
3016F with 1P: Documentation of medical reason(s) for not screening for unhealthy
alcohol use (eg, limited life expectancy)
Unhealthy Alcohol Use Screening not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3016F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3016F with 8P: Unhealthy alcohol use screening not performed, reason not otherwise
specified
DENOMINATOR:
All patients aged 18 years and older
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Patient encounter during the reporting period (CPT or HCPCS): 90801, 90802, 90804,
90805, 90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90845,
90862, 96150, 96152, 97003, 97004, 97802, 97803, 97804, 98960, 98961, 98962, 99201,
99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, G0270, G0271
RATIONALE:
Screening for unhealthy alcohol use can identify patients can identify patients whose habits may
put them at risk for adverse health outcomes due to their alcohol use. While this measure does not
require counseling for those patients to be found at risk, brief counseling interventions for
unhealthy alcohol use have shown to be effective in reducing alcohol use. It would be expected
that if a provider found their patient to be at risk after screening that intervention would be provided.
A systematic method of assessing for unhealthy alcohol use should be utilized. Please refer to the
National Institute on Alcohol Abuse and Alcoholism publication: Helping Patients Who Drink Too
Much: A Clinician’s Guide for additional information regarding systematic screening methods.
CLINICAL RECOMMENDATION STATEMENTS:
The USPSTF strongly recommends screening and behavioral counseling interventions to reduce
alcohol misuse by adults, including pregnant women, in primary care settings. (B
Recommendation) (USPSTF, 2004)
During new patient encounters and at least annually, patients in general and mental healthcare
settings should be screened for at-risk drinking, alcohol use problems and illnesses, and any
tobacco use. (NQF, 2007)
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All patients identified with alcohol use in excess of National Institute on Alcohol Abuse and
Alcoholism guidelines and/or any tobacco use should receive brief motivational counseling
intervention by a healthcare worker trained in this technique. (NQF, 2007)
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Measure #174: Pediatric End Stage Renal Disease (ESRD): Plan of Care for Inadequate
Hemodialysis
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of calendar months during the 12-month reporting period in which patients aged 17
years and younger with a diagnosis of ESRD receiving hemodialysis have a single-pool Kt/V ≥ 1.2
or have a single-pool Kt/V < 1.2 with a documented plan of care for inadequate hemodialysis
INSTRUCTIONS:
This measure is to be reported each calendar month hemodialysis is performed on pediatric ESRD
patients seen during the reporting period. It is anticipated that clinicians providing care for pediatric
patients with ESRD will submit this measure.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The listed numerator options are used to report
the numerator of the measure. The quality-data codes have been provided for registry only
measures for use by registries that utilize claims data. It is not necessary to submit these codes for
registry-based submissions. There are no allowable performance exclusions for this measure. Do
not report this measure via claims.
NUMERATOR:
Number of patient calendar months during which patients have a single-pool Kt/V ≥ 1.2 OR have a
single-pool Kt/V < 1.2 with a documented plan of care for inadequate hemodialysis
Definition:
Documented Plan of Care – May include checking for adequacy of the AV access,
increasing the blood flow, increasing the dialyzer size, increasing the time of dialysis
sessions, increasing the number of days of dialysis, documenting residual renal function,
documenting that patient has an inborn error of metabolism or is undergoing an alternate
hemodialysis modality.
Numerator Options:
Kt/V ≥ 1.2 and less than 1.7 (Clearance of urea (Kt)/volume(V)) (3083F)
OR
Kt/V ≥ 1.7 (Clearance of urea (Kt)/volume(V)) (3084F)
OR
OR
Kt/V < 1.2 (Clearance of urea (Kt)/volume (V)) (3082F)
AND
Hemodialysis plan of care documented (0505F)
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Kt/V not performed or documented, reason not specified (3083F with 8P)
OR
Hemodialysis plan of care not documented, reason not specified (0505F with 8P)
AND
Kt/V < 1.2 (Clearance of urea (Kt)/Volume(V) (3082F)
DENOMINATOR:
Calendar months for all patients aged 17 years and younger with a diagnosis of ESRD and
receiving hemodialysis
Denominator Criteria (Eligible Cases):
Patients aged ≤ 17 years on date of encounter
AND
Diagnosis for ESRD (ICD-9-CM): 585.6
AND
Patient encounter during the reporting period (CPT): 90951, 90952, 90953, 90954,
90955, 90956, 90957, 90958, 90959
RATIONALE:
Patients receiving hemodialysis must be monitored (by assessing Kt/V) regularly to ensure that
their dialysis dose is sufficient. A patient receiving thrice weekly hemodialysis whose Kt/V is less
than 1.2 is not receiving adequate dialysis. This measure assesses whether the treating physician
addressed a low Kt/V level. A plan of care (defined as checking for adequacy of the AV access,
increasing the blood flow, increasing the dialyzer size, increasing the time of dialysis sessions,
increasing the number of days of dialysis, documenting residual renal function, or documenting that
patient has an inborn error of metabolism or is undergoing an alternate hemodialysis modality)
should be documented by the physician for every time the Kt/V is less than 1.2.
CLINICAL RECOMMENDATION STATEMENTS:
Children should receive at least the delivered dialysis dose as recommended for the adult
population. (NKF K/DOQI 2006) (Grade A Recommendation)
Quantifying HD is the first step toward assessment of its adequacy. Fortunately, the intermittent
rapid decrease in urea concentration during HD allows a relatively easy measurement of the dose.
The delivered dose should be measured at regular intervals and no less than monthly. (NKF
K/DOQI 2006) (Grade A Recommendation)
The minimally adequate dose of HD given three times per week with Kr less than 2 mL/min/1.73m2
should be an spKt/V (excluding RKF) of 1.2 per dialysis. For treatment times less than 5 hours, an
alternative minimum dose is a URR of 65%. (NKF K/DOQI 2006) (Grade A Recommendation)
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Measure #175: Pediatric End Stage Renal Disease (ESRD): Influenza Immunization
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 6 months through 17 years with a diagnosis of ESRD and receiving
dialysis seen for a visit between November 1 and February 15 who have documented
administration of influenza immunization OR patient reported receipt of an influenza immunization
from another provider
INSTRUCTIONS:
This measure is to be reported a minimum of once for visits occurring between January 1, 2010
and February 15, 2010 for the 2009-2010 influenza season AND a minimum of once for visits
occurring between November 1, 2010 and December 31, 2010 for the 2010-2011 influenza season
for ESRD patients receiving dialysis seen during the reporting period. This measure is intended to
determine whether or not ESRD patients receiving dialysis received an influenza immunization
during the flu season. It is anticipated that clinicians providing care for pediatric patients with ESRD
will submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, and the
appropriate CPT Category II codes OR the CPT Category II code(s) with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 3P- system
reasons, 8P- reason not otherwise specified. All measure-specific coding should be reported ON
THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions however these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients who have documented administration of an influenza immunization OR patient reported
receipt of influenza immunization from another provider
NUMERATOR NOTE: Children with renal disease should receive the inactivated flu
vaccine
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OR
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Influenza Immunization Received
CPT II 4274F: Influenza immunization administered or previously received
Influenza Immunization not Received, for Medical, Patient or System Reasons
Append a modifier (1P, 2P or 3P) to CPT Category II code 4274F to report documented
circumstances that appropriately exclude patients from the denominator.
4274F with 1P: Documentation of medical reason(s) for patient not receiving influenza
immunization during the flu season (eg, patient allergy, other
contraindication)
4274F with 2P: Documentation of patient reason(s) for patient not receiving influenza
immunization during the flu season (eg, patient/caregiver declined)
4274F with 3P: Documentation of system reason(s) for patient not receiving influenza
immunization during the flu season (eg, vaccine not available)
Influenza Immunization not Received, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4274F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4274F with 8P: Influenza immunization not administered or previously received, reason
not otherwise specified
DENOMINATOR:
All patients aged 6 months through 17 years with a diagnosis of ESRD and receiving dialysis seen
for a visit between November 1 and February 15
Denominator Criteria (Eligible Cases):
Patients aged 6 months through 17 years on date of encounter
AND
Diagnosis for ESRD (line-item ICD-9-CM): 585.6
AND
Patient encounter during the reporting period (CPT): 90951, 90952, 90953, 90954,
90955, 90956, 90957, 90958, 90959, 90963, 90964, 90965
RATIONALE:
Infectious disease is a common reason for hospitalization, morbidity, and mortality among pediatric
end stage renal disease patients. All-cause hospital admission rates for pediatric end stage renal
disease patients was 14% higher in 2005 when compared to all-cause hospital admission rates for
adults. Hospitalizations for infections are also higher in children with end stage renal disease (46%)
than in adults.
CLINICAL RECOMMENDATION STATEMENTS:
Vaccination of all children aged 6 months-18 years should begin before or during the 2008-09
influenza season if feasible, but no later than during the 2009-10 influenza season. Vaccination of
all children aged 5-18 years is a new ACIP recommendation. (CDC/ACIP, 2008)
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Children and adolescents at high risk for influenza complications should continue to be a focus of
vaccination efforts as providers and programs transition to routinely vaccinating all children and
adolescents. Recommendations for these children have not changed. Children and adolescents at
higher risk for influenza complication are those:
• aged 6 months-4 years
• who have chronic pulmonary (including asthma), cardiovascular (except hypertension),
renal, hepatic, hematological, or metabolic disorders (including diabetes mellitus)
• who are immunosupressed (including immunosupression caused by medication or by
human immunodeficiency virus) (CDC/ACIP, 2008)
All children aged 6 months-8 years who have not received vaccination against influenza previously
should receive 2 doses of the vaccine the first influenza season they are vaccinated. The second
dose should be administered 4 or more weeks after the initial dose. (CDC/ACIP, 2008)
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Measure #176: Rheumatoid Arthritis (RA): Tuberculosis Screening
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of RA who have documentation of
a tuberculosis (TB) screening performed and results interpreted within 6 months prior to receiving a
first course of therapy using a biologic disease-modifying anti-rheumatic drug (DMARD)
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all RA patients who are
being considered or prescribed a first course of biologic disease-modifying anti-rheumatic drug
therapy. It is anticipated that clinicians who provide care for patients with a diagnosis of RA will
submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II codes OR the CPT Category II code(s) with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 8P- reason not otherwise specified.
All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions however these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients for whom a TB screening was performed and results interpreted within six months prior to
receiving a first course of therapy using a biologic disease-modifying anti-rheumatic drug (DMARD)
Numerator Instructions: Patients are considered to be receiving a first course of therapy
using a biologic DMARD only if they have never previously been prescribed or dispensed a
biologic DMARD.
Definition:
Biologic DMARD Therapy – Includes Adalimunab, Etanercept, Infliximab, Abatacept,
Anakinra (Rituximab is excluded)
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NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Tuberculosis Screening Performed and Results Interpreted
(Two CPT II codes [3455F & 4195F] are required on the claim form to submit this
numerator option)
CPT II 3455F: TB screening performed and results interpreted within six months prior to
initiation of first-time biologic disease modifying anti-rheumatic drug therapy for RA
AND
CPT II 4195F: Patient receiving first-time biologic disease modifying anti-rheumatic drug
therapy for rheumatoid arthritis
TB Screening not Performed or Results not Interpreted for Medical Reasons
(Two CPT II codes [3455F-1P & 4195F] are required on the claim form to submit this
numerator option)
Append a modifier (1P) to CPT Category II code 3455F to report documented
circumstances that appropriately exclude patients from the denominator.
3455F with 1P: Documentation of medical reason for not screening for TB or interpreting
results (i.e., patient positive for TB and documentation of past treatment;
patient has recently completed a course of anti-TB therapy)
AND
CPT II 4195F: Patient receiving first-time biologic disease modifying anti-rheumatic drug
therapy for rheumatoid arthritis
OR
OR
If patient does not meet denominator inclusion because biologic DMARD
prescription is Rituximab or this is not the first course of biologic DMARD therapy
for RA, report:
(One CPT II code [4196F] is required on the claim form to submit this numerator option)
CPT II 4196F: Patient not receiving first-time biologic disease modifying anti-rheumatic
drug therapy for rheumatoid arthritis
TB Screening not Performed or Results not Interpreted, Reason not Specified
(Two CPT II codes [3455F-8P& 4195F] are required on the claim form to submit this
numerator option)
Append a reporting modifier (8P) to CPT Category II code 3455F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3455F with 8P: TB screening not performed or results not interpreted, reason not
otherwise specified
AND
CPT II 4195F: Patient receiving first-time biologic disease modifying anti-rheumatic drug
therapy for rheumatoid arthritis
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DENOMINATOR:
All patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who are receiving
a first course of therapy using a biologic DMARD
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for rheumatoid arthritis (line-item ICD-9-CM): 714.0, 714.1, 714.2, 714.81
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348,
99349, 99350
RATIONALE:
Before initiating biologic DMARDs for a patient with RA, it is essential to screen the patient for
tuberculosis, as research has documented a higher incidence of TB after anti-TNFα therapy. All
patients being considered for biologic DMARD should receive a tuberculin skin test, even if the
patient has previously received the BCG vaccination. Test results, in addition to patient risk for TB
and other tests, should be used to assess the patient’s risk for latent TB infection. This is a patient
safety measure.
CLINICAL RECOMMENDATION STATEMENTS:
The American College of Rheumatology’s updated Recommendations for the use of nonbiologic
and biologic therapies in RA recommend routine tuberculosis screening to identify latent TB
infection (LTBI) in patients being considered for therapy with biologics. The evidence for TB testing
is based on a documented higher incidence of TB following ant-TNFα therapy. To begin, clinicians
should ask all RA patients being considered for biologic DMARDs about their potential risk factors
for TB infection (see below) and, irrespective of prior Bacillus-Calmette-Guérin (BCG) vaccination,
use a Tuberculin Skin Test (TST) as a diagnostic aid to assess their patient’s probability of latent
TB infection.
In addition to the ACR recommendations, guidelines from the British Society for Rheumatology
have consistent recommendations. There have been a large number of cases of tuberculosis (TB)
reported in association with the use of infliximab, and studies that demonstrate a significantly
higher rate of TB in patients on this treatment compared with controls. Cases of TB have also been
reported in association with etanercept and adalimumab. Reactivation of latent TB is highest in the
first 12 months of treatment, so particular vigilance is required during this time. With infliximab, the
majority of cases occurred within three cycles of treatment, with a median of 12 weeks after
starting treatment, suggesting reactivation of latent TB as the main factor predisposing to TB in
these cases. The following are the British Society for Rheumatology’s recommended guidelines for
patients with RA: Prior to commencing treatment with anti-TNF, all patients should be screened for
TB in accordance with the British Thoracic Society (BTS) guidelines. Active TB needs to be
adequately treated before anti-TNF therapy can be started; prior to commencing anti-TNF therapy,
consideration of prophylactic anti-TB therapy (as directed by the BTS guidelines) should be given
to patients with evidence of potential latent disease (past history of TB treatment or abnormal chest
X-ray raising the possibility of TB) after consultation with a local TB specialist; all patients
commenced on anti-TNF therapies need to be closely monitored for TB. This needs to continue for
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6 months after discontinuing infliximab treatment due to the prolonged elimination phase of
infliximab; patients on anti-TNF therapy who develop symptoms suggestive of TB should receive
full anti-TB chemotherapy, but may continue with their anti-TNF therapy if it is clinically indicated;
anti-TNF therapy should only be resumed in accordance with the BTS guidelines and after
agreement in collaboration with a TB specialist. (Level of Evidence C)
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Measure #177: Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of RA who have an assessment
and classification of disease activity within 12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with RA seen
during the reporting period. While there are disease activity assessment tools and instruments
used as examples in this measure, they are not required. The intent of this measure is to promote
physician assessment of the level of RA disease activity to inform treatment decisions. It is
anticipated that clinicians who provide care for patients with a diagnosis of RA will submit this
measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II codes OR the CPT Category II code(s) with the modifier. The
reporting modifier allowed for this measure is: 8P- reason not otherwise specified. There are no
allowable performance exclusions for this measure. All measure-specific coding should be reported
ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions however these codes may be submitted for
those registries that utilize claims data. There are no allowable performance exclusions for this
measure.
NUMERATOR:
Patients with disease activity assessed by a standardized descriptive or numeric scale or
composite index and classified into one of the following categories: low, moderate or high, at least
once within 12 months
Definition:
Assessment and Classification of Disease Activity – Assesses if physicians are
utilizing a standardized, systematic approach for evaluating the level of disease activity.
The scales/instruments listed are examples of how to define activity level and cut-off points
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can differ by scale. Standardized descriptive or numeric scales and/or composite indexes
could include but are not limited to: DAS28, SDAI, CDAI, RADAI, RAPID.
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Disease Activity Assessed and Classified
CPT II 3470F: Rheumatoid arthritis (RA) disease activity, low
OR
CPT II 3471F: Rheumatoid arthritis (RA) disease activity, moderate
OR
CPT II 3472F: Rheumatoid arthritis (RA) disease activity, high
Disease Activity not Assessed and Classified, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3470F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3470F with 8P: Disease activity not assessed and classified, reason not otherwise
specified
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA)
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for rheumatoid arthritis (line-item ICD-9-CM): 714.0, 714.1, 714.2, 714.81
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348,
99349, 99350
RATIONALE:
After establishing a diagnosis of RA, risk assessment is crucial for guiding optimal treatment. For
the purposes of selecting therapies, physicians should consider the patient’s disease activity at the
time of the treatment decisions.
CLINICAL RECOMMENDATION STATEMENTS:
Several indices to measure RA disease activity have been developed each of which has
advantages and disadvantages. Evidence-based guidelines require clear definitions of disease
activity to make rational therapeutic choices, but it is not possible or appropriate to mandate use of
a single disease activity score for the individual physician, and different studies have used different
definitions. Therefore, the TFP was asked to consider a combined estimation of disease activity,
which allowed reference to many past definitions. With these instruments as our guide, we rated
RA disease activity in an ordinal manner as low, moderate, or high, as previously requested by the
CEP.
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Measure #178: Rheumatoid Arthritis (RA): Functional Status Assessment
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of RA for whom a functional
status assessment was performed at least once within 12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with RA seen
during the reporting period. It is anticipated that clinicians who provide care for patients with a
diagnosis of RA will submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes can be used to
report the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II codes OR the CPT Category II code(s) with the modifier. The
reporting modifier allowed for this measure is: 8P- reason not otherwise specified. There are no
allowable performance exclusions for this measure. All measure-specific coding should be reported
ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions however these codes may be submitted for
those registries that utilize claims data. There are no allowable performance exclusions for this
measure.
NUMERATOR:
Patients for whom a functional status assessment was performed at least once within 12 months
Definitions:
Functional Status Assessment – This measure assesses if physicians are using a
standardized descriptive or numeric scale, standardized questionnaire, or notation of
assessment of the impact of RA on patient activities of daily living. Examples of tools used
to assess functional status include but are not limited to: Health Assessment Questionnaire
(HAQ), Modified HAQ, HAQ-2; American College of Rheumatology’s Classification of
Functional Status in Rheumatoid Arthritis.
Activities of Daily Living – Could include a description of any of the following:
dressing/grooming, rising from sitting, walking/running/ability to ambulate, stair climbing,
reaching, gripping, shopping/running errands/house or yard work.
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OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Functional Status Assessed
CPT II 1170F: Functional status assessed
Functional Status not Assessed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 1170F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
1170F with 8P: Functional status not assessed, reason not otherwise specified
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA)
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for rheumatoid arthritis (line-item ICD-9-CM): 714.0, 714.1, 714.2, 714.81
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348,
99349, 99350
RATIONALE:
Functional limitations are a significant and disruptive complication for patients living with RA.
Assessments of functional limitations are used to assess prognosis and guide treatment and
therapy decisions. Functional status should be assessed at the baseline and each follow-up visit,
using questionnaires such as the ACR’s Classification of Functional Status in RA or the Health
Assessment Questionnaire or an assessment of activities of daily living. Regardless of the
assessment tool used, it should indicate whether a functional decline is due to inflammation,
mechanical damage, or both, as treatment strategies will vary accordingly.
CLINICAL RECOMMENDATION STATEMENTS:
The management of RA is an iterative process, and patients should be periodically reassessed for
evidence of disease or limitation of function with significant alteration of joint anatomy. Baseline
evaluation of disease activity and damage in patients with rheumatoid arthritis through evaluation
of functional status or quality of life assessments using standardized questionnaires, a physician’s
global assessment of disease activity, or patient’s global assessment of disease activity. The initial
evaluation of the patient with RA should document symptoms of active disease (i.e., presence of
joint pain, duration of morning stiffness, degree of fatigue), functional status, objective evidence of
disease activity (i.e., synovitis, as assessed by tender and swollen joint counts, and the ESR or
CRP level), mechanical joint problems, etc.
At each follow up visit, the physician must assess whether the disease is active or inactive.
Symptoms of inflammatory (as contrasted with mechanical) joint disease, which include prolonged
morning stiffness, duration of fatigue, and active synovitis on joint examination, indicate active
disease and necessitate consideration of changing the treatment program. Occasionally, findings
of the joint examination alone may not adequately reflect disease activity and structural damage;
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therefore, periodic measurements of the ESR or CRP level and functional status, as well as
radiographic examinations of involved joints should be performed. It is important to determine
whether a decline in function is the result of inflammation, mechanical damage, or both; treatment
strategies will differ accordingly.
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Measure #179: Rheumatoid Arthritis (RA): Assessment and Classification of Disease
Prognosis
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of RA who have an assessment
and classification of disease prognosis at least once within 12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with RA seen
during the reporting period. It is anticipated that clinicians who provide care for patients with a
diagnosis of RA will submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II codes OR the CPT Category II code(s) with the modifier. The
reporting modifier allowed for this measure is: 8P- reason not otherwise specified. There are no
allowable performance exclusions for this measure. All measure-specific coding should be reported
ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions however these codes may be submitted for
those registries that utilize claims data. There are no allowable performance exclusions for this
measure.
NUMERATOR:
Patients with at least one documented assessment and classification (good/poor) of disease
prognosis utilizing clinical markers of poor prognosis at least once within 12 months
Numerator Instructions: This measure evaluates if physicians are assessing and
classifying disease prognosis using a standardized, systematic approach. Disease
prognosis should be classified as either poor or good.
Definitions:
Poor Prognosis – RA patients with features of poor prognosis have active disease with
high tender and swollen joint counts, often have evidence of radiographic erosions,
elevated levels of rheumatoid factor (RF) and or anti-cyclic citrullinated peptide (anti-CCP)
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antibodies, and an elevated erythrocyte sedimentation rate, and an elevated C-reactive
protein level.
Clinically Important Markers of Poor Prognosis – Classification should be based upon
at a minimum the following: functional limitation (e.g., HAQ Disability Index), extraarticular
disease (e.g. vasculitis, Sjorgen’s syndrome, RA lung disease, rheumatoid nodules), RF
positivity, positive anti-CCP antibodies (both characterized dichotomously, per CEP
recommendation), and/or bony erosions by radiography.
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Disease Prognosis Assessed and Classified
CPT II 3475F: Disease prognosis for rheumatoid arthritis assessed, poor prognosis
documented
OR
CPT II 3476F: Disease prognosis for rheumatoid arthritis assessed, good prognosis
documented
Disease Prognosis not Assessed and Classified, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3475F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3475F with 8P: Disease prognosis for rheumatoid arthritis not assessed and classified,
reason not otherwise specified
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA)
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for rheumatoid arthritis (line-item ICD-9-CM): 714.0, 714.1, 714.2, 714.81
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348,
99349, 99350
RATIONALE:
After establishing a diagnosis of RA, risk assessment is crucial for guiding optimal treatment. For
the purposes of selecting therapies, physicians should consider the presence of these prognostic
factors at the time of the treatment decisions.
CLINICAL RECOMMENDATION STATEMENTS:
Important clinical markers of disease prognosis were reviewed by a recent expert panel convened
by the American College of Rheumatology as part of an effort to update clinical recommendations.
The American College of Rheumatology 2008 Recommendations for the Use of Nonbiologic and
Biologic Therapies in Rheumatoid Arthritis were published in Arthritis & Rheumatism, June 2008.
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Poor prognosis is suggested by earlier age at disease onset, high titer of RF, elevated ESR, and
swelling of >20 joints. Extraarticular manifestations of RA, such as rheumatoid nodules, Sjogren’s
syndrome, episcleritis and scleritis, interstitial lung disease, pericardial involvement, systemic
vasculitis, and Felty’s syndrome, may also indicate a worse prognosis. Since studies have
demonstrated that treatment with DMARDs may alter the disease course in patients with recentonset RA, particularly those with unfavorable prognostic factors, aggressive treatment should be
initiated as soon as the diagnosis has been established. (Level C evidence)
Assessment of prognosis should be performed at baseline, before starting medications, to assess
organ dysfunction due to comorbid diseases. The literature agrees that a thorough assessment
includes recording a complete blood cell count, electrolyte levels, creatinine levels, hepatic enzyme
levels (AST – aspartate aminotransferase, ALT – alanine aminotransferase, and albumin), and
performing a urinalysis and stool guaiac. If necessary prognosis at baseline should rule out other
diseases; this may be repeated during disease flares to rule out septic arthritis through synovial
fluid analysis. (Level C evidence)
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Measure #180: Rheumatoid Arthritis (RA): Glucocorticoid Management
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY,
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of RA who have been assessed
for glucocorticoid use and, for those on prolonged doses of prednisone ≥ 10 mg daily (or
equivalent) with improvement or no change in disease activity, documentation of glucocorticoid
management plan within 12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with RA seen
during the reporting period. It is anticipated that clinicians who provide care for patients with a
diagnosis of RA will submit this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II codes OR the CPT Category II code(s) with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 8P- reason not otherwise specified.
All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions however these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients who have been assessed for glucocorticoid use and for those on prolonged doses of
prednisone ≥ 10 mg daily (or equivalent) with improvement or no change in disease activity,
documentation of a glucocorticoid management plan within 12 months
Definitions:
Prolonged Dose – Doses > 6 months in duration
Prednisone Equivalents – Determine using the following:
1 mg of prednisone = 1 mg of prednisolone; 5 mg of cortisone; 4 mg of hydrocortisone; 0.8
mg of triamcinolone; 0.8 mg of methylprednisolone; 0.15 mg of dexamethasone; 0.15 mg
of betamethasone
Glucocorticoid Management Plan – Includes documentation of attempt to taper steroids
OR documentation of a new prescription for a non-glucocorticoid disease-modifying
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antirheumatic drug (DMARD) OR increase in dose of non-glucocorticoid DMARD dose for
persistent RA disease activity at current or reduced dose
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Glucocorticoid Use Assessed
(One CPT II code [419xF] is required on the claim form to submit this numerator option)
CPT II 4192F: Patient not receiving glucocorticoid therapy
OR
CPT II 4193F: Patient receiving < 10 mg daily prednisone (or equivalent), or RA disease
activity is worsening, or glucocorticoid use is for less than 6 months
OR
OR
OR
Glucocorticoid Use Assessed and Management Plan Documented
(Two CPT II codes [4194F and 0540F] are required on the claim form to submit this
numerator option)
CPT II 4194F: Patient receiving ≥ 10 mg daily prednisone (or equivalent) for longer than 6
months, and improvement or no change in disease activity
AND
CPT II 0540F: Glucocorticoid Management Plan documented
Glucocorticoid Plan not Documented for Medical Reasons
(Two CPT II codes [0540F-1P and 4194F] are required on the claim form to submit this
numerator option)
Append a modifier (1P) to CPT Category II code 0540F to report documented
circumstances that appropriately exclude patients from the denominator.
0540F with 1P: Documentation of medical reason(s) for not documenting glucocorticoid
dose and documenting management plan (i.e., glucocorticoid prescription
is for a medical condition other than RA)
AND
CPT II 4194F: Patient receiving ≥ 10 mg daily prednisone (or equivalent) for longer than 6
months, and improvement or no change in disease activity
Glucocorticoid Dose not Documented, Reason not Specified
(One CPT II code [4194F-8P] is required on the claim form to submit this category)
Append a reporting modifier (8P) to CPT Category II code 4194F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4194F with 8P: Glucocorticoid dose was not documented, reason not otherwise specified
OR
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Glucocorticoid Plan not Documented, Reason not Specified
(Two CPT II codes [0540F-8P and 4194F] are required on the claim form to submit this
numerator option)
Append a reporting modifier (8P) to CPT Category II code 0540F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
0540F with 8P: Glucocorticoid plan not documented, reason not otherwise specified
AND
CPT II 4194F: Patient receiving ≥ 10 mg daily prednisone (or equivalent) for longer than 6
months, and improvement or no change in disease activity
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA)
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for rheumatoid arthritis (line-item ICD-9-CM): 714.0, 714.1, 714.2, 714.81
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348,
99349, 99350
RATIONALE:
Glucocorticoids are an important part of RA treatment as they inhibit inflammation and may control
synovitis. However, long-term use of glucocorticoids, especially at high doses, should be avoided,
due to the potential health complications. Monitoring length and dose of glucocorticoid treatment
for patients with RA is integral to making other clinical decisions.
CLINICAL RECOMMENDATION STATEMENTS:
The 1993 American College of Rheumatology guidelines acknowledge the importance of the use
and the tracking of glucocorticoid as a RA symptom reliever. The benefits of low-dose systemic
glucocorticoids, however, should always be weighed against their adverse effects. The adverse
effects of long-term oral glucocorticoids at low doses are protean and include osteoporosis,
hypertension, weight gain, fluid retention, hyperglycemia, cataracts, and skin fragility, as well as the
potential for premature atherosclerosis. These adverse effects should be considered and should be
discussed in detail with the patient before glucocorticoid therapy is begun. For long term disease
control, the glucocorticoid dosage should be kept to a minimum. For the majority of patients with
RA, this means equal or less than 10 mg of prednisone per day.
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Measure #181: Elder Maltreatment Screen and Follow-Up Plan
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 65 years and older with documentation of a screen for elder
maltreatment AND documented follow-up plan
INSTRUCTIONS:
This measure is to be reported for each initial patient evaluation during the reporting period. When
reporting CPT service code 96116, 97803, and G0270 the measure is to be reported each time the
code is submitted. The not eligible code can be used to report if it is not an initial evaluation with
screening for elder maltreatment. This measure may be reported by non-MD/DO clinicians who
perform the quality actions described in the measure based on the services provided and the
measure-specific denominator coding.
Measure Reporting via Claims:
CPT codes, G-codes, and patient demographics are used to identify patients who are included in
the measure’s denominator. G-codes are used to report the numerator of the measure.
When reporting the measure via claims, submit the listed CPT codes, HCPCS codes, and the
appropriate numerator G-code. All measure-specific coding should be reported ON THE SAME
CLAIM.
Measure Reporting via Registry:
CPT codes, G-codes, and patient demographics are used to identify patients who are included in
the measure’s denominator. The numerator options as described in the quality-data codes are
used to report the numerator of the measure. The quality-data codes listed do not need to be
submitted for registry-based submissions however these codes may be submitted for those
registries that utilize claims data.
NUMERATOR:
Patients with a documented screen for elder maltreatment and follow-up plan
Definitions:
Documented – Evidenced in the clinical record. Such evidence can include narrative
notes, a formal screen and/or an assessment and treatment plan tool/form, copy of a
documented plan or referral request for further evaluation, etc.
Screen for Elder Maltreatment – The screen includes a review of the following
components: (1) physical abuse, (2) emotional or psychological abuse, (3) neglect, (4)
sexual abuse, (5) abandonment, (6) financial or material exploitation, (7) self-neglect, and
(8) unwanted control. (Institute of Medicine 2002)
Physical Abuse – Infliction of physical injury by punching, beating, kicking, biting,
burning, shaking or other actions that result in harm. (Institute of Medicine, 2002)
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Emotional or Psychological Abuse – Involves psychological abuse, verbal
abuse, or mental injury and includes act or omissions by loved ones or caregivers
that have caused or could cause serious behavioral, cognitive, emotional, or
mental disorders.
Neglect – Involves attitudes of others or actions caused by others-such as family
members, friends, or institutional caregivers-that have an extremely detrimental
effect upon well-being. (Reyes-Ortiz 2001)
Active – Behavior that is willful, the caregiver intentionally withholds care
or necessities. The neglect may be motivated by financial gain or reflect
interpersonal conflicts. (NCPEA)
Passive – Situations where the caregiver is unable to fulfill his or her care
giving responsibilities as a result of illness, disability, stress, ignorance,
lack of maturity, or lack of resources. (NCPEA)
Sexual Abuse – Involves adults who are unable to fully comprehend and/or give
informed consent in sexual activities that violate the taboos of society. (Institute of
Medicine 2002)
Abandonment – Desertion of an elderly person by an individual who has
assumed responsibility for providing care for an elder, or by a person with physical
custody of an elder. (NCPEA)
Financial or Material Exploitation – Taking advantage of a person for monetary
gain or profit. (Institute of Medicine 2002)
Self-Neglect – Self-imposed attitudes or actions that contribute to decline in the
persons overall health and well being, may be associated with an inappropriate or
nontraditional lifestyle. Other names used may include Diogenes syndrome (DS),
aged reclusion, social breakdown, and squalor syndrome. (Reyes-Ortiz 2001)
Unwarranted Control – Controlling a person’s ability to make choices about living
situations, household finances, and medical care. (Institute of Medicine 2002)
Follow-Up Plan – May include but is not limited to documentation of a referral or
discussion with other providers, on-going monitoring or assessment, and/or a direct
intervention.
Not Eligible – A patient is not eligible if the following condition(s) exist:
• Patient refuses to participate.
• 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.
• Patient elder maltreatment screen was negative and no further follow-up required.
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Elder Maltreatment Screen and Follow-Up Plan Documented
G8534: Documentation of an elder maltreatment screen and follow-up plan
OR
Elder Maltreatment Screen Documented, Follow-Up Plan not Documented, Patient
not Eligible
G8537: Elder maltreatment screen documented, follow-up plan not documented, patient
not eligible
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OR
Elder Maltreatment Screen not Documented, Patient not Eligible
G8535: No documentation of an elder maltreatment screen, patient not eligible
Elder Maltreatment Screen not Documented, Reason not Specified
G8536: No documentation of an elder maltreatment screen, reason not specified
OR
Elder Maltreatment Screen Documented, Follow-Up Plan not Documented, Reason
not Specified
G8538: Elder maltreatment screen documented, follow-up plan not documented, reason
not specified
DENOMINATOR:
All patients aged 65 years and older
Denominator Criteria (Eligible Cases):
Patients aged ≥ 65 years on date of encounter
AND
Patient encounter during the reporting period (CPT or HCPCS): 90801, 90802,
96116*, 96150, 97003, 97802, 97803*, G0270*
Note: *When reporting CPT code 96116, 97803, and G0270, the measure is to be
reported each time the code is submitted.
RATIONALE:
Elder abuse is the infliction of physical, emotional, or psychological harm on an older adult, but also
can take the form of financial exploitation or intentional or unintentional neglect of an older adult by
the caregiver. Over the past ten years there has been an increase in elder abuse, which is not
being picked up and reported to appropriate authorities. The reasons for underreporting are twofold: health care professionals don’t ask patients if they are being abused and patients don’t tell, for
fear of retaliation by their caregivers. In the American Psychological Association’s “Elder Abuse
and Neglect: In Search of Solutions,” found on their website, it is reported that every year an
estimated 2.1 million older Americans are victims of physical, psychological, or other forms of
abuse and neglect and that for every reported case of elder abuse and neglect, it is estimated that
there may be as many as five unreported cases. Recent research suggests that elders who have
been abused tend to die earlier than those who are not abused, even in the absence of chronic
conditions or life threatening disease.
It is difficult to obtain accurate information on the extent of elder abuse and neglect in the United
States. Studies often focus on reports of selected populations and many cases are unreported.
Victims may be embarrassed, intimidated and overwhelmed by the situation. They may be fearful
of reprisals or unaware of the availability of help. In some cases, victims may be unable to report
maltreatment or do not realize that they are being maltreated. Finally, health professionals may
ignore the signs and symptoms of elder maltreatment because they are unaware of the extent of
the problem and uncomfortable with the responsibility of further assessment and action.
The extent to which elder maltreatment affects the health care system is largely unknown.
Common clinical findings associated with maltreatment include bruises, lacerations, abrasions,
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head injury, fractures, dehydration, and malnutrition. These injuries commonly result in
hospitalization. In one descriptive study that tracked the emergency department utilization of known
elderly victims of physical abuse identified through adult protective services, 114 individuals had
628 emergency department visits during a 5-year window surrounding the referral; 30 percent of
these visits resulted in hospital admission. (Institute of Medicine 2002)
Studies do indicate that the effects of elder maltreatment increase the medical needs of victims.
One longitudinal study of elderly victims of maltreatment documented a threefold increased risk of
death in the 3-year period following maltreatment, after adjusting for comorbidity and other factors
that predict death in older cohorts (Lachs 1998). In addition, maltreatment may exacerbate or
interfere with the treatment of other medical and psychosocial conditions. For example, angina
pectoris, emphysema, diabetes mellitus, and arthritis are much more challenging to treat in an
abusive environment (Lachs 1997). No studies of the costs associated with these increased
medical needs have been published. (Institute of Medicine 2002)
Website searches of the National Quality Measures Database (NQMC) using the keywords Elder
Abuse and Elder Neglect resulted in 9 measures. The measures only pertain to intimate partner
violence and not the broader topic of elder maltreatment. One measure was focused on preventive
counseling on violence and abuse, which is not the measure focus.
CLINICAL RECOMMENDATION STATEMENTS:
Every clinical setting should have a protocol for the detection and assessment of elder
maltreatment. This may be a narrative, a checklist, or some other type of standardized form that
enables all providers in that practice setting to rapidly assess for elder maltreatment and document
it in a way that allows clinicians to look at patterns over time. (Aravanis and Adelman 1993)
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Measure #182: Functional Outcome Assessment in Chiropractic Care
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with documentation of a current functional
outcome assessment using a standardized tool AND documentation of a care plan based on
identified functional outcome deficiencies
INSTRUCTIONS:
This measure is to be reported each visit indicating the appropriate numerator code; however, the
assessment is required to be current as defined for patients seen during the reporting period. This
measure may be reported by non-MD/DO clinicians who perform the quality actions described in
the measure based on the services provided and the measure-specific denominator coding.
Clarification:
The intent of the measure is for the functional outcome assessment tool to be utilized at a
minimum of every 30 days but reporting is required each visit due to coding limitations.
Therefore, for visits between each 30 day functional outcome assessment, the
denominator exclusion code not documented/not eligible would be used for reporting
purposes.
Measure Reporting via Claims:
CPT codes and patient demographics are used to identify patients that are included in the
measure’s denominator. G-codes are used to report the numerator of the measure.
When reporting the measure via claims, submit the listed CPT codes, and the appropriate
numerator G-code. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
CPT codes and patient demographics are used to identify patients who are included in the
measure’s denominator. The numerator options as described in the quality-data codes are used to
report the numerator of the measure. The quality-data codes listed do not need to be submitted for
registry-based submissions however these codes may be submitted for those registries that utilize
claims data.
NUMERATOR:
Patients with a documented current functional outcome assessment using a standardized tool AND
a documented care plan
Definitions:
Standardized Tool – An assessment tool that has been appropriately normalized and
validated for the population in which it is used. Examples of tools for functional outcome
assessment include, but are not limited to, Oswestry Disability Index (ODI), Roland Morris
Disability/Activity Questionnaire (RM), and Neck Disability Index (NDI).
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Functional Outcome Assessment – Questionnaires designed to measure a patient's
limitations in performing the usual human tasks of living. Functional questionnaires seek to
quantify symptoms, functional and behavior directly, rather than to infer them from less
relevant physiological tests. (Mercy guideline, pg. 143)
Current – A patient having a documented functional assessment within the previous 30
days.
Functional Outcome Deficiencies – Impairment or loss of physical function related to
neuromusculoskeletal capacity, including but not limited to, restricted flexion, extension
and rotation, back pain, neck pain, pain in the joints of the arms or legs, and headaches.
Care Plan – A care plan is an ordered assembly of expected or planned activities,
including observations goals, services, appointments and procedures, usually organized in
phases or sessions, which have the objective of organizing and managing health care
activity for the patient, often focused upon one or more of the patient’s health care
problems. Care plans may include order sets as actionable elements, usually supporting a
single session or phase. Also known as Treatment Plan.
Not Eligible – A patient is not eligible if the following condition(s) exist:
• Patient refuses to participate.
• Patient unable to complete questionnaire.
OR
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Current Functional Outcome Assessment and Care Plan Documented
G8539: Documentation of a current functional outcome assessment using a standardized
tool AND care plan based on identified deficiencies
OR
Current Functional Assessment Documented, Care Plan not Documented, Patient
not Eligible
G8542: Documentation of a current functional outcome assessment using a standardized
tool; no documentation of a care plan, patient not eligible
Current Functional Outcome Assessment not Documented, Patient not Eligible
G8540: Documentation that the patient is not eligible for a functional outcome assessment
using a standardized tool
Current Functional Outcome Assessment not Documented, Reason not Specified
G8541: No documentation of a current functional outcome assessment using a
standardized tool, reason not specified
OR
Current Functional Assessment Documented, Care Plan not Documented, Reason
not Specified
G8543: Documentation of a current functional outcome assessment using a standardized
tool; no documentation of a care plan, reason not specified
DENOMINATOR:
All patients aged 18 years and older
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Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Patient encounter during the reporting period (CPT): 98940, 98941, 98942
RATIONALE:
Researchers studying the efficacy of chiropractic care have long recognized that patient focused
assessment is a critical component of the evaluation process. Chiropractors can utilize the
standardized tools to help establish patient centered treatment goals and objective evaluation of
achievement of treatment goals if done more frequently. The benefits are also cited by the
American College of Physicians (Nelson and Wasson1994) such as: detecting, quantifying, and
identifying the source(s) of decreased functional capacity; guiding management decisions; guiding
the efficient use of resources; improving the prediction of the course of chronic disease; and
improving patient outcomes: symptoms, mortality, satisfaction with care, function, and quality of
life. Although the benefits of utilizing standardized functional assessment outcome tools are known,
they are not typically utilized and instead information is gathered only by patient interview.
The use of outcome assessment is imperative for the practicing clinician as a means to document
health status and improvement (van Hemert 1998). Goertz (1994) identified the importance of
using a self-report questionnaire as a means of obtaining a functional health status assessment.
Through use of a questionnaire, communication is increased between the physician and patient by
focusing not only on location and severity of a specific condition but also on how the condition is
affecting the patient’s physical and emotional health status. Questionnaires, which measure pain
level (visual analog scale), patient satisfaction, or functional assessment (Oswestry) take little time
and are valid and reliable (Liebenson 1995). Use of a standardized tool to assess functional status
provides a consistent approach in demonstrating the patient’s status and response to treatment.
A recent unpublished review of the literature found more than 50 references to the use of functional
health status assessment tools in evaluating chiropractic spinal manipulation. Among those most
commonly identified were the Oswestry Pain Disability Index (ODI), Roland Morris
Disability/Activity Questionnaire (RM), and Neck Disability Index (NDI). While there is a strong
scientific basis for the use of outcome assessment in evaluating the impact of chiropractic
manipulative procedures, these tools have not yet been widely incorporated into the clinical setting
as a quality benchmark.
A review of the National Quality Measures Clearinghouse revealed no same or similar measures.
CLINICAL RECOMMENDATION STATEMENTS:
Functional questionnaires seek to quantify symptoms, function and behavior directly, rather than to
infer them from less relevant physiological tests. Clinicians contemplating the use of functional
instruments should be aware of differences between them and be able to choose the most
appropriate assessment for their specific situation. (Haldeman, et al., 2005)
As a category, functional outcome assessments of everyday tasks are very suitable for evaluating
treatment of dysfunctions of the neuromusculoskeletal system. Many questionnaires could be
used; choice should depend upon the validity, reliability, responsiveness, and practicality
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demonstrated in the scientific literature. (Evidence Class: I, II, III, Consensus Level: 1) (Haldeman,
et al., 2005)
Keep appropriate records of the patient's evaluation and case management. (The Council on
Chiropractic Education, 2007)
Appropriately respond to changes in patient status, or failure of the patient to respond to care. (The
Council on Chiropractic Education, 2007)
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Measure #183: Hepatitis C: Hepatitis A Vaccination in Patients with HCV
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
If reporting Measure #183 - Hepatitis C: Hepatitis A Vaccination in Patients with HCV, also
report Measure #184 - Hepatitis C: Hepatitis B Vaccination in Patients with HCV.
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who received at
least one injection of hepatitis A vaccine, or who have documented immunity to hepatitis A
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with a
diagnosis of hepatitis C seen during the reporting period. This measure may be reported by
clinicians who perform the quality actions described in the measure based on the services provided
and the measure-specific denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes
and the appropriate CPT Category II codes OR the CPT Category II codes with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 8P- reason not
otherwise specified. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions however these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients who have received at least one injection of hepatitis A vaccine, or who have documented
immunity to hepatitis A
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Hepatitis A Vaccine Injection Received or Patient Has Documented Immunity to
Hepatitis A
CPT II 4148F: Hepatitis A vaccine injection administered or previously received
OR
CPT II 3215F: Patient has documented immunity to Hepatitis A
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OR
Hepatitis A Vaccine Injection not Received for Medical or Patient Reasons
Append a modifier (1P or 2P) to CPT Category II code 4148F to report documented
circumstances that appropriately exclude patients from the denominator.
4148F with 1P: Documentation of medical reason(s) for not administering at least one
injection of hepatitis A vaccine
4148F with 2P: Documentation of patient reason(s) for not administering at least one
injection of hepatitis A vaccine
Hepatitis A Vaccine Injection not Received, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4148F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4148F with 8P: Hepatitis A Vaccine not received, reason not otherwise specified
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of hepatitis C
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for hepatitis C (line-item ICD-9-CM): 070.51, 070.54, 070.70
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Assure that hepatitis A vaccination is received except for cases of documented medical or patient
reasons. This vaccination decreases the potential for a patient acquiring hepatitis A which would
contribute to further liver damage.
CLINICAL RECOMMENDATION STATEMENTS:
All patients with chronic hepatitis C should be vaccinated against hepatitis A, and seronegative
persons with risk factors for hepatitis B virus (HBV) should be vaccinated against hepatitis B. (NIH)
Persons in whom the diagnosis of hepatitis C is established are candidates for hepatitis A and
hepatitis B vaccines. (AGA)
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Measure #184: Hepatitis C: Hepatitis B Vaccination in Patients with HCV
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
If reporting Measure #184 - Hepatitis C: Hepatitis B Vaccination in Patients with HCV, also
report Measure #183 - Hepatitis C: Hepatitis A Vaccination in Patients with HCV.
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who received at
least one injection of hepatitis B vaccine, or who have documented immunity to hepatitis B
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with a
diagnosis of hepatitis C seen during the reporting period. This measure may be reported by
clinicians who perform the quality actions described in the measure based on the services provided
and the measure-specific denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II codes OR the CPT Category II codes with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 8P- reason not
otherwise specified. All measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions however these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients who have received at least one injection of hepatitis B vaccine or who have documented
immunity to hepatitis B
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Hepatitis B Vaccine Injection Received or Patient Has Documented Immunity to
Hepatitis B
CPT II 4149F: Hepatitis B vaccine injection administered or previously received
OR
CPT II 3216F: Patient has documented immunity to Hepatitis B
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OR
Hepatitis B Vaccine Injection not Received for Medical or Patient Reasons
Append a modifier (1P or 2P) to CPT Category II code 4149F to report documented
circumstances that appropriately exclude patients from the denominator.
4149F with 1P: Documentation of medical reason(s) for not administering at least one
injection of hepatitis B vaccine
4149F with 2P: Documentation of patient reason(s) for not administering at least one
injection of Hepatitis B vaccine
Hepatitis B Vaccine not Received, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4149F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4149F with 8P: Hepatitis B Vaccine not received, reason not otherwise specified
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of hepatitis C
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for hepatitis C (line-item ICD-9-CM): 070.51, 070.54, 070.70
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Assure that hepatitis B vaccination is received except for cases of documented medical or patient
reasons. These vaccinations decrease the potential for a patient acquiring hepatitis B which would
contribute to further liver damage.
CLINICAL RECOMMENDATION STATEMENTS:
All patients with chronic hepatitis C should be vaccinated against hepatitis A, and seronegative
persons with risk factors for hepatitis B virus (HBV) should be vaccinated against hepatitis B. (NIH)
Persons in whom the diagnosis of hepatitis C is established are candidates for hepatitis A and
hepatitis B vaccines. (AGA)
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Measure #185: Endoscopy & Polyp Surveillance: Colonoscopy Interval for Patients with
a History of Adenomatous Polyps – Avoidance of Inappropriate Use
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older receiving a surveillance colonoscopy and a history
of colonic polyp(s) in a previous colonoscopy, who had a follow-up interval of 3 or more years since
their last colonoscopy documented in the colonoscopy report
INSTRUCTIONS:
This measure is to be reported each time a surveillance colonoscopy is performed during the
reporting period. It is anticipated the clinician who performs the listed procedures, as specified in
the denominator coding, will report on this measure. Patients who have a coded colonoscopy
procedure that has a modifier 52, 53, 73 or 74 will not qualify for inclusion into this measure.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT code or G-codes, and patient demographics are used
to identify patients who are included in the measure’s denominator. CPT Category II codes are
used to report the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
G-codes, and the appropriate CPT Category II codes OR the CPT Category II code(s) with the
modifier. The modifiers allowed for this measure are: 1P- medical reasons, 3P- system reasons,
8P- reason not otherwise specified. All measure-specific coding should be reported ON THE SAME
CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, G-codes and patient demographics are used to identify
patients who are included in the measure’s denominator. The numerator options as described in
the quality-data codes are used to report the numerator of the measure. The quality-data codes
listed do not need to be submitted for registry-based submissions however these codes may be
submitted for those registries that utilize claims data.
NUMERATOR:
Patients who had an interval of 3 or more years since their last colonoscopy
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Interval of Three or More Years Since Patient’s Last Colonoscopy
CPT II 0529F: Interval of three or more years since patient’s last colonoscopy,
documented
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OR
Interval of Less Than Three Years Since Patient’s Last Colonoscopy for Medical or
System Reasons
Append a modifier (1P or 3P) to CPT Category II code 0529F to report documented
circumstances that appropriately exclude patients from the denominator.
0529F with 1P: Documentation of medical reason(s) for an interval of less than three
years since the last colonoscopy (eg, patients with high risk for colon
cancer, last colonoscopy incomplete, last colonoscopy had inadequate
prep, piecemeal removal of adenomas, or last colonoscopy found greater
than 10 adenomas)
0529F with 3P: Documentation of system reason(s) for an interval of less than three years
since the last colonoscopy (eg, unable to locate previous colonoscopy
report)
Interval of Less Than Three Years Since Patient’s Last Colonoscopy, Reason not
Specified
Append a reporting modifier (8P) to CPT Category II code 0529F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
0529F with 8P: Interval of less than three years since patient’s last colonoscopy, reason
not otherwise specified
DENOMINATOR:
All patients aged 18 years and older receiving a surveillance colonoscopy with a history of colonic
polyp(s) in a previous colonoscopy
Denominator Instruction: Clinicians who indicate that the colonoscopy procedure is
incomplete or was discontinued should use the procedure number and the addition (as
appropriate) of modifier 52, 53, 73, or 74. Patients who have a coded colonoscopy
procedure that has a modifier 52, 53, 73, or 74 will not qualify for inclusion into this
measure.
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for history of colonic polyp(s) (line-item ICD-9-CM): V12.72
AND
Patient encounter during the reporting period (CPT or HCPCS): 44388, 44389, 44392,
44393, 44394, 45355, 45378, 45380, 45381, 45383, 45384, 45385, G0105
WITHOUT
CPT Category I Modifiers: 52, 53, 73 or 74
RATIONALE:
Colonoscopy is the recommended method of surveillance after the removal of adenomatous polyps
because it has been shown to significantly reduce subsequent Colorectal Cancer incidence. The
timing of follow-up colonoscopy should be tailored to the number, size, and pathologic findings of
the adenomatous polyps removed. The time interval for the development of malignant changes in
adenomatous polyps is estimated at 5 to 25 years (ICSI, 2006). A randomized controlled trial of
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699 patients showed that after newly diagnosed adenomatous polyps have been removed by
colonoscopy, follow-up colonoscopy at three years detects important colonic lesions as effectively
as follow-up colonoscopy at both one and three years. (ICSI, 2006)
Performing colonoscopy too often not only increases patients’ exposure to procedural harm, but
also drains limited resources that could be more effectively used to adequately screen those in
need. Recent evidence from four surveys indicated that postpolypectomy surveillance colonoscopy
in the United States is frequently performed at intervals that are shorter than those recommended
in guidelines (Rex et al, 2006). Some endoscopists in these studies performed colonoscopy in
patients with only small hyperplastic polyps or a single tubular adenoma at one year. These
surveys underscore the importance of measuring intervals between examinations in continuous
quality improvement programs.
CLINICAL RECOMMENDATION STATEMENTS:
Patients with one to two small (1 cm) tubular adenomas with only low-grade dysplasia should
undergo follow-up colonoscopy no earlier than five years later. Patients with advanced
adenomatous lesions or >3 adenomas should have repeat colonoscopy in three years as long as
all visualized polyps were completely removed, the colonoscopy was completed up the cecum, and
the colonic preparation was adequate. A shorter interval of follow-up is recommended in those
patients with numerous adenomatous (>10) polyps and in those whom the colonoscopy was
incomplete or the preparation was inadequate. After a surveillance colonoscopy has normal
results, repeat examinations should be done at five-year intervals. Patients with large, sessile
adenomatous lesions removed in a piecemeal fashion should have a repeat examination within two
to six months to exclude and remove any remnant polypoid tissue. (Grade 1a) (Davila et al, 2006)
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Measure #186: Wound Care: Use of Compression System in Patients with Venous
Ulcers
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of venous ulcer who were
prescribed compression therapy within the 12-month reporting period
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with venous
ulcer(s) seen during the reporting period. This measure is intended to reflect the quality of services
provided for the primary management of patients with venous ulcers of the lower extremities.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 3P- system
reasons, 8P- reason not otherwise specified. All measure-specific coding should be reported ON
THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions however these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients who were prescribed compression therapy within the 12 month reporting period
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Compression Therapy Prescribed
CPT II 4267F: Compression Therapy Prescribed
Compression Therapy not Prescribed for Medical, Patient or System Reasons
Append a modifier (1P, 2P or 3P) to CPT Category II code 4267F to report documented
circumstances that appropriately exclude patients from the denominator.
4267F with 1P: Documentation of medical reason(s) for not prescribing compression
therapy (eg, severe arterial occlusive disease)
4267F with 2P: Documentation of patient reason(s) for not prescribing compression
therapy
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OR
4267F with 3P: Documentation of system reason(s) for not prescribing compression
therapy
Compression Therapy not Prescribed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4267F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
4267F with 8P: Compression therapy not prescribed, reason not otherwise specified
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of venous ulcer
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for venous ulcer (line-item ICD-9-CM): 454.0, 454.2, 459.31, 459.33, 459.81
AND
Diagnosis for ulcer of lower limbs (line-item ICD-9-CM): 707.12, 707.13, 707.14,
707.15, 707.19
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Compression therapy is fundamental to promote healing and prevent recurrence of ulcers in
patients with venous abnormality. Although it has proven efficacy, research has shown that it is not
universally used in the treatment of patients with venous ulcers. One study found that one third of
patients did not receive compression of any sort and there was great variability in the level and
type of compression therapy used. Graduated high compression (>30 mmHg) produces the best
results. However, some compression is better than no compression.
CLINICAL RECOMMENDATION STATEMENTS:
For patients with venous hypertension or risk for venous insufficiency, consider graduated
compression stockings. (Grade B) (ASPS, 2007)
The use of a Class 3 (most supportive) high-compression system (three layer, four layer, short
stretch, paste-containing bandages, e.g., Unna’s boot, Duke boot) is indicated in the treatment of
venous ulcers. Although these modalities are similar in effectiveness, they can differ significantly in
comfort and cost. The degree of compression must be modified when mixed venous/arterial
disease is confirmed during the diagnostic work-up. Intermittent pneumatic pressure (IPC) can be
used with or without compression dressings and can provide another option in patients who cannot
or will not use an adequate compression dressing system. (Level I) (WHS, 2006)
Compression therapy heals more venous leg ulcers than no compression therapy as well as
decreases the healing time. High compression is more effective than low compression, but there
are no differences in the effectiveness of the different types of products available for high
compression. (Level A) (WOCN, 2005)
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Compression options:
• Elastic compression bandage heals more than inelastic compression (Grade A)
• Multi-layer (2, 3, or 4 layers) sustained, elastic high-compression bandage (Grade A)
• Elastic high-compression stockings to heal venous ulcers (Grade A)
• Elastic multiple-layer high-compression stockings to heal venous ulcers (Grade A)
• Duke Boot or Unna Boot + elastic compression (Grade A)
• Gradient compression better than uniform compression (Grade C)
• Short stretch bandage (Grade A)
• Unna boot zinc paste impregnated bandage (Grade A)
• Intermittent pneumatic compression (Grade A)
• Non-elastic compression with Circaid [or similar device] (Grade B)
• Sequential-gradient pneumatic compression (Grade C) (AAWC, 2005)
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Measure #187: Stroke and Stroke Rehabilitation: Thrombolytic Therapy
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who
arrive at the hospital within two hours of time last known well and for whom IV t-PA was initiated
within three hours of time last known well
INSTRUCTIONS:
This measure is to be reported for each episode of acute ischemic stroke for patients who arrive at
the hospital within two hours of time last known well and for whom IV t-PA was initiated within three
hours of time last known well. It is anticipated that clinicians providing care for patients with acute
ischemic stroke in the hospital setting will submit this measure.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The listed numerator options are used to report
the numerator of the measure. The quality-data codes have been provided for registry only
measures for use by registries that utilize claims data. It is not necessary to submit these codes for
registry-based submissions. Do not report this measure via claims.
NUMERATOR:
Patients for whom IV thrombolytic therapy was initiated at the hospital within three hours (≤ 180
minutes) of time last known well
Definitions:
Last Known Well - The date and time prior to hospital arrival at which it was witnessed or
reported that the patient was last known to be without the signs and symptoms of the
current stroke or at his or her baseline state of health.
OR
OR
Numerator Options:
IV t-PA initiated within three hours (≤180 minutes) of time last known well (G8600)
IV t-PA not initiated within three hours (≤180 minutes) of time last known well for reasons
documented by clinician (e.g., patient enrolled in clinical trial for stroke, patient admitted for
elective carotid intervention) (G8601)
IV t-PA not initiated within three hours (≤180 minutes) of time last known well, reason not
specified (G8602)
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of acute ischemic stroke whose time of arrival
is within two hours (≤ 120 minutes) of time last known well
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Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter.
AND
Diagnosis for ischemic stroke (ICD-9-CM): 433.01, 433.10, 433.11, 433.21, 433.31,
433.81, 433.91, 434.00, 434.01, 434.11, 434.91, 436
AND
Patient encounter during reporting period (CPT): 99221, 99222, 99223, 99291
AND
Time last known well to arrival in the emergency department less than or equal to two
hours (≤120 minutes)
RATIONALE:
The administration of thrombolytic agents to carefully screened, eligible patients with acute
ischemic stroke has been shown to be beneficial in several clinical trials. These included two
positive randomized controlled trials in the United States; The National Institute of Neurological
Disorders and Stroke (NINDS) Studies, Part I and Part II. Based on the results of these studies, the
Food and Drug Administration approved the use of intravenous recombinant tissue plasminogen
activator (IV r-TPA or t-PA) for the treatment of acute ischemic stroke when given within 3 hours of
stroke symptom onset. A large meta-analysis controlling for factors associated with stroke outcome
confirmed the benefit of IV t-PA in patients treated within 3 hours of symptom onset. While
controversy still exists among some specialists, the major society practice guidelines developed in
the United States all recommend the use of IV t-PA for eligible patients. Physicians with experience
and skill in stroke management and the interpretation of CT scans should supervise treatment.
CLINICAL RECOMMENDATION STATEMENTS:
Intravenous r-TPA (0.9 mg/kg, maximum dose 90 mg) is recommended for selected patients who
may be treated within 3 hours of onset of ischemic stroke (Class 1, Level of Evidence A)
(AHA/ASA).
For eligible patients (see inclusion and exclusion criteria listed below), we recommend
administration of IV t-PA in a dose of 0.9 mg/kg (maximum of 90 mg), with 10% of the total dose
given as an initial bolus and the remainder infused over 60 min, provided that treatment is initiated
within 3 h of clearly defined symptom onset (Class 1, Grade 1A) (ACP).
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Measure #188: Referral for Otologic Evaluation for Patients with Congenital or Traumatic
Deformity of the Ear
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged birth and older referred to a physician (preferably a physician with
training in disorders of the ear) for an otologic evaluation subsequent to an audiologic evaluation
after presenting with a congenital or traumatic deformity of the ear (internal or external)
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all patients seen during
the reporting period who present with congenital or traumatic deformity of the ear. This measure is
intended to ensure that patients with congenital or traumatic deformity of the ear receive a referral
in order to facilitate appropriate care and follow-up. This measure may be reported by clinicians
who perform the quality actions described in the measure based on the services provided and the
measure-specific denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. G-codes are used to report the numerator
of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes
and appropriate numerator G-code. All measure-specific coding should be reported ON THE
SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions however these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients referred to a physician (preferably a physician with training in disorders of the ear) for an
otologic evaluation subsequent to an audiologic evaluation who present with congenital or
traumatic deformity of the ear
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Referral for Otologic Evaluation
G8556: Referred to a physician (preferably a physician with training in disorders of
the ear) for an otologic evaluation
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OR
Referral for Otologic Evaluation not Performed for Documented Reasons
G8557: Patient is not eligible for the referral for otologic evaluation measure (e.g. patients
for whom an assessment of the congenital or traumatic deformity of the ear has been
performed by a physician (preferably a physician with training in disorders of the ear)
within the past six months, patients who are already under the care of a physician
(preferably a physician with training in disorders of the ear) for congenital or traumatic
deformity of the ear.)
Referral for Otologic Evaluation not Performed, Reason not Specified
G8558: Not referred to a physician (preferably a physician with training in disorders of the
ear) for an otologic evaluation, reason not specified
DENOMINATOR:
Patients age birth and older who present with congenital or traumatic deformity of the ear
Denominator Criteria (Eligible Cases):
Patients age birth and older on date of encounter
AND
Diagnosis for congenital and traumatic anomalies (line-item ICD-9-CM): 744.01,
744.02, 744.03, 744.09, 380.00, 380.01, 380.02, 380.03, 380.10, 380.30, 380.31, 380.32,
380.39, 380.51, 380.81, 380.89, 380.9
AND
Patient encounter during reporting period (CPT): 92557, 92567, 92568, 92575
RATIONALE:
Studies demonstrate that patients who present with congenital or traumatic deformity of the ear
may suffer from underlying problems, so therefore referral is necessary. Without referral, patients
may suffer consequences of the underlying problems.
CLINICAL RECOMMENDATION STATEMENTS:
The American Academy of Otolaryngology-Head and Neck Surgery policy statement
(approved 9/12/2002):
Hearing loss and balance disorders are medical conditions. Only licensed physicians with medical
training may diagnose and direct the management of disease and medical disorders. A full history
and physical examination by a physician (preferably a physician specially trained in disorders of the
ear) to determine the accurate medical diagnosis and appropriate medical/surgical treatment for
hearing loss and balance disorders are indicated for patients with the following “red flags”:
1) Hearing loss with a positive history of familial hearing loss, TB, syphilis, HIV,
Meniere’s disease, autoimmune disorder, otosclerosis, von Recklinghausen’s
neurofibromatosis, Paget’s disease of bone, head trauma related to onset.
2) History of pain, active drainage, or bleeding from an ear.
3) Sudden onset or rapidly progressive hearing loss.
4) Acute, chronic, or recurrent episodes of dizziness.
5) Evidence of congenital or traumatic deformity of the ear.
6) Visualization of blood, pus, cerumen plug, or foreign body in the ear canal.
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7) Conductive hearing loss or abnormal tympanogram.
8) Unilateral or asymmetric hearing loss; or bilateral hearing loss > 80 dB.
9) Unilateral or pulsatile tinnitus.
10) Unilateral or asymmetrically poor speech discrimination scores.
The red flags do not include all indications for a medical referral and are not intended to replace
clinical judgment in determining the need for consultation with an otolaryngologist.
21 C.F.R. section 801.420:
A hearing aid dispenser should advise a prospective hearing aid user to consult promptly with a
licensed physician (preferably an ear specialist) before dispensing a hearing aid if the hearing aid
dispenser determines through inquiry, actual observation, or review of any other available
information concerning the prospective user, that the prospective user has any of the following
conditions:
I. Congenital or traumatic deformity of the ear.
II. History of active drainage from the ear within the previous 90 days.
III. History of sudden or rapidly progressive hearing loss within the previous 90
days.
IV. Acute or chronic dizziness.
V. Unilateral hearing loss of sudden or recent onset within the previous 90 days.
VI. Audiometric air-bone gap equal to or greater than 15 decibels at 500 hertz (Hz),
1,000 Hz, and 2,000 Hz.
VII. Evidence of significant cerumen accumulation or a foreign body in the ear canal.
VIII. Pain or discomfort in the ear.
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Measure #189: Referral for Otologic Evaluation for Patients with a History of Active
Drainage From the Ear Within the Previous 90 Days
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged birth and older who have disease of the ear and mastoid processes
referred to a physician (preferably a physician with training in disorders of the ear) for an otologic
evaluation subsequent to an audiologic evaluation after presenting with a history of active drainage
from the ear within the previous 90 days
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all patients seen during
the reporting period who present with a history of active drainage from the ear within the previous
90 days. This measure is intended to ensure that patients with active drainage receive a referral in
order to receive appropriate care. This measure may be reported by clinicians who perform the
quality actions described in the measure based on the services provided and the measure-specific
denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. G-codes are used to report the numerator
of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate numerator G-code(s). All measure-specific coding should be reported ON THE
SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions however these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients referred to a physician (preferably a physician with training in disorders of the ear) for an
otologic evaluation subsequent to an audiologic evaluation who present with a history of active
drainage from the ear within the previous 90 days
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Referral for Otologic Evaluation
G8559: Patient referred to a physician (preferably a physician with training in
disorders of the ear) for an otologic evaluation
AND
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OR
G8560: Patient has a history of active drainage from the ear within the previous 90 days
Referral for Otologic Evaluation not Performed for Documented Reasons
G8561: Patient is not eligible for the referral for otologic evaluation for patients with a
history of active drainage measure (e.g. Patients who are already under the care of a
physician for active ear drainage.)
AND
G8560: Patient has a history of active drainage from the ear within the previous 90 days
OR
OR
If patient is not eligible for this measure because no history of active drainage,
report:
G8562: Patient does not have a history of active drainage from the ear within the previous
90 days
Referral for Otologic Evaluation not Performed, Reason not Specified
G8563: Patient not referred to a physician (preferably a physician with training in disorders
of the ear) for an otologic evaluation, reason not specified
AND
G8560: Patient has a history of active drainage from the ear within the previous 90 days
DENOMINATOR:
Patients age birth and older who have disease of the ear and mastoid processes who present with
active drainage from the ear within the previous 90 days.
Denominator Criteria (Eligible Cases):
Patients age birth and older on date of encounter
AND
Diagnosis for disease of the ear and mastoid processes (line-item ICD-9-CM):
381.01, 382.00, 382.01, 382.02, 382.1, 382.2, 382.3, 382.4, 382.9, 388.60. 388.61, 388.69
AND
Patient encounter during reporting period (CPT): 92557, 92567, 92568, 92575
RATIONALE:
Studies demonstrate that patients who present with a history of active drainage from the ear within
the previous 90 days may suffer from underlying problems, so therefore referral is necessary.
Without referral, patients may suffer consequences of the underlying problems.
CLINICAL RECOMMENDATION STATEMENTS:
The American Academy of Otolaryngology-Head and Neck Surgery policy statement
(approved 9/12/2002):
Hearing loss and balance disorders are medical conditions. Only licensed physicians with medical
training may diagnose and direct the management of disease and medical disorders. A full history
and physical examination by a physician (preferably a physician specially trained in disorders of the
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ear) to determine the accurate medical diagnosis and appropriate medical/surgical treatment for
hearing loss and balance disorders are indicated for patients with the following “red flags”:
1) Hearing loss with a positive history of familial hearing loss, TB, syphilis, HIV,
Meniere’s disease, autoimmune disorder, otosclerosis, von Recklinghausen’s
neurofibromatosis, Paget’s disease of bone, head trauma related to onset.
2) History of pain, active drainage, or bleeding from an ear.
3) Sudden onset or rapidly progressive hearing loss.
4) Acute, chronic, or recurrent episodes of dizziness.
5) Evidence of congenital or traumatic deformity of the ear.
6) Visualization of blood, pus, cerumen plug, or foreign body in the ear canal.
7) Conductive hearing loss or abnormal tympanogram.
8) Unilateral or asymmetric hearing loss; or bilateral hearing loss > 80 dB.
9) Unilateral or pulsatile tinnitus.
10) Unilateral or asymmetrically poor speech discrimination scores.
The red flags do not include all indications for a medical referral and are not intended to replace
clinical judgment in determining the need for consultation with an otolaryngologist.
21 C.F.R. section 801.420:
A hearing aid dispenser should advise a prospective hearing aid user to consult promptly with a
licensed physician (preferably an ear specialist) before dispensing a hearing aid if the hearing aid
dispenser determines through inquiry, actual observation, or review of any other available
information concerning the prospective user, that the prospective user has any of the following
conditions:
I. Visible congenital or traumatic deformity of the ear.
II. History of active drainage from the ear within the previous 90 days.
III. History of sudden or rapidly progressive hearing loss within the previous 90
days.
IV. Acute or chronic dizziness.
V. Unilateral hearing loss of sudden or recent onset within the previous 90 days.
VI. Audiometric air-bone gap equal to or greater than 15 decibels at 500 hertz (Hz),
1,000 Hz, and 2,000 Hz.
VII. Visible evidence of significant cerumen accumulation or a foreign body in the ear
canal.
VIII. Pain or discomfort in the ear.
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Measure #190: Referral for Otologic Evaluation for Patients with a History of Sudden or
Rapidly Progressive Hearing Loss
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged birth and older referred to a physician (preferably a physician with
training in disorders of the ear) for an otologic evaluation immediately following an audiologic
evaluation that verifies and documents sudden or rapidly progressive hearing loss
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all patients seen during
the reporting period who present with a history of sudden or rapidly progressive hearing loss.
This measure is intended to ensure that patients with sudden or rapidly progressive hearing loss
receive a referral in order to receive appropriate care. This measure may be reported by clinicians
who perform the quality actions described in the measure based on the services provided and the
measure-specific denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. G-codes are used to report the numerator
of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes
and the appropriate numerator G-code(s). All measure-specific coding should be reported ON THE
SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions however these codes may be submitted for
those registries that utilize claims data.
NUMERATOR:
Patients referred to a physician (preferably a physician with training in disorders of the ear) for an
otologic evaluation immediately following an audiologic evaluation that verifies and documents
sudden or rapidly progressive hearing loss
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Referral for Otologic Evaluation
G8564: Patient was referred to a physician (preferably a physician with training in
disorders of the ear) for an otologic evaluation
AND
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OR
OR
G8565: Verification and documentation of sudden or rapidly progressive hearing loss
Referral for Otologic Evaluation not Performed for Documented Reasons
G8566: Patient is not eligible for the “Referral for Otologic Evaluation for Sudden or
Rapidly Progressive Hearing Loss” measure (e.g. patients who are under current care of a
physician for sudden or rapidly progressive hearing loss.)
AND
G8565: Verification and documentation of sudden or rapidly progressive hearing loss
OR
If patient is not eligible for this measure because there is no documentation of
sudden or rapidly progressive hearing loss, report:
G8567: Patient does not have verification and documentation of sudden or rapidly
progressive hearing loss
Referral for Otologic Evaluation not Performed, Reason not Specified
G8568: Patient was not referred to a physician (preferably a physician with training in
disorders of the ear) for an otologic evaluation, reason not specified
AND
G8565: Verification and documentation of sudden or rapidly progressive hearing loss
DENOMINATOR:
Patients aged birth and older with verification and documentation of sudden or rapidly progressive
hearing loss.
Denominator Criteria (Eligible Cases):
Patients age birth and older on date of encounter
AND
Diagnosis for hearing loss (line-item ICD-9-CM): 389.00, 389.01, 389.02, 389.03,
389.04, 389.05, 389.06, 389.08, 389.10, 389.11, 389.12, 389.13, 389.14, 389.15, 389.16,
389.17, 389.18, 389.20, 389.21, 389.22; 389.8, 389.9
AND
Patient encounter during reporting period (CPT): 92557, 92567, 92568, 92575
RATIONALE:
Studies demonstrate that patients who present sudden or rapidly progressive hearing loss not only
suffer from hearing loss, but may suffer from underlying problems, so therefore referral is
necessary. Without referral, patients may suffer consequences of the underlying problems.
CLINICAL RECOMMENDATION STATEMENTS:
The American Academy of Otolaryngology-Head and Neck Surgery policy statement
(approved 9/12/2002):
Hearing loss and balance disorders are medical conditions. Only licensed physicians with medical
training may diagnose and direct the management of disease and medical disorders. A full history
and physical examination by a physician (preferably a physician specially trained in disorders of the
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ear) to determine the accurate medical diagnosis and appropriate medical/surgical treatment for
hearing loss and balance disorders are indicated for patients with the following “red flags”:
1) Hearing loss with a positive history of familial hearing loss, TB, syphilis, HIV,
Meniere’s disease, autoimmune disorder, otosclerosis, von Recklinghausen’s
neurofibromatosis, Paget’s disease of bone, head trauma related to onset.
2) History of pain, active drainage, or bleeding from an ear.
3) Sudden onset or rapidly progressive hearing loss.
4) Acute, chronic, or recurrent episodes of dizziness.
5) Evidence of congenital or traumatic deformity of the ear.
6) Visualization of blood, pus, cerumen plug, or foreign body in the ear canal.
7) Conductive hearing loss or abnormal tympanogram.
8) Unilateral or asymmetric hearing loss; or bilateral hearing loss > 80 dB.
9) Unilateral or pulsatile tinnitus.
10) Unilateral or asymmetrically poor speech discrimination scores.
The red flags do not include all indications for a medical referral and are not intended to replace
clinical judgment in determining the need for consultation with an otolaryngologist.
21 C.F.R. section 801.420:
A hearing aid dispenser should advise a prospective hearing aid user to consult promptly with a
licensed physician (preferably an ear specialist) before dispensing a hearing aid if the hearing aid
dispenser determines through inquiry, actual observation, or review of any other available
information concerning the prospective user, that the prospective user has any of the following
conditions:
I. Visible congenital or traumatic deformity of the ear.
II. History of active drainage from the ear within the previous 90 days.
III. History of sudden or rapidly progressive hearing loss within the previous
90 days.
IV. Acute or chronic dizziness.
V. Unilateral hearing loss of sudden or recent onset within the previous 90 days.
VI. Audiometric air-bone gap equal to or greater than 15 decibels at 500 hertz (Hz),
1,000 Hz, and 2,000 Hz.
VII. Visible evidence of significant cerumen accumulation or a foreign body in the ear
canal.
VIII. Pain or discomfort in the ear.
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Measure #191: Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract
Surgery
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who
had cataract surgery and no significant ocular conditions impacting the visual outcome of surgery
and had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days
following the cataract surgery
INSTRUCTIONS:
This measure is to be calculated each time a procedure for uncomplicated cataracts is performed
during the reporting period. This measure is intended to reflect the quality of services provided for
the patients receiving uncomplicated cataract surgery.
Note: This is an outcomes measure and can be calculated solely using registry data.
• For patients who receive the cataract surgical procedures specified in the denominator
coding, it should be reported whether or not the patient had best-corrected visual
acuity of 20/40 or better achieved within 90 days following cataract surgery.
• Patients who have any of the listed comorbid conditions in the exclusion criteria should
be removed from the denominator; these patients have existing ocular conditions that
could impact the outcome of surgery and are not included in the measure calculation
for those patients who have best-corrected visual acuity of 20/40 or better (distance or
near) achieved within 90 days following the cataract surgery.
• Include only procedures performed through September 30 of the reporting period. This
will allow the post operative period to occur within the reporting year.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes and patient demographics are used to identify patients who
are included in the measure’s denominator. The listed numerator options are used to report the
numerator of the measure. The quality-data codes have been provided for registry only measures
for use by registries that utilize claims data. It is not necessary to submit these codes for registrybased submissions. There are no allowable performance exclusions for this measure. Do not
report this measure via claims.
NUMERATOR:
Patients who had best-corrected visual acuity of 20/40 or better (distance or near) achieved within
90 days following cataract surgery
OR
Numerator Options:
Best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days
following cataract surgery (4175F)
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Best-corrected visual acuity of 20/40 or better (distance or near) NOT achieved within 90
days following cataract surgery, reason not otherwise specified (4175F with 8P)
DENOMINATOR:
All patients aged 18 years and older who had cataract surgery and no significant pre-operative
ocular conditions impacting the visual outcome of surgery
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Patient encounter during the reporting period (CPT): 66840, 66850, 66852, 66920,
66930, 66940, 66982, 66983, 66984
AND
Patients WITHOUT any of the following comorbid conditions that impact the visual
outcome of surgery
(Patients with documentation of any of the following comorbid conditions that impact the
visual outcome of surgery prior to date of cataract surgery are excluded from the measure
calculation)
Comorbid Condition
Acute and subacute iridocyclitis
Amblyopia
Burn confined to eye and
adnexa
Cataract secondary to ocular
disorders
Certain types of iridocyclitis
Choroidal degenerations
Choroidal detachment
Choroidal hemorrhage and
rupture
Chorioretinal scars
Chronic iridocyclitis
Cloudy cornea
Corneal opacity and other
disorders of cornea
Corneal edema
Degeneration of macula and
posterior pole
Degenerative Disorders of
Globe
Diabetic Macular Edema
Diabetic Retinopathy
Disorders of optic chiasm
Disorders of visual cortex
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Corresponding ICD-9-CM Codes
364.00, 364.01, 362.02, 364.03, 364.04, 364.05
368.01, 368.02, 368.03
940.0, 940.1, 940.2, 940.3, 940.4, 940.5, 940.9
366.32, 366.33
364.21, 364.22, 364.23, 364.24, 364.3
363.43
363.72
363.61, 363.62, 363.63
363.30, 363.31, 363.32, 363.33, 363.35
364.10, 364.11
371.01, 371.02, 371.03, 371.04
371.00, 371.03, 371.04
371.20, 371.21, 371.22, 371.23, 371.43, 371.44
362.50, 362.51, 362.52, 362.53, 362.54, 362.55,
362.56, 362.57
360.20, 360.21, 360.23, 360.24,360.29
362.07
362.01, 362.02, 362.03, 362.04, 362.05, 362.06
377.51, 377.52, 377.53, 377.54
377.75
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Comorbid Condition
Disseminated chorioretinitis and
disseminated retinochoroiditis
Focal chorioretinitis and focal
retinochoroiditis
Glaucoma
Glaucoma associated with
congenital anomalies,
dystrophies, and systemic
syndromes
Hereditary corneal dystrophies
Hereditary choroidal dystrophies
Hereditary retinal dystrophies
High myopia
Injury to optic nerve and
pathways
Keratitis
Moderate or severe impairment,
better eye, profound impairment
lesser eye
Nystagmus and other irregular
eye movements
Open wound of eyeball
Optic Atrophy
Optic neuritis
Other background retinopathy
and retinal vascular changes
Other corneal deformities
Other disorders of optic nerve
Other disorders of sclera
Other endophthalmitis
Other retinal disorders
Other and unspecified forms of
chorioretinitis and
retinochoroiditis
Prior penetrating keratoplasty
Profound impairment, both eyes
Purulent endophthalmitis
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Corresponding ICD-9-CM Codes
363.10, 363.11, 363.12, 363.14, 363.15
363.00, 363.01, 363.03, 363.04, 363.05, 363.06,
363.07, 363.08
365.20, 365.21, 365.23, 365.24, 365.51, 365.52,
365.59, 365.60, 365.61, 365.62, 365.63, 365.64,
365.65, 365.81, 365.82, 365.83, 365.89
365.41, 365.42, 365.43, 365.44, 365.60, 365.61,
365.62, 365.63, 365.64, 365.65, 365.81, 365.82,
365.83, 365.89, 365.9
371.50, 371.51, 371.52, 371.53, 371.54, 371.55,
371.56, 371.57, 371.58
363.50, 363.51, 363.52, 363.53, 363.54, 363.55,
363.56, 363.57
362.70, 362.71, 362.72, 362.73, 362.74, 362.75,
362.76
360.20, 360.32
950.0, 950.1, 950.2, 950.3, 950.9
370.03
369.10, 369.11, 369.12, 369.13, 369.14, 369.15,
369.16, 369.17, 369.18
379.51
871.0, 871.1, 871.2, 871.3, 871.4, 871.5, 871.6,
871.7, 871.9, 921.3
377.10, 377.11, 377.12, 377.13, 377.14, 377.15,
377.16
377.30, 377.31, 377.32, 377.33, 377.34, 377.39
362.12, 362.16, 362.18
371.70, 371.71, 371.72, 371.73
377.41
379.11, 379.12
360.11, 360.12, 360.13, 360.14, 360.19
362.81, 362.82, 362.83, 362.84, 362.85, 362.89
363.20, 363.21, 363.22
371.60, 371.61, 371.62
369.00, 369.01, 369.02, 369.03, 369.04, 369.05,
369.06, 369.07, 369.08
360.00, 360.01, 360.02, 360.03, 360.04
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Comorbid Condition
Retinal detachment with retinal
defect
Retinal vascular occlusion
Retinopathy of prematurity
Scleritis and episcleritis
Separation of retinal layers
Uveitis
Visual field defects
Corresponding ICD-9-CM Codes
361.00, 361.01, 361.02, 361.03, 361.04, 361.05,
361.06, 361.07
362.31, 362.32, 362.35, 362.36,
362.21
379.04, 379.05, 379.06, 379.07, 379.09
362.41, 362.42, 362.43
360.11, 360.12
368.41
RATIONALE:
1. Scientific basis for measuring visual acuity outcomes after cataract surgery
The only reason to perform cataract surgery (other than for a limited set of medical indications) is
to improve a patient’s vision and associated functioning. The use of a 20/40 visual acuity threshold
is based on several considerations. First, it is the level for unrestricted operation of a motor vehicle
in the US. Second, it has been consistently used by the FDA in its assessment for approval of IOL
and other vision devices. Third, it is the literature standard to denote success in cataract surgery.
Fourth, work by West et al in the Salisbury Eye Study suggests that 20/40 is a useful threshold for
th
50 percentile functioning for several vision-related tasks.
Most patients achieve excellent visual acuity after cataract surgery (20/40 or better). This outcome
is achieved consistently through careful attention through the accurate measurement of axial length
and corneal power and the appropriate selection of an IOL power calculation formula. As such, it
reflects the care and diligence with which the surgery is assessed, planned and executed. Failure
to achieve this after surgery in eyes without comorbid ocular conditions that would impact the
success of the surgery would reflect care that should be assessed for opportunities for
improvement.
The exclusion of patients with other ocular and systemic conditions known to increase the risk of
an adverse outcome reflects the findings of the two published prediction rule papers for cataract
surgery outcomes, by Mangione et al and Steinberg et al. In both papers, the presence of comorbid
glaucoma and macular degeneration negatively impacted the likelihood of successful outcomes of
surgery. Further, as noted in the prior indicator, exclusion of eyes with ocular conditions that could
impact the success of the surgery would NOT eliminate the large majority of eyes undergoing
surgery while also minimizing the potential adverse selection that might otherwise occur relative to
those patients with the most complex situations who might benefit the most from having surgery to
maximize their remaining vision.
2. Evidence of a gap in care
This is an outcome of surgery indicator of direct relevance to patients and referring providers. The
available evidence suggests that cataract surgery achieves this in between 86 and 98% of
surgeries in eyes without comorbid ocular conditions (this indicator). While small, the volume of
cataract surgery in the US of over 2.8 million surgeries suggests that the impact could affect more
than 100,000 patients per year. Because of the exclusion of comorbid ocular conditions, one would
expect performance on this indicator to be as high as possible, with significantly lower rates
suggestive of opportunities for improvement.
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The ASCRS National Cataract Database reported that at 3 months postoperatively, 85.5% of all
patients had a 20/40 or better best-corrected visual acuity, 57.2% of patients had 20/25 or better
postoperative best-corrected visual acuity, and 74.6% of patients were within ± 1.0 D of target
spherical equivalent. Based on 5,788 responses, the mean visual function index score at 3 months
postoperatively was 70.3% compared with 55.0% preoperatively. (The score is based on a scale of
0 to 100, with 0 indicating an inability to perform any of the activities.) The European Cataract
Outcome Study reported for 1999 that 89% of patients achieved a postoperative visual acuity of 0.5
or more (20/40 or better), the average induced astigmatism was 0.59 D, and 86% of patients had
an induced astigmatism within ± 1.0 D.
The AAO National Eyecare Outcomes Network (NEON) database also found similar rates of
success, with an improvement in visual acuity in 92.2% of patients and improvement in VF-14 in
over 90% of patients.33 Best-corrected visual acuity of 20/40 was achieved by 89% of all NEON
patients and 96% of NEON patients without preoperative ocular comorbid conditions. Seventyeight percent of patients were within ± 1.0 D of target spherical equivalent. Ninety-five percent of
patients reported being satisfied with the results of their surgery. Patients who were dissatisfied
with the results of their surgery were slightly older and more likely to have ocular comorbidity.
In studies of phacoemulsification cataract surgery performed by ophthalmology residents, the
reported range of patients with postoperative BCVA of 20/40 or better is 80% to 91%. Eyes with
ocular comorbidities are excluded, the reported range of patients with postoperative BCVA of 20/40
or better is 86% to 98%.37 (AAO)
CLINICAL RECOMMENDATION STATEMENTS:
This is an outcomes measure. As such, there are no statements in the guideline specific to this
measurement topic.
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Measure #192: Cataracts: Complications within 30 Days Following Cataract Surgery
Requiring Additional Surgical Procedures
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who
had cataract surgery and had any of a specified list of surgical procedures in the 30 days following
cataract surgery which would indicate the occurrence of any of the following major complications:
retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or
wound dehiscence
INSTRUCTIONS:
This measure is to be calculated each time a procedure for non-complicated cataracts is performed
during the reporting period. This measure is intended to reflect the quality of services provided for
the patients receiving uncomplicated cataract surgery.
Note: This is an outcomes measure and can be calculated solely using registry data.
• For patients who receive the cataract surgical procedures specified in the denominator
coding, claims should be reviewed to determine if any of the procedure codes listed in the
numerator were performed within 30 days of the date of cataract surgery.
• Patients who have any of the listed comorbid conditions in the exclusion criteria should be
removed from the denominator, and not considered as having a complication within 30
days following cataract surgery.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes and patient demographics are used to identify patients who
are included in the measure’s denominator. The listed numerator options are used to report the
numerator of the measure. The quality-data codes have been provided for registry only measures
for use by registries that utilize claims data. It is not necessary to submit these codes for registrybased submissions. There are no allowable performance exclusions for this measure. Do not
report this measure via claims.
NUMERATOR:
Patients who had one or more specified operative procedures for any of the following major
complications within 30 days following cataract surgery: retained nuclear fragments,
endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence
Numerator Instructions: For performance, a lower rate indicates better performance.
Numerator Instructions: Codes for major complications (e.g., retained nuclear
fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or
wound dehiscence): 65235, 65800, 65810, 65815, 65860, 65880, 65900, 65920, 65930,
66030, 66250, 66820, 66825, 66830, 66852, 66986, ,67005, 67010, 67015, 67025, 67028,
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67030, 67031, 67036, 67038, 67039, 67101, 67105, 67107, 67108, 67110, 67112, 67141,
67145, 67250, 67255
OR
Numerator Options:
Surgical procedure performed within 30 days following cataract surgery for major
complications (e.g., retained nuclear fragments, endophthalmitis, dislocated or wrong
power IOL, retinal detachment or wound dehiscence) (G8627)
Surgical procedure not performed within 30 days following cataract surgery for major
complications (e.g., retained nuclear fragments, endophthalmitis, dislocated or wrong
power IOL, retinal detachment or wound dehiscence) (G8628)
DENOMINATOR:
All patients aged 18 years and older who had cataract surgery and no significant pre-operative
ocular conditions impacting the surgical complication rate
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Patient encounter during the reporting period (CPT): 66840, 66850, 66852, 66920,
66930, 66940, 66982, 66983, 66984
AND
Patients WITHOUT comorbid conditions that impact the visual outcome of surgery.
(Patients with documentation of one or more of the following comorbid conditions prior to
date of cataract surgery are excluded from the measure calculation).
Comorbid Condition
Corresponding ICD-9-CM Codes
Acute and subacute iridocyclitis
364.00, 364.01, 362.02, 364.03, 364.04,
364.05
Adhesions and disruptions of iris and
ciliary body
364.70, 364.71, 364.72, 364.73, 364.74,
364.75, 364.76, 364.77, 364.81
Anomalies of puillary function
379.42
Aphakia and other disorders of lens
379.32, 379.33, 379.34
Burn confined to eye and adnexa
940.0, 940.1, 940.2, 940.3, 940.4, 940.5,
940.9
Cataract secondary to ocular disorders 366.32, 366.33
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Cataract, congenital
743.30
Cataract, mature or hypermature
366.9
Cataract, posterior polar
743.31
Certain types of iridocyclitis
364.21, 364.22, 364.23, 364.24, 364.3
Chronic iridocyclitis
364.10, 364.11
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Comorbid Condition
Corresponding ICD-9-CM Codes
Cloudy cornea
371.01, 371.02, 371.03, 371.04
371.00, 371.03, 371.04
Corneal opacity and other disorders of
cornea
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Corneal edema
371.20, 371.21, 371.22, 371.23, 371.43,
371.44
Cysts of iris, ciliary body, and anterior
chamber
364.60, 364.61, 364.62, 364.63, 364.64
Enophthalmos
376.50, 376.51, 376.52
Glaucoma
365.20, 365.21, 365.23, 365.24, 365.51,
365.52, 365.59, 365.60, 365.61, 365.62,
365.63, 365.64, 365.65, 365.81, 365.82,
365.83, 365.89
Hereditary corneal dystrophies
371.50, 371.51, 371.52, 371.53, 371.54,
371.55, 371.56, 371.57, 371.58
High hyperopia
367.0
High myopia
360.21
Hypotony of eye
360.30, 360.31, 360.21, 360.33, 360.34
Injury to optic nerve and pathways
950.0, 950.1, 950.2, 950.3, 950.9
Keratitis
370.03
Open wound of eyeball
871.0, 871.1, 871.2, 871.3, 871.4, 871.5,
871.6, 871.7, 871.9, 921.3
Pathologic myopia
360.20, 360.21
Posterior lenticonus
743.36
Prior pars plana vitrectomy
67036, 67038, 67039, 67040 (patient with
history of this procedure)
Pseudoexfoliation syndrome
365.52
Retinopathy of prematurity
362.21
Senile cataract
366.11
Traumatic cataract
366.21, 366.22, 366.23, 366.20
Use of systemic sympathetic alpha-1a
antagonist medication for treatment of
prostatic hypertrophy
Patient taking tamsulosin hydrochloride
Uveitis
360.11, 360.12
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Comorbid Condition
Corresponding ICD-9-CM Codes
Vascular disorders of iris and ciliary
body
364.42
RATIONALE:
1. Scientific basis for assessing short-term complications following cataract surgery.
Complications that may result in a permanent loss of vision following cataract surgery are
uncommon. This short-term outcomes of surgery indicator seeks to identify those
complications from surgery that can reasonably be attributed to the surgery and surgeon and
which reflect situations which - if untreated - generally result in significant avoidable vision loss
that would negatively impact patient functioning. Further, it seeks to reduce surgeon burden
and enhance accuracy in reporting by focusing on those significant complications that can be
assessed from administrative data alone and which can be captured by the care of another
physician or the provision of additional, separately coded, post-operative services. Finally, it
focuses on patient safety and monitoring for events that, while hopefully uncommon, can
signify important issues in the care being provided. For example, the need to reposition or
exchange an IOL reflects in part “wrong power” IOL placement, a major patient safety issue.
In order to achieve these ends, the indicator excludes patients with other known, pre-operative
ocular conditions that could impact the likelihood of developing a complication. Based on the
results of the Cataract Appropriateness Project at RAND, other published studies, and one
analysis performed by on national MCO data base, the exclusion codes would preserve over
2/3 of all cataract surgery cases for analysis. Thus, this provides a “clean” indicator that
captures care for the large majority of patients undergoing cataract surgery.
2. Evidence for gap in care.
The advances in technology and surgical skills over the last 30 years have made cataract
surgery much safer and more effective. An analysis of a single company’s database
(commercial age MCO) demonstrated that the rate of complications found for this indicator was
approximately 1 to 2%. Nevertheless, as noted above, the occurrence of one of these events is
associated with a significant potential for vision loss that is otherwise avoidable. Furthermore,
with an annual volume of 2.8 million cataract surgeries in the US, a 2% rate would mean that
over 36,000 surgeries are accompanied by these complications (2/3 of 56,000 surgeries).
A synthesis of the literature published prior to 1992 found weighted mean complication rates
among all patients undergoing cataract surgery of 0.13% for endophthalmitis, 0.3% for bullous
keratopathy, 1.4% clinically detectable CME, 3.5% for angiographically demonstrated CME,
0.7% for retinal detachment, and 1.1% for IOL dislocation. Bullous keratopathy and CME are
not included in this indicator because they are conditions that are almost always temporary and
resolve without additional intervention through additional procedures and associated care in
this population of patients without prior known ocular conditions.
Additional studies similarly demonstrate the low occurrence of complications, including many
that are temporary in nature and without a significant impact on patient outcomes. A national
survey of over 100 hospitals from 1997 to 1998 found the following results on 18,454 patients
50 years old or older. Seventy-seven percent of these patients had surgery performed by
phacoemulsification. Rates for events that occurred during surgery were 4.4% for posterior
capsule rupture and vitreous loss, 1.0% for incomplete cortical cleanup, 1.0% for anterior
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chamber hemorrhage and or collapse, and 0.77% for iris damage. Short-term (within 48 hours)
perioperative complications included corneal edema (9.5%), increased IOP (7.9%), uveitis
(5.6%), wound leak (1.2%), hyphema (1.1%), and retained lens material (1.1%).
A retrospective study from New Zealand of 1,793 consecutive patients undergoing
phacoemulsification reported a rate of 1.8% for posterior capsule rupture and a rate of 1.2% for
rhegmatogenous retinal detachment. (AAO)
CLINICAL RECOMMENDATION STATEMENTS:
This is an outcomes measure. As such, there are no statements in the guideline specific to this
measurement topic.
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Measure #193: Perioperative Temperature Management
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients, regardless of age, undergoing surgical or therapeutic procedures under
general or neuraxial anesthesia of 60 minutes duration or longer, except patients undergoing
cardiopulmonary bypass, for whom either active warming was used intraoperatively for the purpose
of maintaining normothermia, OR at least one body temperature equal to or greater than 36
degrees Centigrade (or 96.8 degrees Fahrenheit) was recorded within the 30 minutes immediately
before or the 15 minutes immediately after anesthesia end time
INSTRUCTIONS:
This measure is to be reported each time a surgical or therapeutic procedure not involving
cardiopulmonary bypass is performed under general or neuraxial anesthesia during the reporting
period. There is no diagnosis associated with this measure. It is anticipated that clinicians who
provide the listed anesthesia services as specified in the denominator coding will submit this
measure.
Measure Reporting via Claims:
CPT codes are used to identify patients who are included in the measure’s denominator. CPT
Category II codes are used to report the numerator of the measure.
When reporting the measure via claims, submit the listed CPT Procedure code and the appropriate
CPT Category II codes OR the CPT Category II code(s) with the modifier. The modifiers allowed
for this measure are: 1P- Medical reasons or 8P- reasons not otherwise specified. All measurespecific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
CPT codes are used to identify patients who are included in the measure’s denominator. The
numerator options as described in the quality-data codes are used to report the numerator of the
measure. The quality-data codes listed do not need to be submitted for registry-based submissions
however these codes may be submitted for those registries that utilize claims data.
NUMERATOR:
Patients for whom either:
• Active warming was used intraoperatively for the purpose of maintaining normothermia,
OR
• At least one body temperature equal to or greater than 36 degrees Centigrade (or 96.8
degrees Fahrenheit) was recorded within the 30 minutes immediately before or the 15
minutes immediately after anesthesia end time
Numerator Instructions: The anesthesia time used for this measure should be the time
recorded in the anesthesia record.
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Definition: For purposes of this measure, “active warming” is limited to over-the-body
active warming (e.g., forced air, warm-water garments, and resistive heating blankets).
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Active Warming Used Intraoperatively OR At Least One Body Temperature Equal to
or Greater than 36 Degrees Centigrade Recorded Within Designated Timeframe
(Two CPT II codes [4250F & 4255F] are required on the claim form to submit this
numerator option)
CPT II 4250F: Active warming used intraoperatively for the purpose of maintaining
normothermia, OR at least one body temperature equal to or greater than 36 degrees
Centigrade (or 96.8 degrees Fahrenheit) recorded within the 30 minutes immediately
before or the 15 minutes immediately after anesthesia end time.
AND
CPT II 4255F: Duration of general or neuraxial anesthesia 60 minutes or longer, as
documented in the anesthesia record
Active Warming Not Performed OR at Least One Body Temperature Equal to or
Greater than 36 Degrees Centigrade not Achieved Within Designated Timeframe for
one of the following Medical Reasons:
(Two CPT II codes [4250F-1P & 4255F] are required on the claim form to submit this
numerator option)
Append a modifier (1P) to CPT Category II code 4250F to report one of the following
documented circumstances that appropriately exclude patients from the denominator:
4250F with 1P: Intentional hypothermia OR active warming not indicated due to anesthetic
technique: peripheral nerve block without general anesthesia, OR
monitored anesthesia care
AND
CPT II 4255F: Duration of general or neuraxial anesthesia 60 minutes or longer, as
documented in the anesthesia record
OR
OR
If patient does not meet denominator inclusion because anesthesia time as
indicated on the anesthesia record is less than 60 minutes duration:
(One CPT II code [4256F] is required on the claim form to submit this numerator option)
CPT II 4256F: Duration of general or neuraxial anesthesia less than 60 minutes, as
documented in the anesthesia record
Active Warming Not Performed OR at Least One Body Temperature Equal to or
Greater than 36 Degrees Centigrade Not Achieved Within Designated Timeframe,
Reason Not Specified
(Two CPT II codes [4250F-8P & 4255F] are required on the claim form to submit this
numerator option)
Append a reporting modifier (8P) to CPT Category II code 4250F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
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4250F with 8P: Active warning not performed OR at least one body temperature equal to
or greater than 36 degrees Centigrade Not Achieved within designated
timeframe, reason not otherwise specified
AND
CPT II 4255F: Duration of general or neuraxial anesthesia 60 minutes or longer, as
documented in the anesthesia record
DENOMINATOR:
All patients, regardless of age, undergoing surgical or therapeutic procedures under general or
neuraxial anesthesia of 60 minutes duration or longer, except patients undergoing cardiopulmonary
bypass
Denominator Criteria (Eligible Cases):
Patient encounter during the reporting period (CPT): Anesthesia codes for surgical or
therapeutic procedures under general or neuraxial anesthesia:
00100, 00102, 00103, 00104, 00120, 00124, 00126, 00140, 00142, 00144, 00145, 00147,
00148, 00160, 00162, 00164, 00170, 00172, 00174, 00176, 00190, 00192, 00210, 00211,
00212, 00214, 00215, 00216, 00218, 00220, 00222, 00300, 00320, 00322, 00326, 00350,
00352, 00400, 00402, 00404, 00406, 00410, 00450, 00452, 00454, 00470, 00472, 00474,
00500, 00520, 00522, 00524, 00528, 00529, 00530, 00532, 00534, 00537, 00539, 00540,
00541, 00542, 00546, 00548, 00550, 00560, 00566, 00580, 00600, 00604, 00620, 00622,
00625, 00626, 00630, 00632, 00634, 00635, 00640, 00670, 00700, 00702, 00730, 00740,
00750, 00752, 00754, 00756, 00770, 00790, 00792, 00794, 00796, 00797, 00800, 00802,
00810, 00820, 00830, 00832, 00834, 00836, 00840, 00842, 00844, 00846, 00848, 00851,
00860, 00862, 00864, 00865, 00866, 00868, 00870, 00872, 00873, 00880, 00882, 00902,
00904, 00906, 00908, 00910, 00912, 00914, 00916, 00918, 00920, 00921, 00922, 00924,
00926, 00928, 00930, 00932, 00934, 00936, 00938, 00940, 00942, 00944, 00948, 00950,
00952, 01112, 01120, 01130, 01140, 01150, 01160, 01170, 01173, 01180, 01190, 01200,
01202, 01210, 01212, 01214, 01215, 01220, 01230, 01232, 01234, 01250, 01260, 01270,
01272, 01274, 01320, 01340, 01360, 01380, 01382, 01390, 01392, 01400, 01402, 01404,
01420, 01430, 01432, 01440, 01442, 01444, 01462, 01464, 01470, 01472, 01474, 01480,
01482, 01484, 01486, 01490, 01500, 01502, 01520, 01522, 01610, 01620, 01622, 01630,
01634, 01636, 01638, 01650, 01652, 01654, 01656, 01670, 01680, 01682, 01710, 01712,
01714, 01716, 01730, 01732, 01740, 01742, 01744, 01756, 01758, 01760, 01770, 01772,
01780, 01782, 01810, 01820, 01829, 01830, 01832, 01840, 01842, 01844, 01850, 01852,
01860, 01924, 01925, 01926, 01930, 01931, 01932, 01933, 01935, 01936, 01951, 01952,
01961, 01962, 01963, 01965, 01966, 01968, 01969
RATIONALE:
Anesthetic-induced impairment of thermoregulatory control is the primary cause of perioperative
hypothermia. Even mild hypothermia (1-2°C below normal) has been associated in randomized
trials with a number of adverse consequences, including: increased susceptibility to infection,
impaired coagulation and increased transfusion requirements, cardiovascular stress and cardiac
complications, post‐anesthetic shivering and thermal discomfort. Whether the benefits of avoiding
hypothermia in patients undergoing cardiopulmonary bypass (CPB) outweigh potential harm is
uncertain, because known complications of CPB include cerebral injury, which may be mitigated by
mild hypothermia. Therefore, patients undergoing CPB are excluded from the denominator
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population for this measure. Several methods to maintain normothermia are available to the
anesthesiologist in the perioperative period; various studies have demonstrated the superior
efficacy of over-the-body active warming (e.g., forced air, warm-water garments, and resistive
heating blankets).. Data elements required for the measure can be captured and the measure is
actionable by the physician.
Existing hospital-level measures for this topic were consulted and, to the extent feasible,
harmonization between physician- and hospital-level measurement was achieved.
CLINICAL RECOMMENDATION STATEMENTS:
Preoperative patient management
Assessment: Identify patient's risk factors for unplanned perioperative hypothermia. Measure
patient temperature on admission. Determine patient's thermal comfort level (ask the patients if
they are cold). Assess for other signs and symptoms of hypothermia (shivering, piloerection, and/or
cold extremities).
Interventions: Institute preventive warming measures for patients who are normothermic
(normothermia is defined as a core temperature range from 36°C-38°C (96.8°F-100.4°F)). A
variety of measures may be used, unless contraindicated. Passive insulation may include warmed
cotton blankets, socks, head covering, limited skin exposure, circulating water mattresses, and
increase in ambient room temperature (minimum 68ºF- 75ºF). Institute active warming measures
for patients who are hypothermic (defined as a core temperature less than 36°C). Active warming
is the application of a forced air convection warming system. Apply appropriate passive insulation
and increase the ambient room temperature (minimum 68ºF-75ºF). Consider warmed intravenous
(IV) fluids. (ASPAN)
Intraoperative patient management
Assessment: Identify patient's risk factors for unplanned perioperative hypothermia. Determine
patient's thermal comfort level (ask the patients if they are cold). Assess for other signs and
symptoms of hypothermia (shivering, piloerection, and/or cold extremities). Monitor patient’s
temperature intraoperatively.
Intervention: Implement warming methods. (ASPAN)
Maintenance of body temperature in a normothermic range is recommended for most procedures
other than during periods in which mild hypothermia is intended to provide organ protection (e.g.,
during high aortic cross-clamping). (Class I Recommendation, Level of Evidence B) (ACC/AHA)
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Measure #194: Oncology: Cancer Stage Documented
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients, regardless of age, with a diagnosis of breast, colon, or rectal cancer who
are seen in the ambulatory setting who have a baseline AJCC cancer stage or documentation that
the cancer is metastatic in the medical record at least once within 12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with breast,
colon or rectal cancer seen during the reporting period. This measure is intended to reflect the
quality of services provided for the primary management of patients with breast, colon or rectal
cancer who are seen in the ambulatory setting or receiving radiation treatment planning.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes and CPT codes are used to identify patients who are included
in the measure’s denominator. CPT Category II codes are used to report the numerator of the
measure.
When reporting the measure via claims, submit the listed CPT Procedure code, ICD-9-CM
diagnosis codes, and the appropriate CPT Category II codes OR the CPT Category II code(s) with
the modifier. The reporting modifier allowed for this measure is: 8P-reasons not otherwise
specified. There are no allowable performance exclusions for this measure. All measure-specific
coding should be reported on the same claim.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes and CPT codes are used to identify patients who are included in the
measure’s denominator. The numerator options as described in the quality-data codes are used to
report the numerator of the measure. The quality-data codes listed do not need to be submitted for
registry-based submissions however these codes may be submitted for those registries that utilize
claims data. There are no allowable performance exclusions for this measure.
NUMERATOR:
Patients who have a baseline AJCC cancer stage* or documentation that the cancer is metastatic
in the medical record at least once within 12 months
Numerator Instructions: *Cancer stage refers to stage at diagnosis
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
CPT II 3300F: American Joint Committee on Cancer (AJCC) stage documented and
reviewed
OR
CPT II 3301F: Cancer stage documented in medical record as metastatic and reviewed
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Cancer Stage Not Documented, Reason Not Specified
Append a reporting modifier (8P) to CPT Category II code 3301F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3301F with 8P: Cancer stage not documented, reason not otherwise specified
DENOMINATOR:
All patients, regardless of age, with a diagnosis of breast, colon, or rectal cancer who are seen in
the ambulatory setting
Denominator Criteria (Eligible Cases):
Diagnosis for breast, colon or rectal cancer (line-item ICD-9-CM): 153.0, 153.1, 153.2,
153.3, 153.4, 153.5, 153.6, 153.7, 153.8, 153.9, 154.0, 154.1, 154.2, 154.3, 154.8, 174.0,
174.1, 174.2, 174.3, 174.4, 174.5, 174.6, 174.8, 174.9, V10.3, V10.05, V10.06
AND
Patient encounter during reporting period (CPT): 77261, 77262, 77263, 99201, 99202,
99203, 99204, 99205, 99212, 99213, 99214, 99215
RATIONALE:
Cancer stage is a critical component in determining treatment options for patients with cancer.
Though critically important, cancer stage is not always documented in the medical record. This
measure is intended to be reported at least once per 12 month reporting period.
CLINICAL RECOMMENDATION STATEMENTS:
A simple classification scheme, which can be incorporated into a form for staging and can be
universally applied, is the goal of the TNM system as proposed by the AJCC. Thus, examination
during the surgical procedure and histologic examination of the surgically removed tissues may
identify significant additional indicators of the prognosis of the patient (T, N, and M) as different
from what could be discerned clinically before therapy. Because this is that pathologic (pTNM)
classification and stage grouping (based on examination of a surgically resected specimen with
sufficient tissue to evaluate the highest T, N, or M classification), it is recorded in addition to the
clinical classification. It does not replace the clinical classification. Both should be maintained in the
patient’s permanent medical record…It is intended to provide a means by which this information
can readily be communicated to others, to assist in therapeutic decisions, and to help estimate
prognosis. (Joint Committee on Cancer 2002)
A central component of the treatment of breast cancer is full knowledge of extent of disease and
biological features. The need for and selection of various local or systemic therapies are based on
a number of prognostic and predictive factors. These factors include tumor histology, clinical and
pathologic characteristics of the primary tumor, axillary node status, tumor hormone receptor
content, tumor HER2 status, presence or absence of detectable metastatic disease, patient
comorbid conditions, patient age, and menopausal status. (NCCN, 2007)
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Measure #195: Stenosis Measurement in Carotid Imaging Reports
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of final reports for all patients, regardless of age, for carotid imaging studies (neck MR
angiography [MRA], neck CT angiography [CTA], neck duplex ultrasound, carotid angiogram)
performed that include direct or indirect reference to measurements of distal internal carotid
diameter as the denominator for stenosis measurement
INSTRUCTIONS:
This measure is to be reported each time a carotid imaging study is performed during the reporting
period for all patients, regardless of age. There is no diagnosis associated with these measures.
Clinicians who provide component of diagnostic imaging studies of the carotids will be reporting on
this measure.
Measure Reporting Via Claims:
CPT codes are used to identify patients who are included in the measure’s denominator. CPT
Category II codes are used to report the numerator of the measure.
When reporting the measure via claims, submit the listed CPT procedure codes and the
appropriate CPT Category II code OR the CPT Category II code with the modifier. The reporting
modifier allowed for this measure is: 8P- reason not otherwise specified. There are no allowable
performance exclusions for this measure. All measure-specific coding should be reporting ON THE
SAME CLAIM.
Measure Reporting via Registry:
CPT codes are used to identify patients who are included in the measure’s denominator. The
numerator options as described in the quality-data codes are used to report the numerator of the
measure. The quality-data codes listed do not need to be submitted for registry-based submissions
however these codes may be submitted for those registries that utilize claims data. There are no
allowable performance exclusions for this measure.
NUMERATOR:
Final carotid imaging study reports that include direct or indirect reference to measurements of
distal internal carotid diameter as the denominator for stenosis measurement
Definition: “Direct or indirect reference to measurements of distal internal carotid diameter
as the denominator for stenosis measurement” includes direct angiographic stenosis
calculation based on the distal lumen as the denominator for stenosis measurement OR an
equivalent validated method referenced to the above method (e.g., for duplex ultrasound
studies, velocity parameters that correlate with anatomic measurements that use the distal
internal carotid lumen as the denominator for stenosis measurement)
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OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Reference to Measurements of Distal Internal Carotid Diameter as the Denominator
for Stenosis Measurement Referenced
CPT II 3100F: Carotid image study report includes direct or indirect reference to
measurements of distal internal carotid diameter as the denominator for stenosis
measurement
Measurements of Distal Internal Carotid Diameter not Referenced, Reason not
Specified
Append a reporting modifier (8P) to CPT Category II code 3100F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
3100F with 8P: Carotid image study report did not include direct or indirect reference to
measurements of distal internal carotid diameter as the denominator for
stenosis measurement, reason not otherwise specified
DENOMINATOR:
All final reports for carotid imaging studies (neck MR angiography [MRA], neck CT angiography
[CTA], neck duplex ultrasound, carotid angiogram) performed
Denominator Criteria (Eligible Cases):
Patient encounter during the reporting period (CPT): 70498, 70547, 70548, 70549,
75660, 75662, 75665, 75671, 75676, 75680, 93880, 93882
RATIONALE:
Since the clinical decision-making is based on randomized trial evidence and degree of stenosis is
an important element of the decision for carotid intervention, characterization of the degree of
stenosis needs to be standardized. Requiring that stenosis calculation be based on a denominator
of distal internal carotid diameter or, in the case of duplex ultrasound, velocity measurements that
have been correlated to angiographic stenosis calculation based on distal internal carotid diameter,
makes the measure applicable to both imaging and duplex studies.
CLINICAL RECOMMENDATION STATEMENTS:
……the NASCET method of calculating stenosis measurement should be employed when
angiography is used to correlate US findings. (Grant et al., SRU, 2003)
For patients with symptomatic atherosclerotic carotid stenosis > 70%, as defined using the
NASCET criteria, the value of carotid endarterectomy (CEA) has been clearly established from the
results of 3 major prospective randomized trials: the NASCET, the European Carotid Surgery Trial
(ECST), and the Veterans Affairs Cooperative Study Program. Among symptomatic patients with
TIAs or minor strokes and high-grade carotid stenosis, each trial showed impressive relative and
absolute risk reductions for those randomized to surgery. For patients with carotid stenosis < 50%,
these trials showed that there was no significant benefit of surgery. (Sacco, ASA, 2006)
It is important to consider that the degree of carotid stenosis in ECST was measured differently
than that in NASCET. The degree of carotid stenosis is significantly higher if calculated by the
NASCET rather than the ECST method. In summary, it appears that patients with a recent TIA or
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nondisabling stroke with ipsilateral carotid stenosis benefit from surgery if the stenosis is > 50% as
measured by the NASCET method; however, this benefit appears to be less pronounced in
women. Recently symptomatic patients with > 70% stenosis as measured by the NASCET method
can expect a far greater benefit from carotid endarterectomy. (Albers, AHA, 1999)
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Measure #196: Coronary Artery Disease (CAD): Symptom and Activity Assessment
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of CAD who were evaluated for
both level of activity and anginal symptoms during one or more visits
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with CAD seen
during the reporting period. This measure is intended to reflect the quality of services provided for
the primary management of patients with CAD who are seen in the ambulatory setting.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The listed numerator options are used to report
the numerator of the measure. The quality-data codes have been provided for registry only
measures for use by registries that utilize claims data. It is not necessary to submit these codes for
registry-based submissions. There are no allowable performance exclusions for this measure. Do
not report this measure via claims.
NUMERATOR:
Patients evaluated for both level of activity and anginal symptoms during one or more office visits
OR
Numerator Options:
Anginal symptoms and level of activity assessed (1002F)
Anginal symptoms and level of activity assessed not assessed, reason not specified
(1002F with 8P)
DENOMINATOR:
All patients aged 18 years and older with CAD
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for CAD (ICD-9-CM): 410.00, 410.01, 410.02, 410.10, 410.11, 410.12, 410.20,
410.21, 410.22, 410.30, 410.31, 410.32, 410.40, 410.41, 410.42, 410.50, 410.51, 410.52,
410.60, 410.61, 410.62, 410.70, 410.71, 410.72, 410.80, 410.81, 410.82, 410.90, 410.91,
410.92, 411.0, 411.1, 411.81, 411.89, 412, 413.0, 413.1, 413.9, 414.00, 414.01, 414.02,
414.03, 414.04, 414.05, 414.06, 414.07, 414.8, 414.9, V45.81, V45.82
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310,
99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343,
99344, 99345, 99347, 99348, 99349, 99350
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RATIONALE:
The cardinal symptom of CAD is anginal chest pain or equivalent symptoms, such as exertional
dyspnea, which may result in limitations on the patient's activities. Clinical management of these
symptoms and associated limitations can best be achieved if the patient's level of activity and
anginal symptoms are regularly assessed.
CLINICAL RECOMMENDATION STATEMENTS:
Regular assessment of patients’ anginal symptoms and levels of activity is recommended
(ACC/AHA).
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Measure #197: Coronary Artery Disease (CAD): Drug Therapy for Lowering LDLCholesterol
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of CAD who were prescribed a
lipid-lowering therapy (based on current ACC/AHA guidelines)
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with CAD seen
during the reporting period. This measure is intended to reflect the quality of services provided for
the primary management of patients with CAD.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The listed numerator options are used to report
the numerator of the measure. The quality-data codes have been provided for registry only
measures for use by registries that utilize claims data. It is not necessary to submit these codes for
registry-based submissions. Do not report this measure via claims.
NUMERATOR:
Patients who were prescribed lipid-lowering therapy
NUMERATOR NOTE: For those registries that utilize claims data, the quality-data code
4002F may be used for this measure.
OR
OR
Numerator Options:
Lipid-lowering therapy prescribed
Lipid-lowering therapy not prescribed for medical reason
OR
Lipid-lowering therapy not prescribed for patient reason
OR
Lipid-lowering therapy not prescribed for system reason
Lipid-lowering therapy not prescribed, reason not specified
DENOMINATOR:
All patients aged 18 years and older with CAD
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
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Diagnosis for CAD (ICD-9-CM): 410.00, 410.01, 410.02, 410.10, 410.11, 410.12, 410.20,
410.21, 410.22, 410.30, 410.31, 410.32, 410.40, 410.41, 410.42, 410.50, 410.51, 410.52,
410.60, 410.61, 410.62, 410.70, 410.71, 410.72, 410.80, 410.81, 410.82, 410.90, 410.91,
410.92, 411.0, 411.1, 411.81, 411.89, 412, 413.0, 413.1, 413.9, 414.00, 414.01, 414.02,
414.03, 414.04, 414.05, 414.06, 414.07, 414.8, 414.9, V45.81, V45.82
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310,
99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343,
99344, 99345, 99347, 99348, 99349, 99350
RATIONALE:
Studies have demonstrated that active treatment with lipid-lowering therapy is associated with
stabilization and regression of coronary atherosclerotic plaques and decreased incidence of clinical
events. Recent clinical trials have further documented that LDL-lowering agents can decrease the
risk of adverse ischemic events in patients with established CAD.
CLINICAL RECOMMENDATION STATEMENTS:
The LDL-C treatment goal is <100 mg/dl. Persons with established coronary heart disease (CHD)
who have a baseline LDL-C ³130 mg/dl should be started on a cholesterol-lowering drug
simultaneously with therapeutic lifestyle changes and control of nonlipid risk factors (National
Cholesterol Education Program [NCEP]).
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Measure #198: Heart Failure: Left Ventricular Function (LVF) Assessment
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of heart failure who have
quantitative or qualitative results of LVF assessment recorded
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with heart
failure seen during the reporting period, regardless of when the education of left ventricular function
was performed. This measure is intended to reflect the quality of services provided for the primary
management of patients with heart failure. The left ventricular systolic dysfunction may be
determined by quantitative or qualitative assessment, which may be current or historical. Examples
of a quantitative or qualitative assessment may include an echocardiogram: 1) that provides a
numerical value of left ventricular systolic function or 2) that uses descriptive terms such as
moderately or severely depressed left ventricular systolic function. This measure may be reported
by clinicians who perform the quality actions described based on the services provided and the
measure-specific denominator coding.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes and patient demographics are used to identify patients who
are included in the measure’s denominator. The listed numerator options are used to report the
numerator of the measure. The quality-data codes have been provided for registry only measures
for use by registries that utilize claims data. It is not necessary to submit these codes for registrybased submissions. There are no allowable performance exclusions for this measure. Do not
report this measure via claims.
NUMERATOR:
Patients with quantitative or qualitative results of LVF assessment recorded
OR
Numerator Options:
Left ventricular function (LVF) assessment (eg, echocardiography, nuclear test, or
ventriculography) documented in the medical record (Includes: Quantitative or qualitative
assessment results) (3020F)
Quantitative or qualitative results of LVF assessment not Performed or Assessed, Reason
Not Specified (3020F with 8P)
DENOMINATOR:
All patients aged ≥ 18 years and older with a diagnosis of heart failure
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
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Diagnosis for heart failure (ICD-9-CM): 398.91, 402.01, 402.11, 402.91, 404.01, 404.03,
404.11, 404.13, 404.91, 404.93, 425.0, 425.1, 425.2, 425.3, 425.4, 425.5, 425.7, 425.8,
425.9, 428.0, 428.1, 428.20, 428.21, 428.22, 428.23, 428.30, 428.31, 428.32, 428.33,
428.40, 428.41, 428.42, 428.43, 428.9
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310,
99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343,
99344, 99345, 99347, 99348, 99349, 99350
RATIONALE:
Evaluation of LVEF in patients with heart failure provides important information that is required to
appropriately direct treatment. Several pharmacologic therapies have demonstrated efficacy in
slowing disease progression and improving outcomes in patients with left ventricular systolic
dysfunction. LVEF assessed during the initial evaluation of patients presenting with heart failure
can be considered valid unless the patient has demonstrated a major change in clinical status,
experienced or recovered from a clinical event, or received therapy that might have a significant
effect on cardiac function. A comprehensive 2-dimensional echocardiogram with Doppler flow
studies has been identified as the single most useful diagnostic test in the evaluation of patients
with heart failure.
CLINICAL RECOMMENDATION STATEMENTS:
Two-dimensional echocardiography with Doppler should be performed during initial evaluation of
patients presenting with HF to assess LVEF, LV size, wall thickness, and valve function.
Radionuclide ventriculography can be performed to assess LVEF and volumes. Radionuclide
ventriculography can be performed to assess LVEF and volumes. (Class I, Level of Evidence: C)
(ACC/AHA, 2009)
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Measure #199: Heart Failure: Patient Education
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of heart failure who were provided
with patient education on disease management and health behavior changes during one or more
visit(s) within 12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with heart
failure seen during the reporting period. This measure is intended to reflect the quality of services
provided for the management of patients with heart failure.
Measure Reporting via Registry:
ICD-9 diagnosis codes, CPT codes, and patient demographics are used to identify patients who
are included in the measure’s denominator. The listed numerator options are used to report the
numerator of the measure. The quality-data codes have been provided for registry only measures
for use by registries that utilize claims data. It is not necessary to submit these codes for registrybased submissions. There are no allowable performance exclusions for this measure. Do not
report this measure via claims.
NUMERATOR:
Patients who were provided with patient education on disease management and health behavior
changes* during one or more visits within 12 months
Definition: *Patient education should include one or more of the following: Weight
monitoring; Diet (sodium restriction); Symptom management; Physical activity; Smoking
cessation; Medication instruction; Minimizing or avoiding use of NSAIDs; Referral for
visiting nurse, or specific educational or management programs; Prognosis/end-of-life
issues.
OR
Numerator Options:
Patient education, written/oral, appropriate for patients with heart failure performed
(4003F)
Patient education, written/oral, appropriate for patients with heart failure not performed,
Reason not Specified (4003F with 8P)
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of heart failure who were seen at least twice
for any visits within 12 months
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter.
AND
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Diagnosis for heart failure (ICD-9-CM): 398.91, 402.01, 402.11, 402.91, 404.01, 404.03,
404.11, 404.13, 404.91, 404.93, 425.0, 425.1, 425.2, 425.3, 425.4, 425.5, 425.7, 425.8,
425.9, 428.0, 428.1, 428.20, 428.21, 428.22, 428.23, 428.30, 428.31, 428.32, 428.33,
428.40, 428.41, 428.42, 428.43, 428.9
AND
Patient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310,
99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343,
99344, 99345, 99347, 99348, 99349, 99350
RATIONALE:
Patient education is an essential nonpharmacological component to heart failure care. It may
reduce the likelihood of noncompliance with recommended therapeutic strategies and lead to early
identification of worsening clinical status and subsequent treatment. Heart failure disease
management programs, in which patient education is an integral component, have been shown to
be effective in improving self-care and reducing readmissions.
CLINICAL RECOMMENDATION STATEMENTS:
Patients at high risk for developing HF should be counseled to avoid behaviors that may increase
the risk of HF (e.g., smoking, excessive alcohol consumption, and illicit drug use). (Class I, Level of
Evidence: C) (ACC/AHA, 2009).
It is recommended that patients with HF and their family members or caregivers receive
individualized education and counseling that emphasizes self-care. (Strength of Evidence=B)
(HFSA, 2006).
Essential Elements of Patient Education With Associated Skills and Target Behaviors (HFSA,
2006).
Elements of Education
Skill Building and Critical Target Behaviors
Definition of HF (linking disease,
symptoms, and treatment) and
cause of patient's HF
Discuss basic HF information, cause of patient's HF, and how
symptoms are related
Recognition of escalating
• Monitor for specific signs and symptoms (e.g., increasing
symptoms and selection of
fatigue doing usual activities, increasing shortness of
appropriate treatments in response
breath with activity, shortness of breath at rest, need to
to particular symptoms
sleep with increasing number of pillows, waking at night
with shortness of breath, edema)
• Perform and document daily weights
• Develop action plan for how and when to notify the
provider
• Institute flexible diuretic regimen, if appropriate
Indications and use of each
medication
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Elements of Education
Skill Building and Critical Target Behaviors
Importance of risk factor
modification
• Smoking cessation
• State blood pressure goal and know own blood pressure
from recent measurement
• Maintain normal HgA1c, if diabetic
• Maintain specific body weight
Specific diet recommendations:
individualized low-sodium diet;
recommendation for alcohol intake
• Reiterate recommended sodium intake
• Demonstrate how to read a food label to check sodium
amount per serving and sort foods into high- and lowsodium groups
• Reiterate limits for alcohol consumption or need for
abstinence if history of alcohol abuse
Specific activity/exercise
recommendations
• Reiterate goals for exercise and plan for achieving
• Reiterate ways to increase activity level
Importance of treatment adherence • Plan and use a medication system that promotes routine
and behavioral strategies to
adherence
promote
• Plan for refills
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Measure #200: Heart Failure: Warfarin Therapy for Patients with Atrial Fibrillation
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of all patients aged 18 and older with a diagnosis of heart failure and paroxysmal or
chronic atrial fibrillation who were prescribed warfarin therapy
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with heart
failure seen during the reporting period. This measure is intended to reflect the quality of services
provided for the primary management of patients with heart failure and with paroxysmal or chronic
atrial fibrillation.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The listed numerator options are used to report
the numerator of the measure. The quality-data codes have been provided for registry only
measures for use by registries that utilize claims data. It is not necessary to submit these codes for
registry-based submissions. Do not report this measure via claims.
NUMERATOR:
Patients who were prescribed warfarin therapy
Definition:
Prescribed - May include prescription given to the patient for warfarin at one or more visits
in the 12 month period OR patient already taking warfarin as documented in current
medication list.
OR
OR
Numerator Options:
Warfarin therapy prescribed (4012F)
Warfarin therapy not prescribed for medical reason (4012F with 1P)
OR
Warfarin therapy not prescribed for patient reason (4012F with 2P)
OR
Warfarin therapy not prescribed for system reason (4012F with 3P)
Warfarin therapy not prescribed, reason not specified (4012F with 8P)
DENOMINATOR:
All heart failure patients aged 18 years and older with paroxysmal or chronic atrial fibrillation
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
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Diagnosis for heart failure (ICD-9-CM): 398.91, 402.01, 402.11, 402.91, 404.01, 404.03,
404.11, 404.13, 404.91, 404.93, 425.0, 425.1, 425.2, 425.3, 425.4, 425.5, 425.7, 425.8,
425.9, 428.0, 428.1, 428.20, 428.21, 428.22, 428.23, 428.30, 428.31, 428.32, 428.33,
428.40, 428.41, 428.42, 428.43, 428.9
AND
Diagnosis for Atrial Fibrillation (ICD-9-CM): 427.31
AND
Patient encounter during reporting period CPT: 99201, 99202, 99203, 99204, 99205,
99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324,
99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344,
99345, 99347, 99348, 99349, 99350
RATIONALE:
Adjusted-dose warfarin is highly efficacious in preventing thromboembolism in patients with AF and
should be prescribed for all patients with AF and heart failure except those with contraindications to
anticoagulation.
CLINICAL RECOMMENDATION STATEMENTS:
Physicians should prescribe anticoagulants in patients with HF who have paroxysmal or persistent
atrial fibrillation or a previous thromboembolic event. (Class I, Level of Evidence: A)
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Measure #201: Ischemic Vascular Disease (IVD): Blood Pressure Management Control
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with Ischemic Vascular Disease (IVD) who had
most recent blood pressure in control (less than 140/90 mmHg)
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with ischemic
vascular disease seen during the reporting period. The performance period for this measure is 12
months. The most recent quality code submitted will be used for performance calculation. This
measure may be reported by clinicians who perform the quality actions described in the measure
based on the services provided and the measure-specific denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. G-codes are used to report the numerator
of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate G-code. There are no allowable performance exclusions for this measure. All
measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions however these codes may be submitted for
those registries that utilize claims data. There are no allowable performance exclusions for this
measure.
NUMERATOR:
Patients whose most recent blood pressure < 140/90 mmHg
Numerator Instructions: To describe both systolic and diastolic blood pressure values,
each must be reported separately. If there are multiple blood pressures on the same date
of service, use the lowest systolic and lowest diastolic blood pressure on that date as the
representative blood pressure.
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Most Recent Blood Pressure Measurement Performed
Systolic Pressure (Select one (1) code from this section):
G8588: Most recent systolic blood pressure < 140 mmHg
OR
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OR
G8589: Most recent systolic blood pressure ≥ 140 mmHg
AND
Diastolic Pressure (Select one (1) code from this section):
G8590: Most recent diastolic blood pressure < 90 mmHg
OR
G8591: Most recent diastolic blood pressure ≥ 90 mmHg
Blood Pressure Measurement not Documented, Reason not Specified
G8592: No documentation of blood pressure measurement
DENOMINATOR:
Patients aged 18 years and older with the diagnosis of ischemic vascular disease, or who were
discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or
percutaneous transluminal coronary angioplasty (PTCA)
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for ischemic vascular disease (line-item ICD-9-CM): 410.11, 410.21, 410.31,
410.41, 410.51, 410.61, 410.71, 410.81, 410.91, 411.0, 411.1, 411.81, 411.89, 413.0,
413.1, 413.9, 414.00, 414.01, 414.02, 414.03, 414.04, 414.05, 414.06, 414.07, 414.8,
414.9, 429.2, 433.00, 433.01, 433.10, 433.11, 433.20, 433.21, 433.30, 433.31, 433.80,
433.81, 433.90, 433.91, 434.00, 434.01, 434.10, 434.11, 434.90, 434.91, 440.1, 440.20,
440.21, 440.22, 440.23, 440.24, 440.29, 440.4, 444.0, 444.1, 444.21, 444.22, 444.81,
444.89, 444.9, 445.01, 445.02, 445.81, 445.89
AND
Patient encounter during reporting period (CPT): 99201, 99202, 99203, 99204, 99205,
99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99341, 99342, 99343,
99344, 99345, 99347, 99348, 99349, 99350, 99455, 99456
OR
Patient encounter during the reporting period (CPT) - Procedure: 33510, 33511,
33512, 33513, 33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534,
33535, 33536, 33140, 92980, 92982, 92995
RATIONALE:
Fifty million or more Americans have high blood pressure that warrants treatment, according to the
NHANES survey (JNC-7, 2003). The USPSTF recommends that clinicians screen adults aged 18
and older for high blood pressure (USPSTF, 2007).
The most frequent and serious complications of uncontrolled hypertension include coronary heart
disease, congestive heart failure, stroke, ruptured aortic aneurysm, renal disease, and retinopathy.
The increased risks of hypertension are present in individuals ranging from 40 to 89 years of age.
For every 20 mmHg systolic or 10 mmHg diastolic increase in BP, there is a doubling of mortality
from both IHD and stroke (JNC-7, 2003).
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Better control of BP has been shown to significantly reduce the probability that these undesirable
and costly outcomes will occur. Thus, the relationship between the measure (control of
hypertension) and the long-term clinical outcomes listed is well established. In clinical trials,
antihypertensive therapy has been associated with reductions in stroke incidence (35-40%),
myocardial infarction (20-25%) and heart failure (>50%) (JNC-7, 2003).
CLINICAL RECOMMENDATION STATEMENTS:
The U.S. Preventive Services Task Force (USPSTF) recommends screening for high blood
pressure in adults age 18 years and older.
The JNC-7 indicates that treating systolic BP and diastolic BP to targets that are <140/90 mmHg is
associated with a decrease in CVD complications.
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Measure #202: Ischemic Vascular Disease (IVD): Complete Lipid Profile
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with Ischemic Vascular Disease (IVD) who
received at least one lipid profile within 12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with IVD seen
during the reporting period. The performance period for this measure is 12 months from the date of
service. This measure may be reported by clinicians who perform the quality actions described in
the measure based on the services provided and the measure-specific denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. G-codes are used to report the numerator
of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate G-code. There are no allowable performance exclusions for this measure. All
measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions however these codes may be submitted for
those registries that utilize claims data. There are no allowable performance exclusions for this
measure.
NUMERATOR:
Patients who received at least one lipid profile (or ALL component tests)
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Lipid Profile Performed
G8593: Lipid panel results documented and reviewed (must include total cholesterol, HDLC, triglycerides and calculated LDL-C)
Note: If LDL-C could not be calculated due to high triglycerides, count as complete
lipid profile.
Lipid Profile not Performed, Reason not Specified
G8594: Lipid profile not performed, reason not otherwise specified
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DENOMINATOR:
Patients aged 18 years and older with the diagnosis of ischemic vascular disease, or who were
discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or
percutaneous transluminal coronary angioplasty (PTCA)
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for ischemic vascular disease (line-item ICD-9-CM): 410.11 , 410.21 ,
410.31, 410.41, 410.51, 410.61, 410.71, 410.81, 410.91, 411.0, 411.1, 411.81, 411.89,
413.0, 413.1, 413.9, 414.00, 414.01, 414.02, 414.03, 414.04, 414.05, 414.06, 414.07,
414.8, 414.9,, 429.2, 433.00, 433.01, 433.10, 433.11, 433.20, 433.21, 433.30, 433.31,
433.80, 433.81, 433.90, 433.91, 434.00, 434.01, 434.10, 434.11, 434.90, 434.91,, 440.1,
440.20, 440.21, 440.22, 440.23, 440.24, 440.29, 440.4, 444.0, 444.1, 444.21, 444.22,
444.81, 444.89, 444.9, 445.01, 445.02, 445.81, 445.89
AND
Patient encounter during reporting period (CPT): 99201, 99202, 99203, 99204, 99205,
99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99341, 99342, 99343,
99344, 99345, 99347, 99348, 99349, 99350, 99455, 99456
OR
Patient encounter during the reporting period (CPT) - Procedure: 33510, 33511,
33512, 33513, 33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534,
33535, 33536, 33140, 92980, 92982, 92995
RATIONALE:
There is general agreement in the literature that individuals with existing coronary artery disease
can reduce their risk of subsequent morbidity and premature mortality by management of
cholesterol levels. Total cholesterol in general and LDL level specifically, is the leading indicator for
management of these patients. Treatments include limits on dietary fat and cholesterol, or in
certain cases, cholesterol lowering medications.
A 10% decrease in total cholesterol levels (population wide) may result in an estimated 30%
reduction in the incidence of CHD (CDC, 2000). Based on data from the Third Report of the Expert
Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults:
• Less than half of persons who qualify for any kind of lipid-modifying treatment for CHD risk
reduction are receiving it.
• Less than half of even the highest-risk persons, those who have symptomatic CHD, are
receiving lipid-lowering treatment.
• Only about a third of treated patients are achieving their LDL goal; less than 20% of CHD
patients are at their LDL goal. (2002)
Several studies have shown that reducing high lipid levels will reduce cardiovascular morbidity and
mortality. These studies include the Coronary Primary Prevention Trial, the Framingham Heart
Study, the Oslo Study Diet and Anti-smoking Trial, the Helsinki Heart Study, the Coronary Drug
Project, the Stockholm Ischemic Heart Study, the Scandinavian Simvastatin Survival Study, the
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West of Scotland Coronary Prevention Study, the Program on the Surgical Control of the
Hyperlipidemias, and Cholesterol and Recurrent Events trial.
CLINICAL RECOMMENDATION STATEMENTS:
Third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection,
Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). (2001)
AND Implications of recent clinical trials for the National Cholesterol Education Program Adult
Treatment Panel III guidelines (2004)
In high-risk persons, the recommended LDL-C goal is <100 mg/dL.
• An LDL-C goal of <70 mg/dL is a therapeutic option on the basis of available clinical trial
evidence, especially for patients at very high risk.
• If LDL-C is >100 mg/dL, an LDL-lowering drug is indicated simultaneously with lifestyle
changes.
• If baseline LDL-C is <100 mg/dL, institution of an LDL-lowering drug to achieve an LDL-C
level <70 mg/dL is a therapeutic option on the basis of available clinical trial evidence.
• If a high-risk person has high triglycerides or low HDL-C, consideration can be given to
combining a fibrate or nicotinic acid with an LDL-lowering drug. When triglycerides are
>200 mg/dL, non-HDL-C is a secondary target of therapy, with a goal 30 mg/dL higher
than the identified LDL-C goal.
The U.S. Preventive Services Task Force (USPSTF) strongly recommends screening men aged 35
and older for lipid disorders and recommends screening men aged 20 to 35 for lipid disorders if
they are at increased risk for coronary heart disease. The USPSTF also strongly recommends
screening women aged 45 and older for lipid disorders if they are at increased risk for coronary
heart disease and recommends screening women aged 20 to 45 for lipid disorders if they are at
increased risk for coronary heart disease.
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Measure #203: Ischemic Vascular Disease (IVD): Low Density Lipoprotein (LDL-C)
Control
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with Ischemic Vascular Disease (IVD) who had
most recent LDL-C level in control (less than 100 mg/dl)
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with IVD seen
during the reporting period. The performance period for this measure is 12 months from the date of
service. The most recent quality code submitted will be used for performance calculation. This
measure may be reported by clinicians who perform the quality actions described in the measure
based on the services provided and the measure-specific denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. G-codes are used to report the numerator
of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate G-code. There are no allowable performance exclusions for this measure. All
measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions however these codes may be submitted for
those registries that utilize claims data. There are no allowable performance exclusions for this
measure.
NUMERATOR:
Patients with most recent LDL-C < 100 mg/dL
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Most Recent LDL-C < 100 mg/dL
G8595: Most recent LDL-C < 100 mg/dL
LDL-C was not Performed
G8596: LDL-C was not performed
OR
Most Recent LDL-C ≥ 100 mg/dL
G8597: Most recent LDL-C ≥ 100 mg/dL
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DENOMINATOR:
Patients aged 18 years and older with the diagnosis of ischemic vascular disease, or who were
discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or
percutaneous transluminal coronary angioplasty (PTCA)
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for ischemic vascular disease (line-item ICD-9-CM): 410.11, 410.21, 410.31,
410.41, 410.51, 410.61, 410.71, 410.81, 410.91, 411.0, 411.1, 411.81, 411.89, 413.0,
413.1, 413.9, 414.00, 414.01, 414.02, 414.03, 414.04, 414.05, 414.06, 414.07, 414.8,
414.9, 429.2, 433.00, 433.01, 433.10, 433.11, 433.20, 433.21, 433.30, 433.31, 433.80,
433.81, 433.90, 433.91, 434.00, 434.01, 434.10, 434.11, 434.90, 434.91, 440.1, 440.20,
440.21, 440.22, 440.23, 440.24, 440.29, 440.4, 444.0, 444.1, 444.21, 444.22, 444.81,
444.89, 444.9, 445.01, 445.02, 445.81, 445.89
AND
Patient encounter during reporting period (CPT): 99201, 99202, 99203, 99204, 99205,
99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99341, 99342, 99343,
99344, 99345, 99347, 99348, 99349, 99350, 99455, 99456
OR
Patient encounter during the reporting period (CPT) - Procedure: 33510, 33511,
33512, 33513, 33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534,
33535, 33536, 33140, 92980, 92982, 92995
RATIONALE:
There is general agreement in the literature that individuals with existing coronary artery disease
can reduce their risk of subsequent morbidity and premature mortality by management of
cholesterol levels. Total cholesterol in general and LDL level specifically, is the leading indicator for
management of these patients. Treatments include limits on dietary fat and cholesterol, or in
certain cases, cholesterol lowering medications.
A 10% decrease in total cholesterol levels (population wide) may result in an estimated 30%
reduction in the incidence of CHD (CDC, 2000). Based on data from the Third Report of the Expert
Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults:
• Less than half of persons who qualify for any kind of lipid-modifying treatment for CHD risk
reduction are receiving it.
• Less than half of even the highest-risk persons, those who have symptomatic CHD, are
receiving lipid-lowering treatment.
• Only about a third of treated patients are achieving their LDL goal; less than 20% of CHD
patients are at their LDL goal. (2002)
Several studies have shown that reducing high lipid levels will reduce cardiovascular morbidity and
mortality. These studies include the Coronary Primary Prevention Trial, the Framingham Heart
Study, the Oslo Study Diet and Anti-smoking Trial, the Helsinki Heart Study, the Coronary Drug
Project, the Stockholm Ischemic Heart Study, the Scandinavian Simvastatin Survival Study, the
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West of Scotland Coronary Prevention Study, the Program on the Surgical Control of the
Hyperlipidemias, and Cholesterol and Recurrent Events trial.
CLINICAL RECOMMENDATION STATEMENTS:
Third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection,
Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). (2001)
AND Implications of recent clinical trials for the National Cholesterol Education Program Adult
Treatment Panel III guidelines (2004)
In high-risk persons, the recommended LDL-C goal is <100 mg/dL.
• An LDL-C goal of <70 mg/dL is a therapeutic option on the basis of available clinical trial
evidence, especially for patients at very high risk.
• If LDL-C is >100 mg/dL, an LDL-lowering drug is indicated simultaneously with lifestyle
changes.
• If baseline LDL-C is <100 mg/dL, institution of an LDL-lowering drug to achieve an LDL-C
level <70 mg/dL is a therapeutic option on the basis of available clinical trial evidence.
• If a high-risk person has high triglycerides or low HDL-C, consideration can be given to
combining a fibrate or nicotinic acid with an LDL-lowering drug. When triglycerides are
>200 mg/dL, non-HDL-C is a secondary target of therapy, with a goal 30 mg/dL higher
than the identified LDL-C goal.
The U.S. Preventive Services Task Force (USPSTF) strongly recommends screening men aged 35
and older for lipid disorders and recommends screening men aged 20 to 35 for lipid disorders if
they are at increased risk for coronary heart disease. The USPSTF also strongly recommends
screening women aged 45 and older for lipid disorders if they are at increased risk for coronary
heart disease and recommends screening women aged 20 to 45 for lipid disorders if they are at
increased risk for coronary heart disease.
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Measure #204: Ischemic Vascular Disease (IVD): Use of Aspirin or Another
Antithrombotic
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: CLAIMS, REGISTRY
DESCRIPTION:
Percentage of patients aged 18 years and older with Ischemic Vascular Disease (IVD) with
documented use of aspirin or other antithrombotic
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with IVD seen
during the reporting period. The performance period for this measure is 12 months from the date of
service. This measure may be reported by clinicians who perform the quality actions described in
the measure based on the services provided and the measure-specific denominator coding.
Measure Reporting via Claims:
Line-item ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify
patients who are included in the measure’s denominator. G-codes are used to report the numerator
of the measure.
When reporting the measure via claims, submit the listed ICD-9-CM diagnosis codes, CPT codes,
and the appropriate G-code. There are no allowable performance exclusions for this measure. All
measure-specific coding should be reported ON THE SAME CLAIM.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The numerator options as described in the qualitydata codes are used to report the numerator of the measure. The quality-data codes listed do not
need to be submitted for registry-based submissions however these codes may be submitted for
those registries that utilize claims data. There are no allowable performance exclusions for this
measure.
NUMERATOR:
Patients who are using aspirin or another antithrombotic therapy
Numerator Instructions: Oral antithrombotic therapy consists of aspirin, clopidogrel or
combination of aspirin and extended release dipyridamole.
OR
Numerator Quality-Data Coding Options for Reporting Satisfactorily:
Aspirin or Another Antithrombotic Therapy Used
G8598: Aspirin or another antithrombotic therapy used
Aspirin or Another Antithrombotic Therapy not Used, Reason not Specified
G8599: Aspirin or another antithrombotic therapy not used, reason not otherwise specified
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DENOMINATOR:
Patients aged 18 years and older with the diagnosis of ischemic vascular disease, or who were
discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or
percutaneous transluminal coronary angioplasty (PTCA)
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for ischemic vascular disease (ICD-9-CM): 410.11, 410.21, 410.31, 410.41,
410.51, 410.61, 410.71, 410.81, 410.91, 411.0, 411.1, 411.81, 411.89, 413.0, 413.1,
413.9, 414.00, 414.01, 414.02, 414.03, 414.04, 414.05, 414.06, 414.07, 414.8, 414.9,,
429.2, 433.00, 433.01, 433.10, 433.11, 433.20, 433.21, 433.30, 433.31, 433.80, 433.81,
433.90, 433.91, 434.00, 434.01, 434.10, 434.11, 434.90, 434.91,, 440.1, 440.20, 440.21,
440.22, 440.23, 440.24, 440.29, 440.4, 444.0, 444.1, 444.21, 444.22, 444.81, 444.89,
444.9, 445.01, 445.02, 445.81, 445.89
AND
Patient encounter during reporting period (CPT): 99201, 99202, 99203, 99204, 99205,
99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99341, 99342, 99343,
99344, 99345, 99347, 99348, 99349, 99350, 99455, 99456
OR
Patient encounter during the reporting period (CPT) - Procedure: 33510, 33511,
33512, 33513, 33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33533, 33534,
33535, 33536, 33140, 92980, 92982, 92995
RATIONALE:
Aspirin therapy has been shown to directly reduce 14% of the odds of cardiovascular events
among men and 12% of the odds for women (Berger, 2006). Aspirin use reduced the number of
strokes by 20%, MI by 30%, and other vascular events by 30% (Weisman, 2002). Also, aspirin
treatments have been shown to prevent 1 cardiovascular event over an average follow-up of 6.4
years. This means that on average in a 6.4 year time period the use of aspirin therapy results in a
benefit of 3 cardiovascular events prevented per 1000 women and 4 events prevented per 1000
men (Berger, 2006). Even for patients with peripheral arterial disease, aspirin has been shown to
reduce CHD in people (Kikano, 2007).
CLINICAL RECOMMENDATION STATEMENTS:
The U.S. Preventive Services Task Force (USPSTF) strongly recommends that clinicians discuss
aspirin chemoprevention with adults who are at increased risk (5-year risk of greater than or equal
to 3 percent) for coronary heart disease (CHD). Discussions with patients should address both the
potential benefits and harms of aspirin therapy.
The USPSTF found good evidence that aspirin decreases the incidence of coronary heart disease
in adults who are at increased risk for heart disease. They also found good evidence that aspirin
increases the incidence of gastrointestinal bleeding and fair evidence that aspirin increases the
incidence of hemorrhagic strokes. The USPSTF concluded that the balance of benefits and harms
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is most favorable in patients at high risk of CHD (5-year risk of greater than or equal to 3 percent)
but is also influenced by patient preferences.
USPSTF encourages men age 45 to 79 years to use aspirin when the potential benefit of a
reduction in myocardial infarctions outweighs the potential harm of an increase in gastrointestinal
hemorrhage. They encourage women age 55 to 79 years to use aspirin when the potential benefit
of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal
hemorrhage.
The ADA recommends use aspirin therapy (75-162 mg/day) as a primary prevention strategy in
those with type 1 or 2 diabetes at increased cardiovascular risk, including those who are 40 years
of age or who have additional risk factors (family history of CVD, hypertension, smoking,
dyslipidemia, or albuminuria).
AHA/ACC: Start aspirin 75 to 162 mg/d and continue indefinitely in all patients with coronary and
other vascular disease unless contraindicated.
ICSI: Aspirin should be prescribed to all patients with stable coronary disease. If a patient is aspirin
intolerant, then use clopidogrel.
VA/DoD: Ensure that all patients with ischemic heart disease or angina symptoms receive
antiplatelet therapy (aspirin 81-325 mg/day). For patients who require warfarin therapy, aspirin may
be safely used at a dose of 80 mg/day. If use of aspirin is contraindicated, clopidogrel (75 mg/day)
may be used.
AHA/ASA: The use of aspirin is recommended for cardiovascular (including but not specific to
stroke) prophylaxis among persons whose risk is sufficiently high for the benefits to outweigh the
risks associated with treatment (a 10-year risk of cardiovascular events of 6% to 10%).
ACCP: For long-term treatment after PCI, the guideline developers recommend aspirin, 75 to 162
mg/day. For long-term treatment after PCI in patients who receive antithrombotic agents such as
clopidogrel or warfarin, the guideline developers recommend lower-dose aspirin, 75 to 100 mg/day.
For patients with ischemic stroke who are not receiving thrombolysis, the guideline developers
recommend early aspirin therapy, 160 to 325 mg/day.
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Measure #205: HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia and
Gonorrhea
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia
and gonorrhea screenings were performed at least once since the diagnosis of HIV infection
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with HIV/AIDS
seen during the reporting period. Only patients who had at least two visits during the reporting
period, with at least 60 days between each visit will be counted in the denominator for this
measure. This measure is intended to reflect the quality of services provided for the primary
management of patients with HIV/AIDS.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The listed numerator options are used to report
the numerator of the measure. The quality-data codes have been provided for registry only
measures for use by registries that utilize claims data. It is not necessary to submit these codes for
registry-based submissions. Do not report this measure via claims.
NUMERATOR:
Patients with chlamydia and gonorrhea screenings performed at least once since the diagnosis of
HIV infection.
OR
OR
Numerator Options:
Chlamydia and gonorrhea screenings documented as performed (3511F)
Chlamydia and gonorrhea screenings not documented as performed, due to patient reason
(3511F with 2P)
Chlamydia and gonorrhea screenings not documented as performed, reason not specified
(3511F with 8P)
DENOMINATOR:
Patients aged 13 and older with a diagnosis of HIV/AIDS who had at least two medical visits during
the measurement year, with at least 60 days between each visit
Denominator Criteria (Eligible Cases):
Patients aged ≥ 13 years of age on date of encounter
AND
Diagnosis for HIV/AIDS (ICD-9-CM): 042, 079.53, V08
AND
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Patient encounters during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Sexually transmitted diseases that cause mucosal inflammation (such as gonorrhea and
chlamydia) increase the risk for HIV-infection (as these diseases and other sexually transmitted
diseases can increase the infectiousness of and a person’s susceptibility to HIV) (Galvin, 2004).
CLINICAL RECOMMENDATION STATEMENTS:
All patients should be screened with laboratory tests for STDs at the initial encounter (A-II for
syphilis, for trichomoniasis in women, and for chlamydial infection in women aged less than 25
years; B-II for gonorrhea and chlamydial infection in all men and women), and thereafter,
depending on reported high-risk behavior, the presence of other STDs, and the prevalence of
STDs in the community (B-III). (Aberg, 2004)
Consideration should be given to screening all HIV-infected men and women for gonorrhea and
chlamydial infections. However, because of the cost of screening and the variability of prevalence
of these infections, decisions about routine screening for these infections should be based on
epidemiologic factors (including prevalence of infection in the community or the population being
served), availability of tests, and cost. (Some HIV specialists also recommend type-specific
serologic testing for herpes simplex virus type 2 for both men and women.) (B-II, for identifying
STDs) (CDC, HRSA, NIH, HIVMA of IDSA, 2003)
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Measure #206: HIV/AIDS: Screening for High Risk Sexual Behaviors
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS who were screened
for high risk sexual behaviors at least once within 12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with HIV/AIDS
seen during the reporting period. Only patients who had at least two visits during the reporting
period, with at least 60 days between each visit will be counted in the denominator for this
measure. This measure is intended to reflect the quality of services provided for the primary
management of patients with HIV/AIDS.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The listed numerator options are used to report
the numerator of the measure. The quality-data codes have been provided for registry only
measures for use by registries that utilize claims data. It is not necessary to submit these codes for
registry-based submissions. There are no allowable performance exclusions for this measure. Do
not report this measure via claims.
NUMERATOR:
Patients who were screened for high risk sexual behaviors at least once within 12 months
OR
Numerator Options:
Patient screened for high risk sexual behavior (4293F)
Patient not screened for high risk sexual behaviors, reason not specified (4293F with 8P)
DENOMINATOR:
Patients aged 13 and older with a diagnosis of HIV/AIDS who had at least two medical visits during
the measurement year, with at least 60 days between each visit
Denominator Criteria (Eligible Cases):
Patients aged ≥ 13 years on date of encounter
AND
Diagnosis for HIV/AIDS (ICD-9-CM): 042, 079.53, V08
AND
Patient encounters during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Each visit of an HIV-infected person to a health care provider should include screening for high-risk
behavior. (IDSA, 2004)
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Within the context of HIV care, brief general HIV prevention messages should be regularly
provided to HIV-infected patients at each visit or periodically, as determined by the clinician, and at
a minimum of twice yearly. These messages should emphasize the need for safer behaviors to
protect their own health and the health of their sex or needle-sharing partners, regardless of
perceived risk. Messages should be tailored to the patient’s needs and circumstances. (CDC,
HRSA, NIH, HIVMA of IDSA, 2003)
CLINICAL RECOMMENDATION STATEMENTS:
Within the context of HIV care, brief general HIV prevention messages should be regularly
provided to HIV-infected patients at each visit or periodically, as determined by the clinician, and at
a minimum of twice yearly. These messages should emphasize the need for safer behaviors to
protect their own health and the health of their sex or needle-sharing partners, regardless of
perceived risk. Messages should be tailored to the patient’s needs and circumstances. (CDC,
HRSA, NIH, HIVMA of IDSA, 2003)
HIV-infected patients should be screened for behaviors associated with HIV transmission by using
a straightforward, nonjudgmental approach. This should be done at the initial visit and subsequent
routine visits or periodically, as the clinician feels necessary, but at a minimum of yearly. Any
indication of risky behavior should prompt a more thorough assessment of HIV transmission risks.
(CDC, 2003)
Obtain a sexual and injection drug use risk assessment and record in medical chart (e.g., number
of sex partners in last 3 months, location of partner meeting, number of anonymous partners,
condom use, drug/alcohol use around sexual activity). Obtain an STD history (disease/infection,
number of times, approximate dates) and record in medical chart. Provide educational material
about STD symptoms and advise about the importance of refraining from sexual activity until a
diagnosis is made and treatment is completed. (CSTDCA, 2001)
Clinicians should screen all HIV-infected patients for substance use at baseline and at least
annually. Screening questions should be phrased to include both alcohol and drug use. (NYSDOH,
2005)
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Measure #207: HIV/AIDS: Screening for Injection Drug Use
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS who were screened
for injection drug use at least once within 12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with HIV/AIDS
seen during the reporting period. Only patients who had at least two visits during the reporting
period, with at least 60 days between each visit will be counted in the denominator for this
measure. This measure is intended to reflect the quality of services provided for the primary
management of patients with HIV/AIDS.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The listed numerator options are used to report
the numerator of the measure. The quality-data codes have been provided for registry only
measures for use by registries that utilize claims data. It is not necessary to submit these codes for
registry-based submissions. There are no allowable performance exclusions for this measure. Do
not report this measure via claims.
NUMERATOR:
Patients who were screened for injection drug use at least once within 12 months
OR
Numerator Options:
Patient screened for injection drug use (4290F)
Patient not screened for injection drug use reason not specified (4290F with 8P)
DENOMINATOR:
Patients aged 13 and older with a diagnosis of HIV/AIDS who had at least two medical visits during
the measurement year, with at least 60 days between each visit
Denominator Criteria (Eligible Cases):
Patients aged ≥ 13 years on date of encounter
AND
Diagnosis for HIV/AIDS (ICD-9-CM): 042, 079.53, V08
AND
Patient encounters during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
RATIONALE:
Each visit of an HIV-infected person to a health care provider should include screening for high-risk
behavior. (IDSA, 2004)
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Within the context of HIV care, brief general HIV prevention messages should be regularly
provided to HIV-infected patients at each visit or periodically, as determined by the clinician, and at
a minimum of twice yearly. These messages should emphasize the need for safer behaviors to
protect their own health and the health of their sex or needle-sharing partners, regardless of
perceived risk. Messages should be tailored to the patient’s needs and circumstances. (CDC,
HRSA, NIH, HIVMA of IDSA, 2003)
CLINICAL RECOMMENDATION STATEMENTS:
Within the context of HIV care, brief general HIV prevention messages should be regularly
provided to HIV-infected patients at each visit or periodically, as determined by the clinician, and at
a minimum of twice yearly. These messages should emphasize the need for safer behaviors to
protect their own health and the health of their sex or needle-sharing partners, regardless of
perceived risk. Messages should be tailored to the patient’s needs and circumstances. (CDC,
HRSA, NIH, HIVMA of IDSA, 2003)
HIV-infected patients should be screened for behaviors associated with HIV transmission by using
a straightforward, nonjudgmental approach. This should be done at the initial visit and subsequent
routine visits or periodically, as the clinician feels necessary, but at a minimum of yearly. Any
indication of risky behavior should prompt a more thorough assessment of HIV transmission risks.
(CDC, 2003)
Obtain a sexual and injection drug use risk assessment and record in medical chart (e.g., number
of sex partners in last 3 months, location of partner meeting, number of anonymous partners,
condom use, drug/alcohol use around sexual activity). Obtain an STD history (disease/infection,
number of times, approximate dates) and record in medical chart. Provide educational material
about STD symptoms and advise about the importance of refraining from sexual activity until a
diagnosis is made and treatment is completed. (CSTDCA, 2001)
Clinicians should screen all HIV-infected patients for substance use at baseline and at least
annually. Screening questions should be phrased to include both alcohol and drug use. (NYSDOH,
2005)
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Measure #208: HIV/AIDS: Sexually Transmitted Disease Screening for Syphilis
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS who were screened
for syphilis at least once within 12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with HIV/AIDS
seen during the reporting period. Only patients who had at least two visits during the reporting
period, with at least 60 days between each visit will be counted in the denominator for this
measure. This measure is intended to reflect the quality of services provided for the primary
management of patients with HIV/AIDS.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The listed numerator options are used to report
the numerator of the measure. The quality-data codes have been provided for registry only
measures for use by registries that utilize claims data. It is not necessary to submit these codes for
registry-based submissions. Do not report this measure via claims.
NUMERATOR:
Patients who were screened for syphilis at least once within 12 months
OR
OR
Numerator Options:
Syphilis screening documented as performed (3512F)
Syphilis screening not documented as performed, due to patient reason (3512F with 2P)
Syphilis screening not documented as performed, reason not specified (3512F with 8P)
DENOMINATOR:
Patients aged 13 and older with a diagnosis of HIV/AIDS who had at least two medical visits during
the measurement year, with at least 60 days between each visit
Denominator Criteria (Eligible Cases):
Patients aged ≥ 13 years on date of encounter
AND
Diagnosis for HIV/AIDS (ICD-9-CM): 042, 079.53, V08
AND
Patient encounters during the reporting period (CPT): 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215
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RATIONALE:
A 2000 literature review investigated the rates of HIV prevalence in U.S. patients with syphilis. Data
from the thirty studies identified and analyzed for the review revealed that HIV prevalence is high
among patients infected with syphilis. The mean rate for HIV-infection among patients with syphilis
was 15.7 (with an interquartile range of 13.6-21.8). This study would indicate that identifying and
treating HIV among patients with syphilis (and vice versa) is an important goal for health systems
(Blocker, 2000).
Another study investigated the effect of syphilis infection on the health of patients infected with HIV.
HIV viral loads and CD4 cell counts were analyzed for 52 patients in the San Francisco and Los
Angeles areas for three time periods: before syphilis infection, during syphilis infection and after
syphilis treatment). When compared to levels before syphilis infection, HIV viral loads were
significantly higher during syphilis infection. Patients' CD4 cell counts were also significantly lower
during syphilis infection than before syphilis infection (Buchacz, 2004). This study further supports
the need to identify and treat syphilis infection among HIV-infected patient.
Currently, the Centers for Disease Prevention and Control, the Health Resources and Services
Administration, the National Institutes of Health, and the Infectious Diseases Society of
America/HIV Medicine Association recommend that all HIV-infected patients should be screened
annually for syphilis. However, according to data collected for 3,840 HIV-infected patients within
the Veterans Affairs system, only 74% had been screened for syphilis (serum RPR or VDRL) in the
past year. The same study reports data from the HIV Cost and Services Utilization Study (HCSUS),
the only national probability sample of HIV-infected persons, which indicates that only 49% of
participants had been screened for syphilis (Korthius, 2004). These data would indicate that there
is indeed room for improvement.
Data from the HIVQual Continuous Quality Program also indicates that there is room for
improvement. According to data from 2006, the median rate for syphilis screening among patients
infected with HIV/AIDS was 86%. It is important to note that these rates represent only those Title
III and IV grantees that are participating in the HIVQUAL Project, a continuous quality improvement
project sponsored by the Ryan White Division of Community Based Programs and managed by the
New York State Department of Health AIDS institute. Nationwide rates are likely to vary (and be
lower) than the rates reported by HIVQUAL. (NYSDOH AIDS Institute, 2007).
CLINICAL RECOMMENDATION STATEMENTS:
Because many STDs are asymptomatic, routine screening for curable STDs (e.g., syphilis,
gonorrhea, and Chlamydia) should be performed at least yearly for sexually active persons. (CDC,
2006)
Screening for STDs should be repeated periodically (i.e., at least annually) if the patient is sexually
active or if earlier screening revealed STDs. (Grade B-III) (CDC, HRSA, NIH, HIVMA of IDSA,
2003)
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Measure #209: Functional Communication Measure – Spoken Language Comprehension
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 16 years and older with a diagnosis of late effects of cerebrovascular
disease (CVD) that make progress on the Spoken Language Comprehension Functional
Communication Measure
INSTRUCTIONS:
This measure is to be reported once per episode of treatment for all patients with late effects of
CVD who are treated for a spoken language comprehension deficit by a speech-language
pathologist (SLP) during the reporting period. Only patients who had at least two visits in the
reporting period will be counted in the denominator for this measure. This is an outcome measure,
and its calculation requires reporting of the patient’s score (see below under numerator) on the
measure at the admission to and discharge from SLP treatment for spoken language
comprehension.The admission score is noted by the SLP at the conclusion of the first treatment
session, and the discharge score at the conclusion of the final treatment session for spoken
language comprehension.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The listed numerator options are used to report
the numerator of the measure. The quality-data codes have been provided for registry only
measures for use by registries that utilize claims data. It is not necessary to submit these codes for
registry-based submissions. There are no allowable performance exclusions for this measure. Do
not report this measure via claims.
NUMERATOR:
Patients whose score on the functional communication measure at discharge were higher than at
admission
Definitions:
Admission - The conclusion of the first treatment session for spoken language
comprehension by an SLP.
Discharge - The conclusion of the final treatment session for spoken language
comprehension by an SLP, regardless of whether the patient is also being discharged from
the facility and/or other SLP services.
Patient’s Score LEVEL 1: The individual is alert, but unable to follow simple directions or respond to
yes/no questions, even with cues.
LEVEL 2: With consistent, maximal cues, the individual is able to follow simple
directions, respond to simple yes/no questions in context, and respond to
simple words or phrases related to personal needs.
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LEVEL 3: The individual usually responds accurately to simple yes/no questions. The
individual is able to follow simple directions out of context, although moderate
cueing is consistently needed. Accurate comprehension of more complex
directions/messages is infrequent.
LEVEL 4: The individual consistently responds accurately to simple yes/no questions and
occasionally follows simple directions without cues. Moderate contextual
support is usually needed to understand complex sentences/messages. The
individual is able to understand limited conversations about routine daily
activities with familiar communication partners.
LEVEL 5: The individual is able to understand communication in structured
conversations with both familiar and unfamiliar communication partners. The
individual occasionally requires minimal cueing to understand more complex
sentences/ messages. The individual occasionally initiates the use of
compensatory strategies when encountering difficulty.
LEVEL 6: The individual is able to understand communication in most activities, but
some limitations in comprehension are still apparent in vocational, avocational,
and social activities. The individual rarely requires minimal cueing to
understand complex sentences. The individual usually uses compensatory
strategies when encountering difficulty.
LEVEL 7: The individual’s ability to independently participate in vocational, avocational,
and social activities are not limited by spoken language comprehension. When
difficulty with comprehension occurs, the individual consistently uses a
compensatory strategy.
OR
Numerator Options:
Score on the spoken language comprehension functional communication measure at
discharge was higher than at admission (G8603)
Score on the spoken language comprehension functional communication measure at
discharge was not higher than at admission, reason not specified (G8604)
OR
Patient was not scored on the spoken language comprehension functional communication
measure either at admission or at discharge (G8605)
DENOMINATOR:
Patients ≥ 16 years and older with late effects of CVD who received SLP treatment for spoken
language comprehension
Denominator Criteria (Eligible Cases):
Patients aged ≥ 16 years on date of encounter
AND
Diagnosis of late effects of CVD (ICD-9-CM): 438.10, 438.11, 438.12, 438.13, 438.14,
438.19, 438.20, 438.21, 438.22, 438.30, 438.31, 438.32, 438.40, 438.41, 438.42, 438.50,
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438.51, 438.52, 438.53, 438.6, 438.7, 438.81, 438.82, 438.83, 438.84, 438.85, 438.89,
438.9, 784.3
AND
Two (2) or more patient encounters during reporting period (CPT): 92507, 92508
RATIONALE:
Assessment of communication ability is important for determining the patient’s capabilities and
limitations in expressing their wants, needs, and understanding; their ability to contribute to their
plan of care (including consent forms and advanced directives), and their ability to comprehend
instructions affecting the success of the rehabilitation process. The results of the assessment may
impact the choice of treatment and disposition.
Disorders of communication (i.e., problems with speaking, listening, reading, writing, gesturing,
and/or pragmatics) and related cognitive impairments may occur in as many as 40% of post stroke
patients. The most common communication disorders occurring after stroke are aphasia and
dysarthria. Rapid spontaneous improvement is common, but early evaluation can identify
communication problems and monitor change. If indicated, intervention can help maximize
recovery of communication abilities and prevent learning of ineffective or inappropriate
compensatory behaviors. Goals of speech and language treatment are to (1)
facilitate the recovery of communication, (2) assist patients in developing strategies to compensate
for communication disorders, and (3) counsel and educate people in the patient’s environment to
facilitate communication, decrease isolation, and meet the patient’s desires and needs.
CLINICAL RECOMMENDATION STATEMENTS:
Aphasic stroke patients should be referred for speech and language therapy. Where the patient is
sufficiently well and motivated, aim for minimum of two hours per week. (Scottish Intercollegiate
Guidelines Network).
Recommend that the clinician use standardized, valid assessments to evaluate the patient’s
stroke-related impairments and functional status and encourage patient’s participation in
community and social activities. Recommend that the standardized assessment results be used to
assess probability of outcome, determine the appropriate level of care, and develop interventions.
(US Department of Veterans’ Affairs; endorsed by the American Heart Association)
Recommend that all patients be evaluated and treated by the SLP for residual communication
difficulties (i.e., speaking, listening, reading, writing, and pragmatics). (US Department of Veterans’
Affairs; endorsed by the American Heart Association)
Interventions for people with aphasia may include: treatment of phonological and semantic deficits
following models derived from cognitive neuropsychology, constraint-induced therapy, and
computer-based therapy programs.(National Stroke Foundation of Australia)
It is recommended that patients who are conscious with communication difficulties be evaluated by
a SLP who can develop appropriate communication techniques. SLP assessment should include
screening for hearing and vision and restoration of glasses or hearing aids. Appropriate patients
(with reasonable cognition and language skills) should be considered for alternative or
augmentative communication. Patients with communication difficulties should be monitored and
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assessed regularly to determine appropriateness for speech and language therapy. An appropriate
treatment program with a system for monitoring progress should be in place for any individuals
receiving speech-language therapy. In developing a communication program, consideration for
premorbid communication style, underlying cognitive deficits, environmental context, social needs,
and necessary communication aids should be given.(Royal College of Medicine and the British
Society of Rehabilitation Medicine)
Where achievable goals can be identified, and continuing progress demonstrated, patients with
communication difficulties should be offered an appropriate treatment program, with monitoring of
progress. The program should: take into account the patient’s premorbid communication style and
any underlying cognitive deficits; give the opportunity to rehearse communication skills in situations
appropriate to the context in which the patient will live/work/study/socialize after discharge; include
the family and caregivers in developing strategies for optimum communication within the immediate
social circle; and consider the need for communication aids including gesture drawing,
communication charts and computerized systems.(Royal College of Medicine and the British
Society of Rehabilitation Medicine)
The speech and language therapist will be involved in all cases where there are communication
problems following stroke.(Republic of South Africa Department of Health; Stroke Foundation of
South Africa)
People with aphasia following stroke should be referred to a speech and language therapist for
assessment and appropriate management of their communication difficulty. (Stroke Foundation of
New Zealand)
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Measure #210: Functional Communication Measure - Attention
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 16 years and older with a diagnosis of late effects of cerebrovascular
disease (CVD) that make progress on the Attention Functional Communication Measure
INSTRUCTIONS:
This measure is to be reported once per episode of treatment for all patients with late effects of
CVD who are treated for an attention deficit by a speech-language pathologist (SLP) during the
reporting period. Only patients who had at least two visits in the reporting period will be counted in
the denominator for this measure. This is an outcome measure, and its calculation requires
reporting of the patient’s score (see below under numerator) on the measure at the admission to
and discharge from SLP treatment for attention. The admission score is noted by the SLP at the
conclusion of the first treatment session, and the discharge score at the conclusion of the final
treatment session for attention.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The listed numerator options are used to report
the numerator of the measure. The quality-data codes have been provided for registry only
measures for use by registries that utilize claims data. It is not necessary to submit these codes for
registry-based submissions. There are no allowable performance exclusions for this measure. Do
not report this measure via claims.
NUMERATOR:
Patients whose score on the functional communication measure at discharge were higher than at
admission
Definitions:
Admission - The conclusion of the first treatment session for attention by an SLP.
Discharge - The conclusion of the final treatment session for attention by an SLP,
regardless of whether the patient is also being discharged from the facility and/or other
SLP services.
Patient’s Score LEVEL 1: Attention is nonfunctional. The individual is generally unresponsive to most
stimuli.
LEVEL 2: The individual can briefly attend with consistent maximal stimulation, but not
long enough to complete even simple living tasks.
LEVEL 3: The individual maintains attention over time to complete simple living tasks of
short duration with consistent maximal cueing in the absence of distracting
stimuli.
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LEVEL 4: The individual maintains attention during simple living tasks of multiple steps
and long duration within a minimally distracting environment with consistent
minimal cueing.
LEVEL 5: The individual maintains attention within simple living activities with occasional
minimal cues within distracting environments. The individual requires
increased cueing to start, continue, and change attention during complex
activities.
LEVEL 6: The individual maintains attention within complex activities, and can attend
simultaneously to multiple demands with rare minimal cues. The individual
usually uses compensatory strategies when encountering difficulty. The
individual has mild difficulty or takes more than a reasonable amount of time to
attend to multiple tasks/stimuli.
LEVEL 7: The individual’s ability to participate in vocational, avocational, or social
activities is not limited by attentional abilities. Independent functioning may
occasionally include the use of compensatory strategies.
OR
Numerator Options:
Score on the attention functional communication measure at discharge was higher than at
admission (G8606)
Score on the attention functional communication measure at discharge was not higher
than at admission, reason not specified (G8607)
OR
Patient was not scored on the attention functional communication measure either at
admission or at discharge (G8608)
DENOMINATOR:
Patients aged 16 years and older with late effects of CVD who received SLP treatment for attention
Denominator Criteria (Eligible Cases):
Patients aged ≥ 16 years on date of encounter
AND
Diagnosis of late effects of CVD (ICD-9-CM): 438.0, 438.10, 438.11, 438.12, 438.13,
438.14, 438.19, 438.20, 438.21, 438.22, 438.30, 438.31, 438.32, 438.40, 438.41, 438.42,
438.50, 438.51, 438.52, 438.53, 438.6, 438.7, 438.81, 438.82, 438.83, 438.84, 438.85,
438.89, 438.9
AND
Two (2) or more patient encounters during reporting period (CPT): 97532
RATIONALE:
Assessment of cognition and arousal is important for determining the patient’s capabilities and
limitations for coping with their stroke and assuring success of the rehabilitation process. The
results of the assessment may impact the choice of treatment and disposition.
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Impairments in cognitive functioning are common after a stroke. In particular, impairments in
attention, memory, and executive functioning (i.e., integrating multiple and complex processes) can
be especially disabling. The treatment of cognitive deficits through cognitive remediation designed
to reduce deficits can be approached in a variety of ways. Cicerone and colleagues completed a
comprehensive review of the evidence-based literature for cognitive remediation for both traumatic
brain injury (TBI) and stroke. The review revealed a large number of randomized control trials
(RCTs) in a variety of areas of cognitive functioning and provided comprehensive guidelines for
cognitive rehabilitation specific to these populations. There is support for cognitive remediation of
deficits in both the acute and post-acute phases of recovery from stroke and TBI, although some of
the improvements were relatively small and task specific. Some benefits were specific to the TBI
population, although it seems reasonable to extend some of these results to the stroke population.
CLINICAL RECOMMENDATION STATEMENTS:
Recommend that the clinician use standardized, valid assessments to evaluate the patient’s
stroke-related impairments and functional status and encourage patient’s participation in
community and social activities. Recommend that the standardized assessment results be used to
assess probability of outcome, determine the appropriate level of care, and develop interventions.
(US Department of Veterans’ Affairs; endorsed by the American Heart Association)
Recommend that patients be assessed for cognitive deficits and be given cognitive retraining, if
any of the following conditions are present:
• Attention deficits
• Visual neglect
• Memory deficits
• Executive function and problem-solving difficulties
(US Department of Veterans’ Affairs; endorsed by the American Heart Association)
Cognitive therapy may be used in rehabilitation of attention and concentration deficits (National
Stroke Foundation of Australia)
Patients with persistent cognitive deficits following acquired brain injury (ABI) should be offered
cognitive rehabilitation which may include management in a structured and distraction-free
environment and targeted programs for those with executive difficulties (i.e. problems with
planning, organization, problem solving and divided attention), and attempts to improve attention
and information processing skills. (Royal College of Medicine and the British Society of
Rehabilitation Medicine)
The speech and language therapist will be involved in all cases where there are communication
problems following stroke. (Republic of South Africa Department of Health; Stroke Foundation of
South Africa)
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Measure #211: Functional Communication Measure - Memory
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 16 years and older with a diagnosis of late effects of cerebrovascular
disease (CVD) that make progress on the Memory Functional Communication Measure
INSTRUCTIONS:
This measure is to be reported once per episode of treatment for all patients with late effects of
CVD who are treated for a memory deficit by a speech-language pathologist (SLP) during the
reporting period. Only patients who had at least two visits in the reporting period will be counted in
the denominator for this measure. This is an outcome measure, and its calculation requires
reporting of the patient’s score (see below under numerator) on the measure at the admission to
and discharge from SLP treatment for memory. The admission score is noted by the SLP at the
conclusion of the first treatment session, and the discharge score at the conclusion of the final
treatment session for memory.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The listed numerator options are used to report
the numerator of the measure. The quality-data codes have been provided for registry only
measures for use by registries that utilize claims data. It is not necessary to submit these codes for
registry-based submissions. There are no allowable performance exclusions for this measure. Do
not report this measure via claims.
NUMERATOR:
Patients whose score on the functional communication measure at discharge were higher than at
admission
Definitions:
Admission - The conclusion of the first treatment session for memory by an SLP.
Discharge - The conclusion of the final treatment session for memory by an SLP,
regardless of whether the patient is also being discharged from the facility and/or other
SLP services.
Patient’s Score –
LEVEL 1: The individual is unable to recall any information, regardless of cueing.
LEVEL 2: The individual consistently requires maximal verbal cues or uses external aids
to recall personal information (e.g., family members, biographical information,
physical location, etc.) in structured environments.
LEVEL 3: The individual usually requires maximum cues to recall or use external aids for
simple routine and personal information (e.g., schedule, names of familiar
staff, location of therapy areas, etc.) in structured environments.
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LEVEL 4: The individual occasionally requires minimal cues to recall or use external
memory aids for simple routine and personal information in structured
environments. The individual requires consistent maximal cues to recall or use
memory aids for complex and novel information (e.g., carry out multiple steps
activities, accommodate schedule changes, anticipate meal times, etc.), plan
and follow through on simple future events (e.g., use calendar to keep
appointments, use log books to complete a single assignment/task, etc.) in
structured environments.
LEVEL 5: The individual consistently requires minimal cues to recall or use external
memory aids for complex and novel information. The individual consistently
requires minimal cues to plan and follow through on complex future events
(e.g., menu planning and meal preparation, planning a party, etc.).
LEVEL 6: The individual is able to recall or use external aids/memory strategies for
complex information and planning complex future events most of the time.
When there is a breakdown in the use of recall/memory strategies/external
memory aids, the individual occasionally requires minimal cues. These
breakdowns may occasionally interfere with the individual’s functioning in
vocational, avocational, and social activities.
LEVEL 7: The individual is successful and independent in recalling or using external
aids/memory strategies for complex information and planning future events in
all vocational, avocational, and social activities.
OR
Numerator Options:
Score on the memory functional communication measure at discharge was higher than at
admission (G8609)
Score on the memory functional communication measure at discharge was not higher than
at admission, reason not specified (G8610)
OR
Patient was not scored on the memory functional communication measure at either
admission or at discharge (G8611)
DENOMINATOR:
Patients aged 16 years and older with late effects of CVD who received SLP treatment for memory
Denominator Criteria (Eligible Cases):
Patients aged ≥ 16 years on date of encounter
AND
Diagnosis of late effects of CVD (ICD-9-CM): 438.0, 438.10, 438.11, 438.12, 438.13,
438.14, 438.19, 438.20, 438.21, 438.22, 438.30, 438.31, 438.32, 438.40, 438.41, 438.42,
438.50, 438.51, 438.52, 438.53, 438.6, 438.7, 438.81, 438.82, 438.83, 438.84, 438.85,
438.89, 438.9
AND
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Two (2) or more patient encounters during reporting period (CPT): 97532
RATIONALE:
Impairments in cognitive functioning are common after a stroke. In particular, impairments in
attention, memory, and executive functioning (i.e., integrating multiple and complex processes) can
be especially disabling. The treatment of cognitive deficits through cognitive remediation designed
to reduce deficits can be approached in a variety of ways. Cicerone and colleagues completed a
comprehensive review of the evidence-based literature for cognitive remediation for both traumatic
brain injury (TBI) and stroke. The review revealed a large number of randomized control trials
(RCTs) in a variety of areas of cognitive functioning and provided comprehensive guidelines for
cognitive rehabilitation specific to these populations. There is support for cognitive remediation of
deficits in both the acute and post-acute phases of recovery from stroke and TBI, although some of
the improvements were relatively small and task specific. Some benefits were specific to the TBI
population, although it seems reasonable to extend some of these results to the stroke population.
Assessment of cognition and arousal is important for determining the patient’s capabilities and
limitations for coping with their stroke and assuring success of the rehabilitation process. The
results of the assessment may impact the choice of treatment and disposition.
CLINICAL RECOMMENDATION STATEMENTS:
Recommend that the clinician use standardized, valid assessments to evaluate the patient’s
stroke-related impairments and functional status and encourage patient’s participation in
community and social activities. Recommend that the standardized assessment results be used to
assess probability of outcome, determine the appropriate level of care, and develop interventions.
(US Department of Veterans’ Affairs; endorsed by the American Heart Association)
Recommend the use of training to develop compensatory strategies for memory deficits in post
stroke patients who have mild short-term memory deficits. (US Department of Veterans’ Affairs;
endorsed by the American Heart Association)
Patients with persistent cognitive deficits following acquired brain injury (ABI) should be offered
cognitive rehabilitation which may include the use of external memory aids to enhance
independence in the presence of memory deficits. (Royal College of Medicine and the British
Society of Rehabilitation Medicine)
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Measure #212: Functional Communication Measure – Motor Speech
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 16 years and older with a diagnosis of late effects of cerebrovascular
disease (CVD) that make progress on the Motor Speech Functional Communication Measure
INSTRUCTIONS:
This measure is to be reported once per episode of treatment for all patients with late effects of
CVD who are treated for a motor speech deficit by a speech-language pathologist (SLP) during the
reporting period. Only patients who had at least two visits in the reporting period will be counted in
the denominator for this measure. This is an outcome measure, and its calculation requires
reporting of the patient’s score (see below under numerator) on the measure at the admission to
and discharge from SLP treatment for motor speech. The admission score is noted by the SLP at
the conclusion of the first treatment session, and the discharge score at the conclusion of the final
treatment session for motor speech.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The listed numerator options are used to report
the numerator of the measure. The quality-data codes have been provided for registry only
measures for use by registries that utilize claims data. It is not necessary to submit these codes for
registry-based submissions. There are no allowable performance exclusions for this measure. Do
not report this measure via claims.
NUMERATOR:
Patients whose score on the functional communication measure at discharge were higher than at
admission
Definitions:
Admission - The conclusion of the first treatment session for motor speech by an SLP.
Discharge - The conclusion of the final treatment session for motor speech by an SLP,
regardless of whether the patient is also being discharged from the facility and/or other
SLP services.
Patient’s Score:
LEVEL 1: The individual attempts to speak, but speech cannot be understood by
familiar or unfamiliar listeners at any time.
LEVEL 2: The individual attempts to speak. The communication partner must assume
responsibility for interpreting the message, and with consistent and maximal
cues, the patient can produce short consonant-vowel combinations or
automatic words that are rarely intelligible in context.
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LEVEL 3: The communication partner must assume primary responsibility for
interpreting the communication exchange. However, the individual is able to
produce short consonant-vowel combinations or automatic words intelligibly.
With consistent and moderate cueing, the individual can produce simple
words and phrases intelligibly, although accuracy may vary.
LEVEL 4: In simple structured conversation with familiar communication partners, the
individual can produce simple words and phrases intelligibly. The individual
usually requires moderate cueing in order to produce simple sentences
intelligibly, although accuracy may vary.
LEVEL 5: The individual is able to speak intelligibly using simple sentences in daily
routine activities with both familiar and unfamiliar communication partners.
The individual occasionally requires minimal cueing to produce more complex
sentences/ messages in routine activities, although accuracy may vary and
the individual may occasionally use compensatory strategies.
LEVEL 6: The individual is successfully able to communicate intelligibly in most
activities, but some limitations in intelligibility are still apparent in vocational,
avocational, and social activities. The individual rarely requires minimal
cueing to produce complex sentences/messages intelligibly. The individual
usually uses compensatory strategies when encountering difficulty.
LEVEL 7: The individual’s ability to successfully and independently participate in
vocational, avocational, or social activities is not limited by speech production.
Independent functioning may occasionally include the use of compensatory
techniques.
OR
Numerator Options:
Score on the motor speech functional communication measure at discharge was higher
than at admission (G8612)
Score on the motor speech functional communication measure at discharge was not
higher than at admission, reason not specified (G8613)
OR
Patient was not scored on the motor speech functional communication measure either at
admission or at discharge (G8614)
DENOMINATOR:
Patients aged 16 years and older with late effects of CVD who received SLP treatment for motor
speech
Denominator Criteria (Eligible Cases):
Patients aged ≥ 16 years on date of encounter
AND
Diagnosis of late effects of CVD (ICD-9-CM): 438.10, 438.11, 438.12, 438.13, 438.14,
438.19, 438.20, 438.21, 438.22, 438.30, 438.31, 438.32, 438.40, 438.41, 438.42, 438.50,
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438.51, 438.52, 438.53, 438.6, 438.7, 438.81, 438.82, 438.83, 438.84, 438.85, 438.89,
438.9, 784.3
AND
Two (2) or more patient encounters during reporting period (CPT): 92507, 92508
RATIONALE:
Assessment of communication ability is important for determining the patient’s capabilities and
limitations in expressing their wants, needs, and understanding; their ability to contribute to their
plan of care (including consent forms and advanced directives), and their ability to comprehend
instructions affecting the success of the rehabilitation process. The results of the assessment may
impact the choice of treatment and disposition.
Disorders of communication (i.e., problems with speaking, listening, reading, writing, gesturing,
and/or pragmatics) and related cognitive impairments may occur in as many as 40% of post stroke
patients. The most common communication disorders occurring after stroke are aphasia and
dysarthria. Rapid spontaneous improvement is common, but early evaluation can identify
communication problems and monitor change. If indicated, intervention can help maximize
recovery of communication abilities and prevent learning of ineffective or inappropriate
compensatory behaviors. Goals of speech and language treatment are to (1)
facilitate the recovery of communication, (2) assist patients in developing strategies to compensate
for communication disorders, and (3) counsel and educate people in the patient’s environment to
facilitate communication, decrease isolation, and meet the patient’s desires and needs.
CLINICAL RECOMMENDATION STATEMENTS:
Recommend that the clinician use standardized, valid assessments to evaluate the patient’s
stroke-related impairments and functional status and encourage patient’s participation in
community and social activities. Recommend that the standardized assessment results be used to
assess probability of outcome, determine the appropriate level of care, and develop interventions.
(US Department of Veterans’ Affairs; endorsed by the American Heart Association)
Recommend that all patients be evaluated and treated by the SLP for residual communication
difficulties (i.e., speaking, listening, reading, writing, and pragmatics). (US Department of Veterans’
Affairs; endorsed by the American Heart Association)
It is recommended that patients who are conscious with communication difficulties be evaluated by
a SLP who can develop appropriate communication techniques. SLP assessment should include
screening for hearing and vision and restoration of glasses or hearing aids. Appropriate patients
(with reasonable cognition and language skills) should be considered for alternative or
augmentative communication. Patients with communication difficulties should be monitored and
assessed regularly to determine appropriateness for speech and language therapy. An appropriate
treatment program with a system for monitoring progress should be in place for any individuals
receiving speech-language therapy. In developing a communication program, consideration for
premorbid communication style, underlying cognitive deficits, environmental context, social needs,
and necessary communication aids should be given. (Royal College of Medicine and the British
Society of Rehabilitation Medicine)
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Where achievable goals can be identified, and continuing progress demonstrated, patients with
communication difficulties should be offered an appropriate treatment program, with monitoring of
progress. The program should: take into account the patient’s premorbid communication style and
any underlying cognitive deficits; give the opportunity to rehearse communication skills in situations
appropriate to the context in which the patient will live/work/study/socialize after discharge; include
the family and caregivers in developing strategies for optimum communication within the immediate
social circle; consider the need for communication aids including gesture drawing, communication
charts and computerized systems; (Royal College of Medicine and the British Society of
Rehabilitation Medicine)
The speech and language therapist will be involved in all cases where there are communication
problems following stroke. (Republic of South Africa Department of Health; Stroke Foundation of
South Africa)
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Measure #213: Functional Communication Measure - Reading
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 16 years and older with a diagnosis of late effects of cerebrovascular
disease (CVD) that make progress on the Reading Functional Communication Measure
INSTRUCTIONS:
This measure is to be reported once per episode of treatment for all patients with late effects of
CVD who are treated for a reading deficit by a speech-language pathologist (SLP) during the
reporting period. Only patients who had at least two visits in the reporting period will be counted in
the denominator for this measure. This is an outcome measure, and its calculation requires
reporting of the patient’s score (see below under numerator) on the measure at the admission to
and discharge from SLP treatment for reading. The admission score is noted by the SLP at the
conclusion of the first treatment session, and the discharge score at the conclusion of the final
treatment session for reading.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The listed numerator options are used to report
the numerator of the measure. The quality-data codes have been provided for registry only
measures for use by registries that utilize claims data. It is not necessary to submit these codes for
registry-based submissions. There are no allowable performance exclusions for this measure. Do
not report this measure via claims.
NUMERATOR:
Patients whose score on the functional communication measure at discharge were higher than at
admission
Definitions:
Admission - The conclusion of the first treatment session for reading by an SLP.
Discharge - The conclusion of the final treatment session for reading by an SLP,
regardless of whether the patient is also being discharged from the facility and/or other
SLP services.
Patient’s Score –
LEVEL 1: The individual attends to printed material, but doesn’t recognize even single
letters or common words.
LEVEL 2: The individual reads single letters and common words with consistent maximal
cueing.
LEVEL 3: The individual reads single letters and common words, and with consistent
moderate cueing, can read some words that are less familiar, longer, and
more complex.
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LEVEL 4: The individual reads words and phrases related to routine daily activities, and
words that are less familiar, longer, and more complex. The individual usually
requires moderate cueing to read sentences of approximately 5–7 words.
LEVEL 5: The individual reads sentence-level material containing some complex words.
The individual occasionally requires minimal cueing to read more complex
sentences and paragraph-level material. The individual occasionally uses
compensatory strategies.
LEVEL 6: The individual is successfully able to read most material but some limitations in
reading are still apparent in vocational, avocational, and social activities. The
individual rarely requires minimal cueing to read complex material. Although
reading is successful, it may take the individual longer to read the material.
The individual usually uses compensatory strategies when encountering
difficulty.
LEVEL 7: The individual’s ability to successfully and independently participate in
vocational, avocational, and social activities is not limited by reading skills.
Independent functioning may occasionally include use of compensatory
strategies.
OR
Numerator Options:
Score on the reading functional communication measure at discharge was higher than at
admission (G8615)
Score on the reading functional communication measure at discharge was not higher than
at admission, reason not specified (G8616)
OR
Patient was not scored on the reading functional communication measure either at
admission or at discharge (G8617)
DENOMINATOR:
Patients aged 16 years and older with late effects of CVD who received SLP treatment for reading
Denominator Criteria (Eligible Cases):
Patients aged ≥ 16 years on date of encounter
AND
Diagnosis of late effects of CVD (ICD-9-CM): 438.10, 438.11, 438.12, 438.13, 438.14,
438.19, 438.20, 438.21, 438.22, 438.30, 438.31, 438.32, 438.40, 438.41, 438.42, 438.50,
438.51, 438.52, 438.53, 438.6, 438.7, 438.81, 438.82, 438.83, 438.84, 438.85, 438.89,
438.9, 784.3
AND
Two (2) or more patient encounters during reporting period (CPT): 92507, 92508
RATIONALE:
Assessment of communication ability is important for determining the patient’s capabilities and
limitations in expressing their wants, needs, and understanding; their ability to contribute to their
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plan of care (including consent forms and advanced directives), and their ability to comprehend
instructions affecting the success of the rehabilitation process. The results of the assessment may
impact the choice of treatment and disposition.
Disorders of communication (i.e., problems with speaking, listening, reading, writing, gesturing,
and/or pragmatics) and related cognitive impairments may occur in as many as 40% of post stroke
patients. The most common communication disorders occurring after stroke are aphasia and
dysarthria. Rapid spontaneous improvement is common, but early evaluation can identify
communication problems and monitor change. If indicated, intervention can help maximize
recovery of communication abilities and prevent learning of ineffective or inappropriate
compensatory behaviors. Goals of speech and language treatment are to (1)
facilitate the recovery of communication, (2) assist patients in developing strategies to compensate
for communication disorders, and (3) counsel and educate people in the patient’s environment to
facilitate communication, decrease isolation, and meet the patient’s desires and needs.
CLINICAL RECOMMENDATION STATEMENTS:
Recommend that the clinician use standardized, valid assessments to evaluate the patient’s
stroke-related impairments and functional status and encourage patient’s participation in
community and social activities. Recommend that the standardized assessment results be used to
assess probability of outcome, determine the appropriate level of care, and develop interventions.
(US Department of Veterans’ Affairs; endorsed by the American Heart Association)
Recommend that all patients be evaluated and treated by the SLP for residual communication
difficulties (i.e., speaking, listening, reading, writing, and pragmatics). (US Department of Veterans’
Affairs; endorsed by the American Heart Association)
Interventions for people with aphasia may include: treatment of phonological and semantic deficits
following models derived from cognitive neuropsychology, constraint-induced therapy, and
computer-based therapy programs. (National Stroke Foundation of Australia)
It is recommended that patients who are conscious with communication difficulties be evaluated by
a SLP who can develop appropriate communication techniques. SLP assessment should include
screening for hearing and vision and restoration of glasses or hearing aids. Appropriate patients
(with reasonable cognition and language skills) should be considered for alternative or
augmentative communication. Patients with communication difficulties should be monitored and
assessed regularly to determine appropriateness for speech and language therapy. An appropriate
treatment program with a system for monitoring progress should be in place for any individuals
receiving speech-language therapy. In developing a communication program, consideration for
premorbid communication style, underlying cognitive deficits, environmental context, social needs,
and necessary communication aids should be given. (Royal College of Medicine and the British
Society of Rehabilitation Medicine)
Where achievable goals can be identified, and continuing progress demonstrated, patients with
communication difficulties should be offered an appropriate treatment program, with monitoring of
progress. The program should: take into account the patient’s premorbid communication style and
any underlying cognitive deficits; give the opportunity to rehearse communication skills in situations
appropriate to the context in which the patient will live/work/study/socialize after discharge; include
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the family and caregivers in developing strategies for optimum communication within the immediate
social circle; and consider the need for communication aids including gesture drawing,
communication charts and computerized systems. (Royal College of Medicine and the British
Society of Rehabilitation Medicine)
The speech and language therapist will be involved in all cases where there are communication
problems following stroke. (Republic of South Africa Department of Health; Stroke Foundation of
South Africa)
People with aphasia following stroke should be referred to a speech and language therapist for
assessment and appropriate management of their communication difficulty. (Stroke Foundation of
New Zealand)
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Measure #214: Functional Communication Measure – Spoken Language Expression
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 16 years and older with a diagnosis of late effects of cerebrovascular
disease (CVD) that make progress on the Spoken Language Expression Functional
Communication Measure
INSTRUCTIONS:
This measure is to be reported once per episode of treatment for all patients with late effects of
CVD who are treated for a spoken language expression deficit by a speech-language pathologist
(SLP) during the reporting period. Only patients who had at least two visits in the reporting period
will be counted in the denominator for this measure. This is an outcome measure, and its
calculation requires reporting of the patient’s score (see below under numerator) on the measure at
the admission to and discharge from SLP treatment for spoken language expression. The
admission score is noted by the SLP at the conclusion of the first treatment session, and the
discharge score at the conclusion of the final treatment session for spoken language expression.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The listed numerator options are used to report
the numerator of the measure. The quality-data codes have been provided for registry only
measures for use by registries that utilize claims data. It is not necessary to submit these codes for
registry-based submissions. There are no allowable performance exclusions for this measure. Do
not report this measure via claims.
NUMERATOR:
Patients whose score on the functional communication measure at discharge were higher than at
admission
Definitions:
Admission - The conclusion of the first treatment session for spoken language expression
by an SLP.
Discharge - The conclusion of the final treatment session for spoken language expression
by an SLP, regardless of whether the patient is also being discharged from the facility
and/or other SLP services.
Patient’s Score –
LEVEL 1: The individual attempts to speak, but verbalizations are not meaningful to
familiar or unfamiliar communication partners at any time.
LEVEL 2: The individual attempts to speak, although few attempts are accurate or
appropriate. The communication partner must assume responsibility for
structuring the communication exchange, and with consistent and maximal
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cueing, the individual can only occasionally produce automatic and/or imitative
words and phrases that are rarely meaningful in context.
LEVEL 3: The communication partner must assume responsibility for structuring the
communication exchange, and with consistent and moderate cueing, the
individual can produce words and phrases that are appropriate and
meaningful in context.
LEVEL 4: The individual is successfully able to initiate communication using spoken
language in simple, structured conversations in routine daily activities with
familiar communication partners. The individual usually requires moderate
cueing, but is able to demonstrate use of simple sentences (i.e., semantics,
syntax, and morphology) and rarely uses complex sentences/messages.
LEVEL 5: The individual is successfully able to initiate communication using spoken
language in structured conversations with both familiar and unfamiliar
communication partners. The individual occasionally requires minimal cueing
to frame more complex sentences in messages. The individual occasionally
self-cues when encountering difficulty.
LEVEL 6: The individual is successfully able to communicate in most activities, but some
limitations in spoken language are still apparent in vocational, avocational, and
social activities. The individual rarely requires minimal cueing to frame
complex sentences. The individual usually self-cues when encountering
difficulty.
LEVEL 7: The individual’s ability to successfully and independently participate in
vocational, avocational, and social activities is not limited by spoken language
skills. Independent functioning may occasionally include use of self-cueing.
OR
Numerator Options:
Score on the spoken language expression functional communication measure at discharge
was higher than at admission (G8618)
Score on the spoken language expression functional communication measure at discharge
was not higher than at admission, reason not specified (G8619)
OR
Patient was not scored on the spoken language expression reading functional
communication measure either at admission or at discharge (G8620)
DENOMINATOR:
Patients aged 16 years and older with late effects of CVD who received SLP treatment for spoken
language expression
Denominator Criteria (Eligible Cases):
Patients aged ≥ 16 years on date of encounter
AND
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Diagnosis of late effects of CVD (ICD-9-CM): 438.10, 438.11, 438.12, 438.13, 438.14,
438.19, 438.20, 438.21, 438.22, 438.30, 438.31, 438.32, 438.40, 438.41, 438.42, 438.50,
438.51, 438.52, 438.53, 438.6, 438.7, 438.81, 438.82, 438.83, 438.84, 438.85, 438.89,
438.9, 784.3
AND
Two (2) or more patient encounters during reporting period (CPT): 92507, 92508
RATIONALE:
Assessment of communication ability is important for determining the patient’s capabilities and
limitations in expressing their wants, needs, and understanding; their ability to contribute to their
plan of care (including consent forms and advanced directives), and their ability to comprehend
instructions affecting the success of the rehabilitation process. The results of the assessment may
impact the choice of treatment and disposition.
Disorders of communication (i.e., problems with speaking, listening, reading, writing, gesturing,
and/or pragmatics) and related cognitive impairments may occur in as many as 40% of post stroke
patients. The most common communication disorders occurring after stroke are aphasia and
dysarthria. Rapid spontaneous improvement is common, but early evaluation can identify
communication problems and monitor change. If indicated, intervention can help maximize
recovery of communication abilities and prevent learning of ineffective or inappropriate
compensatory behaviors. Goals of speech and language treatment are to (1)
facilitate the recovery of communication, (2) assist patients in developing strategies to compensate
for communication disorders, and (3) counsel and educate people in the patient’s environment to
facilitate communication, decrease isolation, and meet the patient’s desires and needs.
CLINICAL RECOMMENDATION STATEMENTS:
Aphasic stroke patients should be referred for speech and language therapy. Where the patient is
sufficiently well and motivated, aim for minimum of two hours per week. (Scottish Intercollegiate
Guidelines Network).
Recommend that the clinician use standardized, valid assessments to evaluate the patient’s
stroke-related impairments and functional status and encourage patient’s participation in
community and social activities. Recommend that the standardized assessment results be used to
assess probability of outcome, determine the appropriate level of care, and develop interventions.
(US Department of Veterans’ Affairs; endorsed by the American Heart Association)
Recommend that all patients be evaluated and treated by the SLP for residual communication
difficulties (i.e., speaking, listening, reading, writing, and pragmatics). (US Department of Veterans’
Affairs; endorsed by the American Heart Association)
Interventions for people with aphasia may include: treatment of phonological and semantic deficits
following models derived from cognitive neuropsychology, constraint-induced therapy, and
computer-based therapy programs. (National Stroke Foundation of Australia)
It is recommended that patients who are conscious with communication difficulties be evaluated by
a SLP who can develop appropriate communication techniques. SLP assessment should include
screening for hearing and vision and restoration of glasses or hearing aids. Appropriate patients
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(with reasonable cognition and language skills) should be considered for alternative or
augmentative communication. Patients with communication difficulties should be monitored and
assessed regularly to determine appropriateness for speech and language therapy. An appropriate
treatment program with a system for monitoring progress should be in place for any individuals
receiving speech-language therapy. In developing a communication program, consideration for
premorbid communication style, underlying cognitive deficits, environmental context, social needs,
and necessary communication aids should be given. (Royal College of Medicine and the British
Society of Rehabilitation Medicine)
Where achievable goals can be identified, and continuing progress demonstrated, patients with
communication difficulties should be offered an appropriate treatment program, with monitoring of
progress. The program should:
take into account the patient’s premorbid communication style and any underlying cognitive
deficits; give the opportunity to rehearse communication skills in situations appropriate to the
context in which the patient will live/work/study/socialize after discharge;
include the family and caregivers in developing strategies for optimum communication within the
immediate social circle; and consider the need for communication aids including gesture drawing,
communication charts and computerized systems. (Royal College of Medicine and the British
Society of Rehabilitation Medicine)
The speech and language therapist will be involved in all cases where there are communication
problems following stroke. (Republic of South Africa Department of Health; Stroke Foundation of
South Africa)
People with aphasia following stroke should be referred to a speech and language therapist for
assessment and appropriate management of their communication difficulty. (Stroke Foundation of
New Zealand)
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Measure #215: Functional Communication Measure - Writing
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 16 years and older with a diagnosis of late effects of cerebrovascular
disease (CVD) that make progress on the Writing Functional Communication Measure
INSTRUCTIONS:
This measure is to be reported once per episode of treatment for all patients with late effects of
CVD who are treated for a writing deficit by a speech-language pathologist (SLP) during the
reporting period. Only patients who had at least two visits in the reporting period will be counted in
the denominator for this measure. This is an outcome measure, and its calculation requires
reporting of the patient’s score (see below under numerator) on the measure at the admission to
and discharge from SLP treatment for writing. The admission score is noted by the SLP at the
conclusion of the first treatment session, and the discharge score at the conclusion of the final
treatment session for writing.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The listed numerator options are used to report
the numerator of the measure. The quality-data codes have been provided for registry only
measures for use by registries that utilize claims data. It is not necessary to submit these codes for
registry-based submissions. There are no allowable performance exclusions for this measure. Do
not report this measure via claims.
NUMERATOR:
Patients whose score on the functional communication measure at discharge were higher than at
admission
Definitions:
Admission - The conclusion of the first treatment session for writing by an SLP.
Discharge - The conclusion of the final treatment session for writing by an SLP,
regardless of whether the patient is also being discharged from the facility and/or other
SLP services.
Patient’s Score –
LEVEL 1: The individual attempts to write, but doesn’t produce recognizable single
Letters or common words.
LEVEL 2: The individual writes single letters and common words with consistent
maximal cueing.
LEVEL 3: The individual writes single letters and common words, and with consistent
moderate cueing, can write some words that are less familiar, longer, and
more complex.
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LEVEL 4: The individual writes words and phrases related to routine daily activities and
words that are less familiar, longer, and more complex. The individual usually
requires moderate cueing to write sentences of approximately 5–7 words.
LEVEL 5: The individual writes sentence-level material containing some complex words.
The individual occasionally requires minimal cueing to write more complex
sentences and paragraph-level material. The individual occasionally uses
compensatory strategies.
LEVEL 6: The individual is successfully able to write most material, but some limitations
in writing are still apparent in vocational, avocational, and social activities. The
individual rarely requires minimal cueing to write complex material. The
individual usually uses compensatory strategies when encountering difficulty.
LEVEL 7: The individual’s ability to successfully and independently participate in
vocational, avocational, and social activities is not limited by writing skills.
Independent functioning may occasionally include use of compensatory
strategies.
OR
Numerator Options:
Score on the writing functional communication measure at discharge was higher than at
admission (G8621)
Score on the writing functional communication measure at discharge was not higher than
at admission, reason not specified (G8622)
OR
Patient was not scored on the writing functional communication measure either at
admission or at discharge (G8623)
DENOMINATOR:
Patients aged 16 years and older on date of encounter who received SLP treatment for writing
Denominator Criteria (Eligible Cases):
Patients aged ≥ 16 years on date of encounter
AND
Diagnosis of late effects of CVD (ICD-9-CM): 438.10, 438.11, 438.12, 438.13, 438.14,
438.19, 438.20, 438.21, 438.22, 438.30, 438.31, 438.32, 438.40, 438.41, 438.42, 438.50,
438.51, 438.52, 438.53, 438.6, 438.7, 438.81, 438.82, 438.83, 438.84, 438.85, 438.89,
438.9, 784.3
AND
Two (2) or more patient encounters during reporting period (CPT): 92507, 92508
RATIONALE:
Assessment of communication ability is important for determining the patient’s capabilities and
limitations in expressing their wants, needs, and understanding; their ability to contribute to their
plan of care (including consent forms and advanced directives), and their ability to comprehend
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instructions affecting the success of the rehabilitation process. The results of the assessment may
impact the choice of treatment and disposition.
Disorders of communication (i.e., problems with speaking, listening, reading, writing, gesturing,
and/or pragmatics) and related cognitive impairments may occur in as many as 40% of post stroke
patients. The most common communication disorders occurring after stroke are aphasia and
dysarthria. Rapid spontaneous improvement is common, but early evaluation can identify
communication problems and monitor change. If indicated, intervention can help maximize
recovery of communication abilities and prevent learning of ineffective or inappropriate
compensatory behaviors. Goals of speech and language treatment are to (1)
facilitate the recovery of communication, (2) assist patients in developing strategies to compensate
for communication disorders, and (3) counsel and educate people in the patient’s environment to
facilitate communication, decrease isolation, and meet the patient’s desires and needs.
CLINICAL RECOMMENDATION STATEMENTS:
Recommend that the clinician use standardized, valid assessments to evaluate the patient’s
stroke-related impairments and functional status and encourage patient’s participation in
community and social activities. Recommend that the standardized assessment results be used to
assess probability of outcome, determine the appropriate level of care, and develop interventions.
(US Department of Veterans’ Affairs; endorsed by the American Heart Association)
Recommend that all patients be evaluated and treated by the SLP for residual communication
difficulties (i.e., speaking, listening, reading, writing, and pragmatics). (US Department of Veterans’
Affairs; endorsed by the American Heart Association)
Interventions for people with aphasia may include: treatment of phonological and semantic deficits
following models derived from cognitive neuropsychology, constraint-induced therapy, and
computer-based therapy programs. (National Stroke Foundation of Australia)
It is recommended that patients who are conscious with communication difficulties be evaluated by
a speech-language pathologist who can develop appropriate communication techniques. SLP
assessment should include screening for hearing and vision and restoration of glasses or hearing
aids. Appropriate patients (with reasonable cognition and language skills) should be considered for
alternative or augmentative communication. Patients with communication difficulties should be
monitored and assessed regularly to determine appropriateness for speech and language therapy.
An appropriate treatment program with a system for monitoring progress should be in place for any
individuals receiving speech-language therapy. In developing a communication program,
consideration for premorbid communication style, underlying cognitive deficits, environmental
context, social needs, and necessary communication aids should be given. (Royal College of
Medicine and the British Society of Rehabilitation Medicine)
Where achievable goals can be identified, and continuing progress demonstrated, patients with
communication difficulties should be offered an appropriate treatment program, with monitoring of
progress. The program should: take into account the patient’s premorbid communication style and
any underlying cognitive deficits; give the opportunity to rehearse communication skills in situations
appropriate to the context in which the patient will live/work/study/socialize after discharge; include
the family and caregivers in developing strategies for optimum communication within the immediate
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social circle; consider the need for communication aids including gesture drawing, communication
charts and computerized systems. (Royal College of Medicine and the British Society of
Rehabilitation Medicine)
The speech and language therapist will be involved in all cases where there are communication
problems following stroke. (Republic of South Africa Department of Health; Stroke Foundation of
South Africa)
People with aphasia following stroke should be referred to a speech and language therapist for
assessment and appropriate management of their communication difficulty. (Stroke Foundation of
New Zealand)
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Measure #216: Functional Communication Measure - Swallowing
2010 PQRI REPORTING OPTIONS FOR INDIVIDUAL MEASURES: REGISTRY ONLY
DESCRIPTION:
Percentage of patients aged 16 years and older with a diagnosis of late effects of cerebrovascular
disease (CVD) that make progress on the Swallowing Functional Communication Measure
INSTRUCTIONS:
This measure is to be reported once per episode of treatment for all patients with late effects of
CVD who are treated for dysphagia by a speech-language pathologist (SLP) during the reporting
period. Only patients who had at least two visits in the reporting period will be counted in the
denominator for this measure. This is an outcome measure, and its calculation requires reporting of
the patient’s score (see below under numerator) on the measure at the admission to and discharge
from SLP treatment for attention. The admission score is noted by the SLP at the conclusion of the
first treatment session, and the discharge score at the conclusion of the final treatment session for
dysphagia.
Measure Reporting via Registry:
ICD-9-CM diagnosis codes, CPT codes, and patient demographics are used to identify patients
who are included in the measure’s denominator. The listed numerator options are used to report
the numerator of the measure. The quality-data codes have been provided for registry only
measures for use by registries that utilize claims data. It is not necessary to submit these codes for
registry-based submissions. There are no allowable performance exclusions for this measure. Do
not report this measure via claims.
NUMERATOR:
Patients whose score on the functional communication measure at discharge were higher than at
admission
Definitions:
Admission - The conclusion of the first treatment session for dysphagia by an SLP.
Discharge - The conclusion of the final treatment session for dysphagia by an SLP,
regardless of whether the patient is also being discharged from the facility and/or other
SLP services.
Patient’s Score LEVEL 1: Individual is not able to swallow anything safely by mouth. All nutrition and
hydration is received through non-oral means (e.g., nasogastric tube, PEG).
LEVEL 2: Individual is not able to swallow safely by mouth for nutrition and hydration,
but may take some consistency with consistent maximal cues in therapy only.
Alternative method of feeding required.
LEVEL 3: Alternative method of feeding required as individual takes less than 50% of
nutrition and hydration by mouth, and/or swallowing is safe with consistent use
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of moderate cues to use compensatory strategies and/or requires maximum
diet restriction.
LEVEL 4: Swallowing is safe, but usually requires moderate cues to use compensatory
strategies, and/or the individual has moderate diet restrictions and/or still
requires tube feeding and/or oral supplements.
LEVEL 5: Swallowing is safe with minimal diet restriction and/or occasionally requires
minimal cueing to use compensatory strategies. The individual may
occasionally self-cue. All nutrition and hydration needs are met by mouth at
mealtime.
LEVEL 6: Swallowing is safe, and the individual eats and drinks independently and may
rarely require minimal cueing. The individual usually self-cues when difficulty
occurs. May need to avoid specific food items (e.g., popcorn and nuts), or
require additional time (due to dysphasia).
LEVEL 7: The individual’s ability to eat independently is not limited by swallow function.
Swallowing would be safe and efficient for all consistencies. Compensatory
strategies are effectively used when needed.
OR
Numerator Options:
Score on the swallowing functional communication measure at discharge was higher than
at admission (G8624)
Score on the swallowing functional communication measure at discharge was not higher
than at admission, reason not specified (G8625)
OR
Patient was not scored on the swallowing functional communication measure at admission
or at discharge (G8626)
DENOMINATOR:
Patients aged 16 years and older with late effects of CVD who received SLP treatment for
dysphagia
Denominator Criteria (Eligible Cases):
Patients aged ≥ 16 years on date of encounter
AND
Diagnosis of late effects of CVD (ICD-9-CM): 438.82, 784.51, 787.20, 787.21, 787.22,
787.23, 787.24, 787.29
AND
Two (2) or more patient encounters during reporting period (CPT): 92526
RATIONALE:
Dysphagia, an abnormality in swallowing fluids or food, is common, occurring in about 45% of all
stroke patients admitted to the hospital. It can seriously affect the patient’s quality of life and
potentially lead to death. It is associated with severe strokes and with worse outcome. The
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presence of aspiration may be associated with an increased risk of developing pneumonia after
stroke. Malnutrition is also common, being present in about 15% of all patients admitted to the
hospital, and increasing to about 30% over the first week after stroke. Malnutrition is associated
with a worse outcome and a slower rate of recovery. Assessment of dysphagia by personnel who
are not adequately trained in the anatomy and physiology of swallowing is often times problematic.
Traditionally, SLPs receive formal training in oropharyngeal anatomy and physiology.
CLINICAL RECOMMENDATION STATEMENTS:
Treatment outcome studies have provided evidence that compensatory strategies designed to
have an immediate effect on the swallow (i.e., postural changes or diet manipulation) can improve
swallowing safety and efficiency. Postural techniques eliminated aspiration on thin liquids in 75 to
80% of dysphagic patients. Likewise, data are beginning to emerge that demonstrate the utility of
pharyngeal muscle strengthening exercises for improving swallowing physiology. Treatment
approaches improve nutritional status and hydration, and reduce morbidity from pneumonia. The
speech-language pathologist’s intervention in swallowing disorders helps contain medical costs by
reducing the length of hospital stays, decreasing the need for non oral feedings, reducing
nutritional problems, and decreasing expenses associated with pneumonia and other pulmonary
complications. (American Speech-Language-Hearing Association)
Recommend that the clinician use standardized, valid assessments to evaluate the patient’s
stroke-related impairments and functional status and encourage patient’s participation in
community and social activities. Recommend that the standardized assessment results be used to
assess probability of outcome, determine the appropriate level of care, and develop interventions.
(US Department of Veterans’ Affairs; endorsed by the American Heart Association)
Recommend that the dysphagic stroke patient receive both direct swallowing treatment and
management by the SLP, when available, when a treatable disorder in swallow anatomy or
physiology is identified. (US Department of Veterans’ Affairs; endorsed by the American Heart
Association)
The speech and language therapist will be involved in all cases where there are communication
problems following stroke. Such therapy should include augmentative communication systems in
cases where intelligible speech is not a reasonable goal. The role of the speech therapist includes
diagnosis and treatment of swallowing disorders. (Republic of South Africa Department of Health;
Stroke Foundation of South Africa)
Any person with an abnormal swallow should be seen by a speech and language therapist, who
should assess the person further and advise the person and staff on safe swallowing techniques
and strategies and the consistency of diet and fluids. (Stroke Foundation of New Zealand)
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Symbol and Copyright Information
The following notice applies to each of the measures that contain an asterisk (
) before the title:
Physician Performance Measures (Measures) and related data specifications, developed by the American Medical
Association (AMA) in collaboration with the Physician Consortium for Performance Improvement (the Consortium)
and the National Committee for Quality Assurance (NCQA) pursuant to government sponsorship under subcontract
6205-05-054 with Mathematica Policy Research, Inc. under contract 500-00-0033 with Centers for Medicare &
Medicaid Services.
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.
The Measures, 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 Measures for commercial gain, or incorporation of the Measures into a product or service
that is sold, licensed or distributed for commercial gain. Commercial uses of the Measures require a license agreement
between the user and the AMA, (on behalf of the Consortium) or NCQA. Neither the AMA, NCQA, Consortium nor its
members shall be responsible for any use of the Measures.
THE MEASURES AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY
KIND.
© 2004-6 American Medical Association and National Committee for Quality Assurance. All Rights Reserved.
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, NCQA, the Consortium and its
members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT®) or other coding
contained in the specifications.
CPT® contained in the Measures specifications is copyright 2005 American Medical Association G codes and
associated descriptions included in these Measure specifications are in the public domain.
The following notice applies to each of the measures that contain a triangle (
) before the title:
Physician Performance Measures (Measures) and related data specifications, developed by the Physician Consortium
for Performance Improvement® (the Consortium), are intended to facilitate quality improvement activities by
physicians.
These Measures are intended to assist physicians in enhancing quality of care. Measures are designed for use by any
physician who manages the care of a patient for a specific condition or for prevention. These performance Measures are
not clinical guidelines and do not establish a standard of medical care. The Consortium has not tested its Measures for
all potential applications. The Consortium encourages the testing and evaluation of its Measures.
Measures are subject to review and may be revised or rescinded at any time by the Consortium. The Measures may not
be altered without the prior written approval of the Consortium. Measures developed by the Consortium, 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
Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or
distributed for commercial gain. Commercial uses of the Measures require a license agreement between the user and
American Medical Association, on behalf of the Consortium. Neither the Consortium nor its members shall be
responsible for any use of these Measures.
THE MEASURES ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.
© 2007 American Medical Association. All Rights Reserved
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 Consortium and its
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members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT®) or other coding
contained in the specifications.
THE SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND.
CPT® contained in the Measures specifications is copyright 2006 American Medical Association.
The following notice applies to each of the measures that contain a clover (
) before the title:
These Physician Performance Measures (Measures) are not clinical guidelines and do not establish a standard of
medical care, and have not been tested for all potential applications.
The Measures, 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 Measures for commercial gain, or incorporation of the Measures into a product or service
that is sold, licensed or distributed for commercial gain. Commercial uses of the Measures require a license agreement
between the user and the American Medical Association (AMA), [on behalf of the Physician Consortium for
Performance Improvement® (Consortium)] or the American Society of Hematology (ASH). Neither the AMA, ASH,
Consortium nor its members shall be responsible for any use of the Measures.
THE MEASURES AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY
KIND.
© 2006-7 American Medical Association and American Society of Hematology. All Rights Reserved. Applicable
FARS/DFARS Restrictions Apply to Government Use.
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, ASH, the Consortium and its
members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT®) or other coding
contained in the specifications.
CPT® contained in the Measures specifications is copyright 2005 American Medical Association. LOINC® copyright
2004 Regenstrief Institute, Inc. SNOMED CLINICAL TERMS (SNOMED CT®) copyright 2004 College of American
Pathologists (CAP). All Rights Reserved. Use of SNOMED CT® is only authorized within the United States.
The following notice applies to each of the measures that contain a diamond (
) before the title:
NCQA Notice of Use. Broad public use and dissemination of these measures is encouraged and the measure developers
have agreed with NQF that noncommercial uses do not require the consent of the measure developer. Use by health
care providers in connection with their own practices is not commercial use. Commercial use of a measure does require
the prior written consent of the measure developer. As used herein, a "commercial use" refers to any sale, license, or
distribution of a measure for commercial gain, or incorporation of a measure into any product or service that is sold,
licensed, or distributed for commercial gain, (even if there is no actual charge for inclusion of the measure.)
These performance measures were developed and are owned by the National Committee for Quality Assurance
("NCQA"). These performance measures are not clinical guidelines and do not establish a standard of medical care.
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. NCQA holds
a copyright in this measure and can rescind or alter this measure at any time. Users of the measure shall not have the
right to alter, enhance, or otherwise modify the measure and shall not disassemble, recompile, or reverse engineer the
source code or object code relating to the measure. Anyone desiring to use or reproduce the measure without
modification for a noncommercial purpose may do so without obtaining any approval from NCQA. All commercial
uses must be approved by NCQA and are subject to a license at the discretion of NCQA. ©2004 National Committee
for Quality Assurance, all rights reserved.
Performance measures developed by NCQA for CMS may look different from the measures solely created and owned
by NCQA.
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The following notice applies to each of the measures that contain a heart (
) before the title:
Physician Performance Measures (Measures) and related data specifications, developed by the Physician Consortium
for Performance Improvement® (the Consortium), are intended to facilitate quality improvement activities by
physicians.
These Measures are intended to assist physicians in enhancing quality of care. Measures are designed for use by any
physician who manages the care of a patient for a specific condition or for prevention. These performance Measures are
not clinical guidelines and do not establish a standard of medical care. The Consortium has not tested its Measures for
all potential applications. The Consortium encourages the testing and evaluation of its Measures.
Measures are subject to review and may be revised or rescinded at any time by the Consortium. The Measures may not
be altered without the prior written approval of the Consortium. Measures developed by the Consortium, 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
Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or
distributed for commercial gain. Commercial uses of the Measures require a license agreement between the user and
American Medical Association, on behalf of the Consortium. Neither the Consortium nor its members shall be
responsible for any use of these Measures.
THE MEASURES ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.
© 2007 American Medical Association and American Society of Clinical Oncology. All Rights Reserved.
CPT® Copyright 2006 American Medical Association.
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 Consortium and its
members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT®) or other coding
contained in the specifications.
THE SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND.
CPT® contained in the Measures specifications is copyright 2006 American Medical Association.
The following notice applies to each of the measures that contain a Yen sign (
) before the title:
Physician Performance Measures (Measures) and related data specifications, developed by the Physician Consortium
for Performance Improvement® (the Consortium), are intended to facilitate quality improvement activities by
physicians.
These Measures are intended to assist physicians in enhancing quality of care. Measures are designed for use by any
physician who manages the care of a patient for a specific condition or for prevention. These performance Measures are
not clinical guidelines and do not establish a standard of medical care. The Consortium has not tested its Measures for
all potential applications. The Consortium encourages the testing and evaluation of its Measures.
Measures are subject to review and may be revised or rescinded at any time by the Consortium. The Measures may not
be altered without the prior written approval of the Consortium. Measures developed by the Consortium, 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
Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or
distributed for commercial gain. Commercial uses of the Measures require a license agreement between the user and
American Medical Association, on behalf of the Consortium. Neither the Consortium nor its members shall be
responsible for any use of these Measures.
THE MEASURES ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND
© 2007 American Medical Association, American Society of Clinical Oncology, and National Comprehensive Cancer
Network. All Rights Reserved.
CPT® Copyright 2006 American Medical Association
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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 Consortium and its
members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT®) or other coding
contained in the specifications.
THE SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND.
CPT® contained in the Measures specifications is copyright 2008 American Medical Association.
The following notice applies to each of the measures that contain a Euro (
) before the title:
Physician Performance Measures (Measures) and related data specifications, developed by the Physician Consortium
for Performance Improvement® (the Consortium), are intended to facilitate quality improvement activities by
physicians.
These Measures are intended to assist physicians in enhancing quality of care. Measures are designed for use by any
physician who manages the care of a patient for a specific condition or for prevention. These performance Measures are
not clinical guidelines and do not establish a standard of medical care. The Consortium has not tested its Measures for
all potential applications. The Consortium encourages the testing and evaluation of its Measures.
Measures are subject to review and may be revised or rescinded at any time by the Consortium. The Measures may not
be altered without the prior written approval of the Consortium. Measures developed by the Consortium, 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
Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or
distributed for commercial gain. Commercial uses of the Measures require a license agreement between the user and
American Medical Association, on behalf of the Consortium. Neither the Consortium nor its members shall be
responsible for any use of these Measures.
THE MEASURES ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.
© 2007 American Medical Association and College of American Pathologists. All Rights Reserved
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 Consortium and its
members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT®) or other coding
contained in the specifications.
THE SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND.
CPT® contained in the Measures specifications is copyright 2008 American Medical Association
The following notice applies to each of the measures that contain a musical note (
These measures are owned by the American Podiatric Medical Association (APMA).
The following notice applies to each of the measures that contain an Omega (
These measures are owned by The Society of Thoracic Surgeons (STS).
) before the title:
) before the title:
The following notice applies to each of the measures that contain a spade ( ) before the title:
These measures were developed by Quality Insights of Pennsylvania as a special project under the Quality Insights'
Medicare Quality Improvement Organization (QIO) contract HHSM-500-2005-PA001C with the Centers for Medicare
& Medicaid Services. These measures are in the public domain.
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The following notice applies to each of the measures that contain a cloverleaf (
) before the title:
Physician Performance Measures (Measures) and related data specifications developed by the American Medical
Association (AMA) in collaboration with the Physician Consortium for Performance Improvement® (PCPI) and the
National Committee for Quality Assurance (NCQA), pursuant to government sponsorship under Subcontract No. 641407-089 with Mathematica Policy Research under Contract HHSM-500-2005-000251(0004) with Centers for Medicare
and Medicaid Services. 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.
The Measures, 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 Measures for commercial gain, or incorporation of the Measures into a product or service
that is sold, licensed or distributed for commercial gain. Commercial uses of the Measures require a license agreement
between the user and the AMA, (on behalf of the PCPI) or NCQA. Neither the AMA, NCQA, PCPI nor its members
shall be responsible for any use of the Measures.
THE MEASURES AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY
KIND.
© 2008 American Medical Association and National Committee for Quality Assurance. All Rights Reserved.
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, NCQA, the PCPI and its
members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT®) or other coding
contained in the specifications.
CPT® contained in the Measures specifications is copyright 2007 American Medical Association. LOINC® copyright
2004 Regenstrief Institute, Inc. SNOMED CLINICAL TERMS (SNOMED CT®) copyright 2004 College of American
Pathologists (CAP). All Rights Reserved. Use of SNOMED CT® is only authorized within the United States.
The following notice applies to each of the measures that contain a square (
) before the title:
Physician Performance Measures (Measures) and related data specifications have been developed by the American
Medical Association (AMA) in collaboration with the Physician Consortium for Performance ImprovementTM (the
Consortium) and the National Committee for Quality Assurance (NCQA).
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.
The Measures, while copyrighted, can be reproduced and distributed, without modification, for noncommercial
purposed, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale,
license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service
that is sold, licensed or distributed for commercial gain. Commercial uses of the Measures require a license agreement
between the user and American Medical Association, (on behalf of the Consortium) or NCQA. Neither the AMA,
NCQA, Consortium nor its members shall be responsible for any use of the Measures.
THE MEASURES AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY
KIND.
© 2007 American Medical Association and National Committee for Quality Assurance. All Rights Reserved
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 Consortium and its
members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT®) or other coding
contained in the specifications.
THE SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND.
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The following notice applies to each of the measures that contain a Compass (
These measures are owned by the Society for Vascular Surgery - SVS.
) before the title:
The following notice applies to each of the measures that contain a Circle ( ) before the title:
These measures are owned by the American Heart Association/American Stroke Association/The Joint Commission on
Accreditation of Healthcare Organizations.
Copyright © by the American Heart Association/American Stroke Association. 7272 Greenville Avenue, Dallas, Texas
75231.
Copyright © 2001 by the Joint Commission on Accreditation of Healthcare Organizations, One Renaissance
Boulevard, Oakbrook Terrace, Illinois 60181.
The following notice applies to each of the measures that contain a Lightning Bolt (
These measures are owned by the Audiology Quality Consortium – AQC.
) before the title:
The following notice applies to each of the measures that contain a Key ( ) before the title:
These measures are owned by the American Speech Hearing Pathology Association - ASHA.
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| File Type | application/pdf |
| File Title | 2010 PQRI Measure Specifications Manual for Claims and Registry |
| Subject | 2010 Physician Quality Reporting Initiative |
| Author | CMS |
| File Modified | 2009-11-13 |
| File Created | 2009-11-13 |