Clinical Quality Measures (CQM) 2021

Clinical Quality Measures (CQM) 2021

Index

Sections
  1. MIPS, MEDICAID & MEANINGFUL USE
  2. HIGH PRIORITY MEASURES
  3. NON-HIGH PRIORITY MEASURES
  4. Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
  5. REPORTING
  6. How to Use the Report
  7. How Tracked in ICANotes
MIPS, MEDICAID & MEANINGFUL USE
  1. Merit-Based Incentive Payment System (MIPS) 
  2. Medicaid / Meaningful Use

HIGH PRIORITY MEASURES
  1. Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment
  2. Documentation of Current Medications in the Medical Record
  3. Use of High-Risk Medications in the Elderly
NON-HIGH PRIORITY MEASURES
  1. Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
  2.  Dementia: Cognitive Assessment
  3. Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
  4. Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up
  5. Preventive Care and Screening: Screening for Depression and Follow-Up Plan
  6.  Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
 
REPORTING
  1.  Reporting
  2. How to Use the Report
  3. Eligibility and Exception Information
 Step 1 of 14

Medicaid / Meaningful Use

How long to report: 2021, the entire 365 days

How many to report on: Six measures need to be reported on. No patient sample or thresholds required.


Step 2 of 14

Merit-Based Incentive Payment System (MIPS) 
How long to report: 2021, the entire 365 days

How many to report on: Medicare providers need to report on six measures but one of the six must be a high priority. Report on all relevant measures including one high priority measure. Also, some are higher scoring in points so best to report on all to see over time which gets the highest percentage - numerator/denominator. The minimum patient sample for MIPS is 20 for each measure.
 
For MIPS the quality category is the highest scoring MIPS category - 40% of your total score.
There are 9 quality measures to choose from.
  • Some are higher scoring in points so best to report on all to see over time which gets the highest  percentage - numerator/denominator.
  • You must have a minimum of 20 patients in the  denominator for any measure to get as many points as possible. Data completeness for a quality measure is that 70 % of possible data for a measure has been submitted.
  • If data completeness is not met on a measure, you will earn 1 point for the measure. Small practices (15 clinicians or less) will earn 3 points for the measure.
  • You can also earn up to 10 additional percentage points based on your improvement in the Quality performance category from the previous year.
  • For ICANotes to collect Quality Measure data, service codes must be included in each note. 
  • Check to make sure the clinician who is reporting on MIPS is the Principal clinician in a patient's chart face in Demographics to get credit for the Quality measure.  See below.

See below:
 

Step 3 of 14
Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment

CMS#: CMS177v9

Measure Description: Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk

High Priority 

Initial Patient Population: All patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder
Denominator Statement: Equals Initial Population
Denominator Exclusions: None
Numerator Statement: Patient visits with an assessment for suicide risk 
Numerator Exclusions: Not Applicable
Denominator Exceptions: None
Improvement Notation: Higher score indicates better quality 
Guidance: A suicide risk assessment should be performed at every visit for major depressive disorder during the measurement period.

Suicide risk assessments completed via telehealth services can also meet numerator performance.

This measure is an episode-of-care measure; the level of analysis for this measure is every visit for major depressive disorder during the measurement period. For example, at every visit for MDD, the patient should have a suicide risk assessment. 
 
How Tracked in ICANotes
Use at least one of these service codes to get credit:
90791, 90792, 90845, 90853, 90846, 90847, 90832, 90834, 90837, 98966, 98967, 98968, 
99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241, 99242, 99243,
99244, 99245,  99441, 99442, 99443
 
Encounter definition allows for Telehealth Services encounters to meet visit requirements. 
 This is measured by the Depression Shrub and Suicide / Violence Assessment button on notes.

CQM Profile
On the right from the Finished Note screen, click on the CQM Profile button to see the CQM Profile Entry.

 
 Step 4 of 14
Documentation of Current Medications in the Medical Record
CMS#: CMS68v10
Measure Description: Percentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency, and route of administration.

High Priority

Initial Patient Population: All visits occurring during the 12-month measurement period for patients aged 18 years and older
Denominator Statement: Equals Initial Population
Denominator Exclusions: None
Numerator Statement: Eligible professional or eligible clinician attests to documenting, updating or reviewing the patient's current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over- the-counters, herbals and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosages, frequency, and route of administration
Numerator Exclusions: Not Applicable
Denominator Exceptions: Medical Reason:
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
Improvement Notation: Higher score indicates better quality

How Tracked in ICANotes
Use at least one of these service codes to get credit:
59400, 59510, 59610, 59618, 90791, 90792, 90832, 90834, 90837, 90839, 92002, 92004,
92012, 92014, 92507, 92508, 92526, 92537, 92538, 92540, 92541, 92542, 92544, 92545,
92547, 92548, 92550, 92557, 92567, 92568, 92570, 92585, 92588, 92626, 96116, 96156,
96158, 97129, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97802, 97803,
97804, 98960, 98961, 98962, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99221, 99222, 99223, 99236, 99281, 99282, 99283, 99284, 99285, 99304, 99305,
99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327,
99328, 99334, 99335, 99336, 99337, 99339, 99340, 99341, 99342, 99343, 99344, 99345,
99347, 99348, 99349, 99350, 99385, 99386, 99387, 99395, 99396, 99397, 99495, 99496

Document medications that are taken by a patient (18 years old or older) or why the medications are not documented. 
 
 
 
 
On the CQM Additional Data Entry window, you are able to choose the prescription medication review was done or the reason why the medication review was not done.
 
 
Step 5 of 14
Use of High-Risk Medications in the Elderly
CMS#: CMS156v9 
 Measure Description: Percentage of patients 65 years of age and older who were ordered high-risk medications. Two rates are reported.
  1.  Percentage of patients who were ordered at least one high-risk
  2.  Percentage of patients who were ordered at least two of the same high-risk medications.
High Priority
  1. Initial Patient Population: Patients 65 years and older who had a visit during the measurement period
  2. Denominator Statement: Equals Initial Population
  3. Denominator Exclusions: Exclude patients who were in hospice care during the measurement year
  4. Numerator Statement:
    1. Numerator 1: Patients with an order for at least one high-risk medication during the measurement period
    2. Numerator 2: Patients with at least two orders for the same high-risk medication during the measurement period
  5. Numerator Exclusions: Not Applicable
  6. Denominator Exceptions: None
  7. Improvement Notation: Lower score indicates better quality
 Note: This is one measure where you are aiming for 0%.
 
How Tracked in ICANotes

Use at least one of these service codes to get credit:
G0438, G0439
92002, 92004, 92012, 92014, 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, 99385, 99386, 99387, 99395, 99396, 99397
 
This is measured by the patient's age and medications.

 
 
 
 
 
 
Step 6 of 14
Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
CMS#: CMS161v9
 
Measure Description: Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified
Initial Patient Population: All patients aged 18 years and older with a diagnosis of major depressive disorder (MDD)
Denominator Statement: Equals Initial Population
Denominator Exclusions: None
Numerator Statement: Patients with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified
Numerator Exclusions: Not Applicable
Denominator Exceptions: None
Improvement Notation: Higher score indicates better quality
 
How Tracked in ICANotes

Use at least one of these service codes to get credit:
90791, 90792, 90832, 90834, 90837, 90845, 99201, 99202, 99203, 99204, 99205, 99212,
99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, 99281, 99282, 99283, 99284,
99285
 
This is measured by the Depression Shrub, Suicide / Violence Assessment button, and Rating Scales/PHQ-9 on notes.


Step 7 of 14

Dementia: Cognitive Assessment
CMS#: CMS149v9

Measure Description: Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12 month period
Initial Patient Population: All patients, regardless of age, with a diagnosis of dementia
Denominator Statement: Equals Initial Population
Denominator Exclusions: None
Numerator Statement: Patients for whom an assessment of cognition is performed and the results reviewed at least once within a 12 month period
Numerator Exceptions: Not Applicable
Denominator Exceptions: Documentation of patient reason(s) for not assessing cognition
Improvement Notation: Higher score indicates better quality

Note: This measure requires two notes; one to perform the cognition assessment and another to review the results, each during a qualifying encounter.

 How Tracked in ICANotes

Use at least one of these service codes to get credit:
90791, 90792, 90832, 90834, 90837, 96116, 96118, 96119, 96120, 97165, 97166, 97167, 97168,  
99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244,
99245, 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 

This is measured from the Denies Neurocog. Dis See list button and Mini-Cog Assessment.
 
 

Step 8 of 14
 
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
CMS#: CMS22v9

Measure Description: Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated
Initial Patient Population: All patients aged 18 years and older before the start of the measurement period with at least one eligible encounter during the measurement period
Denominator Statement: Equals Initial Population
Denominator Exclusions: Patient has an active diagnosis of hypertension
Numerator Statement: Patients who were screened for high blood pressure AND have a recommended follow-up plan documented, as indicated if the blood pressure is pre- hypertensive or hypertensive
Numerator Exclusions: Not Applicable Denominator Exceptions:
Patient Reason(s):

Patient refuses to participate (either BP measurement or follow-up)

OR

Medical Reason(s):

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. This may include but is not limited to severely elevated BP when immediate medical treatment is indicated.
Improvement Notation: Higher score indicates better quality

How Tracked in ICANotes

Use at least one of the service codes to get credit:
90791, 90792, 92002, 92004, 92012, 92014, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 
99214, 99215, 99236, 99281, 99282, 99283, 99284, 99285, 99304, 99305, 99306, 99307, 99308, 
99309, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 
99337, 99339, 99340, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99385, 
99386, 99387, 99395, 99396, 99397

This is measured by Constitutional / Vital Signs area.

 

 

 

There are many choices in Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented. Click the More link to expand the choices.

 

 

Fill out the fields as needed.

 

 

 

Step 9 of 14

Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up
CMS#: CMS69v9

  1. Measure Description: Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter
  2. Normal Parameters: Age 18 years and older BMI => 18.5 and < 25 kg/m2
  3. Initial Patient Population: All patients aged 18 years and older before the start of the measurement period with at least one eligible encounter during the measurement period
  4. Denominator Statement: Equals Initial Population
  5. Denominator Exclusions:
    1. Patients who are pregnant
    2. Patients receiving palliative care
    3. Patients who refuse measurement of height and/or weight or refuse follow-up
  6. Numerator Statement: Patients with a documented BMI during the encounter or during the previous twelve months, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter
  7. Numerator Exclusions: Not Applicable
  8. Denominator Exceptions:
    1. Patients with a documented Medical Reason
    2. Patients in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient's health status
  9. Improvement Notation: Higher score indicates better quality

How Tracked in ICANotes

Use at least one of the service codes to get credit:
43644, 43645, 43659, 43770, 43771, 43772, 43773, 43774, 43842, 43843, 43845, 43846, 43847,
43848, 43886, 43888, 90791, 90792, 90832, 90834, 90837, 96156, 96158, 96159, 97161, 97162,
97163, 97165, 97166,97167, 97802, 97803, 97804, 98960, 99078,  99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99236, 99305, 99306, 99307, 99308, 99309, 99310, 99315,
99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99339, 99340,
99385, 99386, 99387,99395, 99396, 99397, 99401, 99402

This is measured by the Constitutional / Vital Signs area and Instructions and Recommendations shrub.


 

 

 

 


Step 10 of 14

Preventive Care and Screening: Screening for Depression and Follow-Up Plan
CMS#: CMS2v10

Measure Description: Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen
Initial Patient Population: All patients aged 12 years and older before the beginning of the measurement period with at least one eligible encounter during the measurement period
Denominator Statement: Equals Initial Population
Denominator Exclusions: Patients with an active diagnosis of depression or a diagnosis of bipolar disorder
Numerator Statement: Patients screened for depression on the date of the encounter using an age appropriate standardized tool AND if positive, a follow-up plan is documented on the date of the positive screen
Numerator Exclusions: Not Applicable
Denominator Exceptions: Patient Reason(s): Patient refuses to participate
OR

Medical Reason(s): Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient's health stat
 
OR

Situations where the patient's functional capacity or motivation to improve may impact the accuracy of results of standardized depression assessment tools. For example certain court- appointed cases or cases of delirium
Improvement Notation: Higher score indicates better quality

How Tracked in ICANotes

Use at least one of the service codes to get credit:
59400, 59510, 59610, 59618, 90791, 90792, 90832, 90834, 90837, 92625, 96116, 96118,
96156, 96158, 96159, 97165, 97166, 97167, 99201, 99202, 99203, 99204, 99205, 99212,
99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316,
99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99339, 99340,
99384, 99385, 99386, 99387, 99394, 99395, 99396, 99397, 99483, 99484, 99492, 99493

This is measured by the Depression shrub and Diagnosis popover window. From the Finished Note screen, click the CQM


 

 

 

 

 

Step 11 of 14

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
CMS#: CMS138v9

Measure Description: Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user

Three rates are reported:
  1. Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months
  2. Percentage of patients aged 18 years and older who were screened for tobacco use and identified as a tobacco user who received tobacco cessation intervention
  3. Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user
Initial Patient Population: All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period
Denominator Statement:
  1. Population 1: Equals Initial Population
  2. Population 2: Equals Initial Population who were screened for tobacco use and identified as a tobacco user
  3. Population 3: Equals Initial Population
Denominator Exclusions: None
Numerator Statement:
  1. Population 1: Patients who were screened for tobacco use at least once within 24 months
  2. Population 2: Patients who received tobacco cessation intervention
  3. Population 3: Patients who were screened for tobacco use at least once within 24 months AND who received tobacco cessation intervention if identified as a tobacco user
Numerator Exclusions: Not Applicable
Denominator Exceptions:
  1. Population 1: Documentation of medical reason(s) for not screening for tobacco use (eg, limited life expectancy, other medical reason)
  2. Population 2: Documentation of medical reason(s) for not providing tobacco cessation intervention (eg, limited life expectancy, other medical reason)
  3. Population 3: Documentation of medical reason(s) for not screening for tobacco use OR for not providing tobacco cessation intervention for patients identified as tobacco users (eg, limited life expectancy, other medical reason)
Improvement Notation: Higher score indicates better quality

How Tracked in ICANotes

Use at least one of the service codes to get credit:
S9341, 90791, 90792, 90832, 90834, 90837, 90845, 96150, 96151, 96152, 96156, 96158, 99201,
99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99342, 99343, 99344, 99345, 99347,
99348, 99349, 99350, 99385, 99386, 99387, 99395, 99396, 99397, 99401, 99402, 99403, 99404,
99406, 99407, 99411, 99412, 99429

This is measured by the Tobacco Use window.

Locations of the Tobacco Use window:

 

 

 

 

 

Step 12 of 14

Reporting
 
Group administrators can run reports.

 

 





Step 13 of 14

How to Use The Report

This step will show you how to use the information on the report. We will explore CMS 68 v7, Documentation of Current Medications in the Medical Record


 

 

 

 

 

 

Step 14 of 14

Eligibility And Exception Information

If you have any questions about CQM, please go to https://qpp.cms.gov/

To make sure you are eligible and to check your participation status, please go to https://qpp.cms.gov/participation-lookup


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