L1-103: Controlling High Blood Pressure - HHSC - DSRIP …



DSRIP Category CMeasure Specifications: DY7-8Part 3 of 4: Local Health Department SpecificationsContents TOC \o "1-3" \h \z \u L1-103: Controlling High Blood Pressure PAGEREF _Toc504413664 \h 3L1-105: Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention PAGEREF _Toc504413665 \h 8L1-107: Colorectal Cancer Screening PAGEREF _Toc504413666 \h 13L1-108: Childhood Immunization Status (CIS) PAGEREF _Toc504413667 \h 17L1-115: Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) PAGEREF _Toc504413668 \h 24L1-147: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up PAGEREF _Toc504413669 \h 28L1-160: Follow-Up After Hospitalization for Mental Illness PAGEREF _Toc504413670 \h 33L1-186: Breast Cancer Screening PAGEREF _Toc504413671 \h 36L1-205: Third next available appointment PAGEREF _Toc504413672 \h 40L1-207: Diabetes care: BP control (<140/90mm Hg) PAGEREF _Toc504413673 \h 43L1-210: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented PAGEREF _Toc504413674 \h 47L1-211: Weight Assessment and Counseling for Nutrition and Physical Activity for Children/ Adolescents PAGEREF _Toc504413675 \h 54L1-224: Dental Sealant: Children PAGEREF _Toc504413676 \h 58L1-225: Dental Caries: Children PAGEREF _Toc504413677 \h 60L1-227: Dental Caries: Adults PAGEREF _Toc504413678 \h 62L1-231: Preventive Services for Children at Elevated Caries Risk PAGEREF _Toc504413679 \h 64L1-235: Post-Partum Follow-Up and Care Coordination PAGEREF _Toc504413680 \h 67L1-237: Well-Child Visits in the First 15 Months of Life (6 or more visits) PAGEREF _Toc504413681 \h 69L1-241: Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons PAGEREF _Toc504413682 \h 71L1-242: Reduce Emergency Department visits for Chronic Ambulatory Care Sensitive Conditions (ACSC) PAGEREF _Toc504413683 \h 73L1-268: Pneumonia vaccination status for older adults PAGEREF _Toc504413684 \h 75L1-269: Preventive Care and Screening: Influenza Immunization PAGEREF _Toc504413685 \h 78L1-271: Immunization for Adolescents PAGEREF _Toc504413686 \h 84L1-272: Adults (18+ years) Immunization status PAGEREF _Toc504413687 \h 86L1-280: Chlamydia Screening in Women (CHL) PAGEREF _Toc504413688 \h 88L1-343: Syphilis positive screening rates PAGEREF _Toc504413689 \h 93L1-344: Follow-up after Treatment for Primary or Secondary Syphilis PAGEREF _Toc504413690 \h 95L1-345: Gonorrhea Positive Screening Rates PAGEREF _Toc504413691 \h 98L1-346: Follow-up testing for N. gonorrhoeae among recently infected men and women PAGEREF _Toc504413692 \h 100L1-347: Latent Tuberculosis Infection (LTBI) treatment rate PAGEREF _Toc504413693 \h 102L1-387: Reduce Emergency Department visits for Behavioral Health and Substance Abuse (Reported as two rates) PAGEREF _Toc504413694 \h 105L1-400: Tobacco Use and Help with Quitting Among Adolescents PAGEREF _Toc504413695 \h 107L1-103: Controlling High Blood PressureMeasure Description:The percentage of patients 18 to 85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90) during the measurement year.L1-103: Controlling High Blood PressureDY7/DY8 Program IDL1-103Measure DetailsSteward: NCQANQF #: 0018Source: CMS MIPS #236 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusOptionalMeasure ClassificationType: Clinical OutcomeMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: QISMCHPL: 0.7041MPL: 0.4687National Quality Compass 2016 - All LOBs: Average (90th and 25th percentiles)Directionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsMeasure is NOT eligible for a shortened baseline measurement period.Measure is not eligible for a baseline of 0.Denominator DescriptionPatients 18-85 years of age who had a diagnosis of essential hypertension within the first six months of the measurement period or any time prior to the measurement periodDenominator InclusionsCLAIMS/REGISTRY:Patients18 to 85 years of age on date of encounterANDDiagnosis for hypertension (ICD-10-CM): I10ANDPatient encounter during performance period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205,99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0402, G0438, G0439 E.H.R.: AND: Age>= 18 year(s) at: "Measurement Period" AND: Age< 85 year(s) at: "Measurement Period" AND: "Occurrence A of Diagnosis: Essential Hypertension" satisfies any: < 6 month(s) starts after or concurrent with start of "Measurement Period" satisfies all: starts before start of "Measurement Period" overlaps "Measurement Period" AND: Union of: "Encounter, Performed: Office Visit" "Encounter, Performed: Face-to-Face Interaction" "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" "Encounter, Performed: Home Healthcare Services" "Encounter, Performed: Annual Wellness Visit" during "Measurement Period"For both the Claims and E.H.R. specifications, providers should limit office visit/E&M CPT codes 99201 - 99205 and 99211 - 99219 to primary care, outpatient specialty care where primary care is managed, and speciaty care related to diabetes management. Encounters may be limited by clinic, place of service, or physician but not by visit specific services.Denominator ExclusionsCLAIMS/REGISTRY:Hospice services given to patient any time during the measurement period: G9740ORDocumentation of end stage renal disease (ESRD), dialysis, renal transplant before or during the measurement period or pregnancy during the measurement period: G9231 E.H.R.: OR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Home for Hospice Care)" ends during "Measurement Period" OR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Health Care Facility for Hospice Care)" ends during "Measurement Period" OR: Union of: "Intervention, Order: Hospice care ambulatory" "Intervention, Performed: Hospice care ambulatory" overlaps "Measurement Period" OR: Union of: "Diagnosis: Pregnancy" "Diagnosis: End Stage Renal Disease" "Diagnosis: Chronic Kidney Disease, Stage 5" overlaps "Measurement Period" OR: Union of: "Procedure, Performed: Vascular Access for Dialysis" "Encounter, Performed: ESRD Monthly Outpatient Services" "Procedure, Performed: Kidney Transplant" "Procedure, Performed: Dialysis Services" starts before end of "Measurement Period"Numerator DescriptionPatients whose blood pressure at the most recent visit is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement period Numerator Instructions: To describe both systolic and diastolic blood pressure values, each must be reported separately. If there are multiple blood pressures on the same date of service, use the lowest systolic and lowest diastolic blood pressure on that date as the representative blood pressure. NUMERATOR NOTE: In reference to the numerator element, only blood pressure readings performed by an eligible clinician in the provider office are acceptable for numerator compliance with this measure. Blood pressure readings from the patient's home (including readings directly from monitoring devices) are not acceptable.If no blood pressure is recorded during the measurement period, the patient's blood pressure is assumed "not controlled."If there are multiple blood pressure readings on the same day, use the lowest systolic and the lowest diastolic reading as the most recent blood pressure reading.Numerator Inclusions (Performance Met)CLAIMS/REGISTRY:Most recent systolic blood pressure < 140 mmHg (G8752)ANDMost recent diastolic blood pressure < 90 mmHg (G8754) E.H.R.: AND: Most Recent: "Occurrence A of Encounter, Performed: Adult Outpatient Visit" satisfies all: during "Measurement Period" overlaps "Physical Exam, Performed: Diastolic Blood Pressure (result)" overlaps "Physical Exam, Performed: Systolic Blood Pressure (result)" overlaps "Occurrence A of Diagnosis: Essential Hypertension" AND: "Occurrence A of Diagnosis: Essential Hypertension" satisfies all: starts before start of "Occurrence A of Encounter, Performed: Adult Outpatient Visit" overlaps "Occurrence A of Encounter, Performed: Adult Outpatient Visit" AND: "Physical Exam, Performed: Diastolic Blood Pressure" satisfies all: Most Recent: during "Occurrence A of Encounter, Performed: Adult Outpatient Visit" (result < 90 mmHg) AND: "Physical Exam, Performed: Systolic Blood Pressure" satisfies all: Most Recent: during "Occurrence A of Encounter, Performed: Adult Outpatient Visit" (result < 140 mmHg)Numerator Exclusions (Performance Not Met)CLAIMS/REGISTRY:Most recent systolic blood pressure ≥ 140 mmHg (G8753)ORMost recent diastolic blood pressure ≥ 90 mmHg (G8755)ORNo documentation of blood pressure measurement, reason not given (G8756) E.H.R.:NoneDSRIP Specific ModificationsNoneAdditional InformationData Criteria (QDM Data Elements):? "Diagnosis: Chronic Kidney Disease, Stage 5" using "Chronic Kidney Disease, Stage 5 Grouping Value Set (2.16.840.1.113883.3.526.3.1002)"? "Diagnosis: End Stage Renal Disease" using "End Stage Renal Disease Grouping Value Set (2.16.840.1.113883.3.526.3.353)"? "Diagnosis: Essential Hypertension" using "Essential Hypertension Grouping Value Set (2.16.840.1.113883.3.464.1003.104.12.1011)"? "Diagnosis: Pregnancy" using "Pregnancy Grouping Value Set (2.16.840.1.113883.3.526.3.378)"? "Encounter, Performed: Adult Outpatient Visit" using "Adult Outpatient Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1065)"? "Encounter, Performed: Annual Wellness Visit" using "Annual Wellness Visit Grouping Value Set (2.16.840.1.113883.3.526.3.1240)"? "Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient SNOMEDCT Value Set (2.16.840.1.113883.3.666.5.307)"? "Encounter, Performed: ESRD Monthly Outpatient Services" using "ESRD Monthly Outpatient Services Grouping Value Set (2.16.840.1.113883.3.464.1003.109.12.1014)"? "Encounter, Performed: Face-to-Face Interaction" using "Face-to-Face Interaction Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1048)"? "Encounter, Performed: Home Healthcare Services" using "Home Healthcare Services Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1016)"? "Encounter, Performed: Office Visit" using "Office Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1001)"? "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" using "Preventive Care Services - Established Office Visit, 18 and Up Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1025)"? "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" using "Preventive Care Services-Initial Office Visit, 18 and Up Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1023)"? "Intervention, Order: Hospice care ambulatory" using "Hospice care ambulatory SNOMEDCT Value Set (2.16.840.1.113762.1.4.1108.15)"? "Intervention, Performed: Hospice care ambulatory" using "Hospice care ambulatory SNOMEDCT Value Set (2.16.840.1.113762.1.4.1108.15)"? "Physical Exam, Performed: Diastolic Blood Pressure" using "Diastolic Blood Pressure Grouping Value Set (2.16.840.1.113883.3.526.3.1033)"? "Physical Exam, Performed: Systolic Blood Pressure" using "Systolic Blood Pressure Grouping Value Set (2.16.840.1.113883.3.526.3.1032)"? "Procedure, Performed: Dialysis Services" using "Dialysis Services Grouping Value Set (2.16.840.1.113883.3.464.1003.109.12.1013)"? "Procedure, Performed: Kidney Transplant" using "Kidney Transplant Grouping Value Set (2.16.840.1.113883.3.464.1003.109.12.1012)"? "Procedure, Performed: Vascular Access for Dialysis" using "Vascular Access for Dialysis Grouping Value Set (2.16.840.1.113883.3.464.1003.109.12.1011)"? Attribute: "Discharge status: Discharged to Health Care Facility for Hospice Care" using "Discharged to Health Care Facility for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.207)"? Attribute: "Discharge status: Discharged to Home for Hospice Care" using "Discharged to Home for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.209)"L1-105: Preventive Care & Screening: Tobacco Use: Screening & Cessation InterventionMeasure Description:Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco userL1-105: Preventive Care & Screening: Tobacco Use: Screening & Cessation InterventionDY7/DY8 Program IDL1-105Measure DetailsSteward: NCQANQF #: 0028Source: CMS MIPS #226 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionAll patients aged 18 years and older DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the PFS (Physician Fee Schedule). These non-covered services will not be counted in the denominator population for claims-based measures.Denominator InclusionsCLAIMS/REGISTRY:Patients aged ≥ 18 years on date of encounter AND Patient encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90845, 92002, 92004, 92012, 92014, 92521, 92522, 92523, 92524, 92540, 92557, 92625, 96150, 96151, 96152, 96160, 96161 97165, 97166, 97167, 97168, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99406, 99407, 99411*, 99412*, 99429*, G0438, G0439 WITHOUT Telehealth Modifier: GQ, GT E.H.R.:Initial Population = AND: Age>= 18 year(s) at: "Measurement Period" AND: OR: Count>= 2 : Union of: "Encounter, Performed: Face-to-Face Interaction" "Encounter, Performed: Health & Behavioral Assessment - Individual" "Encounter, Performed: Health and Behavioral Assessment - Initial" "Encounter, Performed: Health and Behavioral Assessment, Reassessment" "Encounter, Performed: Home Healthcare Services" "Encounter, Performed: Occupational Therapy Evaluation" "Encounter, Performed: Office Visit" "Encounter, Performed: Ophthalmological Services" "Encounter, Performed: Psych Visit - Diagnostic Evaluation" "Encounter, Performed: Psych Visit - Psychotherapy" "Encounter, Performed: Psychoanalysis" "Encounter, Performed: Speech and Hearing Evaluation" during "Measurement Period" OR: Count>= 1 : Union of: "Encounter, Performed: Annual Wellness Visit" "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" "Encounter, Performed: Preventive Care Services - Group Counseling" "Encounter, Performed: Preventive Care Services - Other" "Encounter, Performed: Preventive Care Services-Individual Counseling" "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" during "Measurement Period" Population Criteria 1:Denominator = AND: Initial Population Population Criteria 2: Denominator = AND: Initial Population AND: $TobaccoUseScreeningUser Population Criteria 3:Denominator = AND: Initial PopulationDenominator ExclusionsCLAIMS/REGISTRY:Documentation of medical reason(s) for notscreening for tobacco use (eg, limited life expectancy, other medical reason) (4004F with 1P) E.H.R.:NoneNumerator DescriptionPatients who were screened for tobacco use at least once within 24 months AND who received tobacco cessation intervention if identified as a tobacco user Definitions: Tobacco Use – Includes any type of tobacco Tobacco Cessation Intervention – Includes brief counseling (3 minutes or less), and/or pharmacotherapy NUMERATOR NOTE: In the event that a patient is screened for tobacco use and identified as a user but did not receive tobacco cessation intervention or tobacco status is unknown report 4004F with8P.This measure defines tobacco cessation counseling as lasting 3 minutes or less. Services typically provided under CPT codes 99406 and 99407 satisfy the requirement of tobacco cessation intervention, as these services provide tobacco cessation counseling for 3-10 minutes. If a patient received these types of services, report CPT II 4004F.Numerator Inclusions (Performance Met)CLAIMS/REGISTRY:Patient screened for tobacco use AND received tobacco cessation intervention (counseling, pharmacotherapy, or both), if identified as a tobacco user (4004F)ORCurrent tobacco non-user (1036F) E.H.R.:Population Criteria 1: AND: OR: $TobaccoUseScreeningNonUser OR: $TobaccoUseScreeningUser Population Criteria 2: AND: Occurrence A of $TobaccoCessationIntervention starts after or concurrent with start of $TobaccoUseScreeningUser AND: Occurrence A of $TobaccoCessationIntervention starts before end of "Measurement Period" Population Criteria 3: AND: OR: $TobaccoUseScreeningNonUser OR: AND: Occurrence A of $TobaccoCessationIntervention starts after or concurrent with start of $TobaccoUseScreeningUser AND: Occurrence A of $TobaccoCessationIntervention starts before end of "Measurement Period"Numerator Exclusions (Performance Not Met)CLAIMS/REGISTRY:Tobacco screening OR tobacco cessation intervention not performed, reason not otherwise specified (4004F with 8P) E.H.R.:Denominator Exceptions = OR: AND: "Occurrence A of Diagnosis: Limited Life Expectancy" starts before end of "Measurement Period" AND NOT: "Occurrence A of Diagnosis: Limited Life Expectancy" ends before end of "Measurement Period" OR: "Assessment, Performed not done: Medical Reason" for "Tobacco Use Screening" <= 24 month(s) starts before end of "Measurement Period"DSRIP Specific ModificationsNOTE: For DSRIP Reporting Purposes, only one rate is reported. If using the E.H.R. version of the specifications, the denominator is all individiuals that meet the initial population (Criteria 1) and the numerator is all individuals from the denominator that meet all applicable criteria (for example, meet numerator criteria 1 if included only in denominator criteria 1, or meet numerator criteria 1, 2, and 3, if included in denominator criteria 1, 2, and 3). Additional InformationData Criteria (QDM Variables):? $TobaccoCessationIntervention = o Union of: "Intervention, Performed: Tobacco Use Cessation Counseling" "Medication, Active: Tobacco Use Cessation Pharmacotherapy" "Medication, Order: Tobacco Use Cessation Pharmacotherapy"? $TobaccoUseScreeningNonUser = o "Assessment, Performed: Tobacco Use Screening" satisfies all: Most Recent: <= 24 month(s) starts before end of "Measurement Period" (result: Tobacco Non-User)? $CounselingNotPerformed = o "Intervention, Performed not done: Medical Reason" for "Tobacco Use Cessation Counseling" starts before end of "Measurement Period"? $TobaccoUseScreeningUser = o "Assessment, Performed: Tobacco Use Screening" satisfies all: Most Recent: <= 24 month(s) starts before end of "Measurement Period" (result: Tobacco User)? $MedicationNotOrdered = o "Medication, Order not done: Medical Reason" for "Tobacco Use Cessation Pharmacotherapy" starts before end of "Measurement Period" Data Criteria (QDM Data Elements):? "Assessment, Performed: Tobacco Use Screening" using "Tobacco Use Screening Grouping Value Set (2.16.840.1.113883.3.526.3.1278)"? "Assessment, Performed not done: Medical Reason" using "Medical Reason Grouping Value Set (2.16.840.1.113883.3.526.3.1007)"? "Diagnosis: Limited Life Expectancy" using "Limited Life Expectancy Grouping Value Set (2.16.840.1.113883.3.526.3.1259)"? "Encounter, Performed: Annual Wellness Visit" using "Annual Wellness Visit Grouping Value Set (2.16.840.1.113883.3.526.3.1240)"? "Encounter, Performed: Face-to-Face Interaction" using "Face-to-Face Interaction Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1048)"? "Encounter, Performed: Health & Behavioral Assessment - Individual" using "Health & Behavioral Assessment - Individual Grouping Value Set (2.16.840.1.113883.3.526.3.1020)"? "Encounter, Performed: Health and Behavioral Assessment - Initial" using "Health and Behavioral Assessment - Initial Grouping Value Set (2.16.840.1.113883.3.526.3.1245)"? "Encounter, Performed: Health and Behavioral Assessment, Reassessment" using "Health and Behavioral Assessment, Reassessment Grouping Value Set (2.16.840.1.113883.3.526.3.1529)"? "Encounter, Performed: Home Healthcare Services" using "Home Healthcare Services Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1016)"? "Encounter, Performed: Occupational Therapy Evaluation" using "Occupational Therapy Evaluation Grouping Value Set (2.16.840.1.113883.3.526.3.1011)"? "Encounter, Performed: Office Visit" using "Office Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1001)"? "Encounter, Performed: Ophthalmological Services" using "Ophthalmological Services Grouping Value Set (2.16.840.1.113883.3.526.3.1285)"? "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" using "Preventive Care Services - Established Office Visit, 18 and Up Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1025)"? "Encounter, Performed: Preventive Care Services - Group Counseling" using "Preventive Care Services - Group Counseling Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1027)"? "Encounter, Performed: Preventive Care Services - Other" using "Preventive Care Services - Other Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1030)"? "Encounter, Performed: Preventive Care Services-Individual Counseling" using "Preventive Care Services-Individual Counseling Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1026)"? "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" using "Preventive Care Services-Initial Office Visit, 18 and Up Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1023)"? "Encounter, Performed: Psych Visit - Diagnostic Evaluation" using "Psych Visit - Diagnostic Evaluation Grouping Value Set (2.16.840.1.113883.3.526.3.1492)"? "Encounter, Performed: Psych Visit - Psychotherapy" using "Psych Visit - Psychotherapy Grouping Value Set (2.16.840.1.113883.3.526.3.1496)"? "Encounter, Performed: Psychoanalysis" using "Psychoanalysis Grouping Value Set (2.16.840.1.113883.3.526.3.1141)"? "Encounter, Performed: Speech and Hearing Evaluation" using "Speech and Hearing Evaluation Grouping Value Set (2.16.840.1.113883.3.526.3.1530)"? "Intervention, Performed: Tobacco Use Cessation Counseling" using "Tobacco Use Cessation Counseling Grouping Value Set (2.16.840.1.113883.3.526.3.509)"? "Intervention, Performed not done: Medical Reason" using "Medical Reason Grouping Value Set (2.16.840.1.113883.3.526.3.1007)"? "Medication, Active: Tobacco Use Cessation Pharmacotherapy" using "Tobacco Use Cessation Pharmacotherapy Grouping Value Set (2.16.840.1.113883.3.526.3.1190)"? "Medication, Order: Tobacco Use Cessation Pharmacotherapy" using "Tobacco Use Cessation Pharmacotherapy Grouping Value Set (2.16.840.1.113883.3.526.3.1190)"? "Medication, Order not done: Medical Reason" using "Medical Reason Grouping Value Set (2.16.840.1.113883.3.526.3.1007)"? Attribute: "Result: Tobacco Non-User" using "Tobacco Non-User Grouping Value Set (2.16.840.1.113883.3.526.3.1189)"? Attribute: "Result: Tobacco User" using "Tobacco User Grouping Value Set (2.16.840.1.113883.3.526.3.1170)"L1-107: Colorectal Cancer ScreeningMeasure Description:The percentage of patients 50–75 years of age who had appropriate screening for colorectal cancer.L1-107: Colorectal Cancer ScreeningDY7/DY8 Program IDL1-107Measure DetailsSteward: NCQANQF #: 0034Source: CMS MIPS #113 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusOptionalMeasure ClassificationType: Cancer ScreeningMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionPatients 50-75 years of age with a visit during the measurement periodDenominator InclusionsCLAIMS/REGISTRY: Patients 50 to 75 years of age on date of encounterANDPatient encounter during the performance period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0402, G0438, G0439, 99386, 99387, 99396, 99397 E.H.R.: AND: Age>= 50 year(s) at: "Measurement Period" AND: Age< 75 year(s) at: "Measurement Period" AND: Union of: "Encounter, Performed: Office Visit" "Encounter, Performed: Face-to-Face Interaction" "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" "Encounter, Performed: Home Healthcare Services" "Encounter, Performed: Annual Wellness Visit" during "Measurement Period"Denominator ExclusionsCLAIMS/REGISTRY: G9710: Patient was provided hospice services any time during the measurement periodORG9711: Patients with a diagnosis or past history of total colectomy or colorectal cancer E.H.R.: OR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Home for Hospice Care)" ends during "Measurement Period" OR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Health Care Facility for Hospice Care)" ends during "Measurement Period" OR: Union of: "Intervention, Order: Hospice care ambulatory" "Intervention, Performed: Hospice care ambulatory" overlaps "Measurement Period" OR: Union of: "Diagnosis: Malignant Neoplasm of Colon" "Procedure, Performed: Total Colectomy" starts before end of "Measurement Period"Numerator DescriptionPatients with one or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria:? Fecal occult blood test (FOBT) during the measurement period? Flexible sigmoidoscopy during the measurement period or the four years prior to the measurement period? Colonoscopy during the measurement period or the nine years prior to the measurement period? Computed tomography (CT) colonography during the measurement period or the four years prior to the measurement period? Fecal immunochemical DNA test (FIT-DNA) during the measurement period or the two years prior to the measurement periodNumerator Inclusions (Performance Met)CLAIMS/REGISTRY: CPT II 3017F: Colorectal cancer screening results documented and reviewed E.H.R.: AND: Union of: "Procedure, Performed: Colonoscopy" <= 9 year(s) ends before or concurrent with end of "Measurement Period" "Laboratory Test, Performed: Fecal Occult Blood Test (FOBT) (result)" during "Measurement Period" "Procedure, Performed: Flexible Sigmoidoscopy" <= 4 year(s) ends before or concurrent with end of "Measurement Period" "Laboratory Test, Performed: FIT DNA (result)" <= 2 year(s) ends before or concurrent with end of "Measurement Period" "Procedure, Performed: CT Colonography" <= 4 year(s) ends before or concurrent with end of "Measurement Period"Numerator Exclusions (Performance Not Met)CLAIMS/REGISTRY: 3017F with 8P: Colorectal cancer screening results were not documented and reviewed, reason not otherwise specified (Append a reporting modifier (8P) to CPT Category II code 3017F to report circumstances when the action described in the numerator is not performed and the reason is not otherwise specified) E.H.R.:NoneDSRIP Specific ModificationsFor DSRIP reporting purpose, HHSC has added CPT values 99386 (Prev visit new age 40 - 64), 99387 (Prev visit new age 65+), 99396 (Prev visit est age 40 - 64), and 99397 (Prev visit est age 65+) to the denominator inclusions for the Claims version of the specifications.Additional InformationData Criteria (QDM Data Elements):? "Diagnosis: Malignant Neoplasm of Colon" using "Malignant Neoplasm of Colon Grouping Value Set (2.16.840.1.113883.3.464.1003.108.12.1001)"? "Encounter, Performed: Annual Wellness Visit" using "Annual Wellness Visit Grouping Value Set (2.16.840.1.113883.3.526.3.1240)"? "Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient SNOMEDCT Value Set (2.16.840.1.113883.3.666.5.307)"? "Encounter, Performed: Face-to-Face Interaction" using "Face-to-Face Interaction Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1048)"? "Encounter, Performed: Home Healthcare Services" using "Home Healthcare Services Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1016)"? "Encounter, Performed: Office Visit" using "Office Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1001)"? "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" using "Preventive Care Services - Established Office Visit, 18 and Up Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1025)"? "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" using "Preventive Care Services-Initial Office Visit, 18 and Up Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1023)"? "Intervention, Order: Hospice care ambulatory" using "Hospice care ambulatory SNOMEDCT Value Set (2.16.840.1.113762.1.4.1108.15)"? "Intervention, Performed: Hospice care ambulatory" using "Hospice care ambulatory SNOMEDCT Value Set (2.16.840.1.113762.1.4.1108.15)"? "Laboratory Test, Performed: Fecal Occult Blood Test (FOBT)" using "Fecal Occult Blood Test (FOBT) Grouping Value Set (2.16.840.1.113883.3.464.1003.198.12.1011)"? "Laboratory Test, Performed: FIT DNA" using "FIT DNA Grouping Value Set (2.16.840.1.113883.3.464.1003.108.12.1039)"? "Procedure, Performed: Colonoscopy" using "Colonoscopy Grouping Value Set (2.16.840.1.113883.3.464.1003.108.12.1020)"? "Procedure, Performed: CT Colonography" using "CT Colonography Grouping Value Set (2.16.840.1.113883.3.464.1003.108.12.1038)"? "Procedure, Performed: Flexible Sigmoidoscopy" using "Flexible Sigmoidoscopy Grouping Value Set (2.16.840.1.113883.3.464.1003.198.12.1010)"? "Procedure, Performed: Total Colectomy" using "Total Colectomy Grouping Value Set (2.16.840.1.113883.3.464.1003.198.12.1019)"? Attribute: "Discharge status: Discharged to Health Care Facility for Hospice Care" using "Discharged to Health Care Facility for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.207)"? Attribute: "Discharge status: Discharged to Home for Hospice Care" using "Discharged to Home for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.209)"L1-108: Childhood Immunization Status (CIS)Measure Description:Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DtaP); three polio (IPV); one measles, mumps and rubella (MMR); three haemophilus influenza type B (HiB); three hepatitis B (HepB); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (HepA); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday.L1-108: Childhood Immunization Status (CIS)DY7/DY8 Program IDL1-108Measure DetailsSteward: NCQANQF #: 0038Source: eMeasure: SourceE.H.R.Required StatusOptionalMeasure ClassificationType: ImmunizationMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: QISMCHPL: 0.4647MPL: 0.2599National Quality Compass 2016 - All LOBs: Average (90th and 25th percentiles)Directionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is eligible for a baseline numerator of 0 per PFM Section VI.22.b.i (page 24). If approved for a baseline of zero, the DY7 goal will be 40.91% and DY8 goal of 41.47%.Denominator DescriptionChildren who turn 2 years of age during the measurement period and who have a visit during the measurement period. Exclusions: Exclude patients who were in hospice care during the measurement yearDenominator InclusionsAND: "Birthdate : Patient Characteristic Birthdate" >= 1 year(s) starts before start of "Measurement Period" AND: "Birthdate : Patient Characteristic Birthdate" = 2 year(s) starts before end of "Measurement Period" AND: Union of: "Encounter, Performed: Office Visit" "Encounter, Performed: Face-to-Face Interaction" "Encounter, Performed: Home Healthcare Services" "Encounter, Performed: Preventive Care - Established Office Visit, 0 to 17" "Encounter, Performed: Preventive Care- Initial Office Visit, 0 to 17" during "Measurement Period"Denominator ExclusionsOR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Home for Hospice Care)" ends during "Measurement Period" OR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Health Care Facility for Hospice Care)" ends during "Measurement Period" OR: Union of: "Intervention, Order: Hospice care ambulatory" "Intervention, Performed: Hospice care ambulatory" overlaps "Measurement Period"Numerator DescriptionChildren who have evidence showing they received recommended vaccines, had documented history of the illness, had a seropositive test result, or had an allergic reaction to the vaccine by their second birthday.Numerator Inclusions (Performance Met)AND: Union of: $DTaPVaccine >= 1 day(s) starts after end of ($DTaPVaccine >= 1 day(s) starts after end of ($DTaPVaccine >= 1 day(s) starts after end of $DTaPVaccine ) ) Union of: "Diagnosis: Anaphylactic Reaction to DTaP Vaccine" "Diagnosis: Encephalopathy due to Childhood Vaccination" <= 730 day(s) starts after start of "Birthdate : Patient Characteristic Birthdate" AND: Union of: $IPVVaccine >= 1 day(s) starts after end of ($IPVVaccine >= 1 day(s) starts after end of $IPVVaccine ) Union of: "Diagnosis: Anaphylactic Reaction to Inactivated Polio Vaccine (IPV)" "Diagnosis: Anaphylactic Reaction to Streptomycin" "Diagnosis: Anaphylactic Reaction to Polymyxin" "Diagnosis: Anaphylactic Reaction to Neomycin" <= 730 day(s) starts after start of "Birthdate : Patient Characteristic Birthdate" AND: OR: Union of: "Immunization, Administered: Measles, Mumps and Rubella (MMR) Vaccine" "Procedure, Performed: Measles, Mumps and Rubella (MMR) Vaccine Administered" <= 730 day(s) ends after start of "Birthdate : Patient Characteristic Birthdate" OR: Union of: "Diagnosis: Disorders of the Immune System" "Diagnosis: HIV" "Diagnosis: Malignant Neoplasm of Lymphatic and Hematopoietic Tissue" "Diagnosis: Anaphylactic Reaction to Neomycin" <= 730 day(s) starts after or concurrent with start of "Birthdate : Patient Characteristic Birthdate" OR: AND: Union of: "Diagnosis: Measles" "Laboratory Test, Performed: Measles Antibody Test (IgG Antibody Titer) (result >= 1.10 )" "Laboratory Test, Performed: Measles Antibody Test (IgG Antibody presence) (result: Positive Finding)" <= 730 day(s) starts after start of "Birthdate : Patient Characteristic Birthdate" AND: Union of: "Diagnosis: Mumps" "Laboratory Test, Performed: Mumps Antibody Test (IgG Antibody Titer) (result >= 1.10 )" "Laboratory Test, Performed: Mumps Antibody Test (IgG Antibody presence) (result: Positive Finding)" <= 730 day(s) starts after start of "Birthdate : Patient Characteristic Birthdate" AND: Union of: "Diagnosis: Rubella" "Laboratory Test, Performed: Rubella Antibody Test (IgG Antibody Titer) (result >= 1.10 )" "Laboratory Test, Performed: Rubella Antibody Test (IgG Antibody presence) (result: Positive Finding)" <= 730 day(s) starts after start of "Birthdate : Patient Characteristic Birthdate" AND: Union of: $HIBVaccine >= 1 day(s) starts after end of ($HIBVaccine >= 1 day(s) starts after end of $HIBVaccine ) "Diagnosis: Anaphylactic Reaction to Hemophilus Influenza B (HiB) Vaccine" <= 730 day(s) starts after start of "Birthdate : Patient Characteristic Birthdate" AND: OR: $HepatitisBVaccine >= 1 day(s) starts after end of ($HepatitisBVaccine >= 1 day(s) starts after end of $HepatitisBVaccine ) OR: "Laboratory Test, Performed: Anti Hepatitis B Virus Surface Ab (result: Positive Finding)" <= 730 day(s) starts after or concurrent with start of "Birthdate : Patient Characteristic Birthdate" OR: Union of: "Diagnosis: Anaphylactic Reaction to Hepatitis B Vaccine" "Diagnosis: Anaphylactic Reaction to Common Baker's Yeast" "Diagnosis: Hepatitis B" <= 730 day(s) starts after or concurrent with start of "Birthdate : Patient Characteristic Birthdate" AND: Union of: Union of: "Immunization, Administered: Varicella Zoster Vaccine (VZV)" "Procedure, Performed: Varicella Zoster Vaccine (VZV) Administered" <= 730 day(s) ends after start of "Birthdate : Patient Characteristic Birthdate" Union of: "Diagnosis: Disorders of the Immune System" "Diagnosis: HIV" "Diagnosis: Malignant Neoplasm of Lymphatic and Hematopoietic Tissue" "Diagnosis: Anaphylactic Reaction to Neomycin" "Diagnosis: Varicella Zoster" "Laboratory Test, Performed: Varicella Zoster Antibody Test (IgG Antibody Titer) (result >= 1.10 )" "Laboratory Test, Performed: Varicella Zoster Antibody Test (IgG Antibody Presence) (result: Positive Finding)" <= 730 day(s) starts after or concurrent with start of "Birthdate : Patient Characteristic Birthdate" AND: Union of: $PneumococcalConjugateVaccine >= 1 day(s) starts after end of ($PneumococcalConjugateVaccine >= 1 day(s) starts after end of ($PneumococcalConjugateVaccine >= 1 day(s) starts after end of $PneumococcalConjugateVaccine ) ) "Diagnosis: Anaphylactic Reaction to Pneumococcal Conjugate Vaccine" <= 730 day(s) starts after start of "Birthdate : Patient Characteristic Birthdate" AND: Union of: Union of: "Immunization, Administered: Hepatitis A Vaccine" "Procedure, Performed: Hepatitis A Vaccine Administered" <= 730 day(s) ends after start of "Birthdate : Patient Characteristic Birthdate" Union of: "Diagnosis: Anaphylactic Reaction to Hepatitis A Vaccine" "Diagnosis: Hepatitis A" "Laboratory Test, Performed: Anti Hepatitis A IgG Antigen Test (result: Positive Finding)" <= 730 day(s) starts after start of "Birthdate : Patient Characteristic Birthdate" AND: OR: $RotavirusVaccine2Dose >= 1 day(s) starts after end of $RotavirusVaccine2Dose OR: Union of: "Diagnosis: Anaphylactic Reaction to Rotavirus Vaccine" "Diagnosis: Severe Combined Immunodeficiency" "Diagnosis: Intussusception" <= 730 day(s) starts after start of "Birthdate : Patient Characteristic Birthdate" OR: Union of: $RotavirusVaccine2Dose >= 1 day(s) starts after end of ($RotavirusVaccine3Dose >= 1 day(s) starts after end of $RotavirusVaccine3Dose ) $RotavirusVaccine3Dose >= 1 day(s) starts after end of ($RotavirusVaccine2Dose >= 1 day(s) starts after end of $RotavirusVaccine3Dose ) $RotavirusVaccine3Dose >= 1 day(s) starts after end of ($RotavirusVaccine3Dose >= 1 day(s) starts after end of $RotavirusVaccine2Dose ) OR: $RotavirusVaccine3Dose >= 1 day(s) starts after end of ($RotavirusVaccine3Dose >= 1 day(s) starts after end of $RotavirusVaccine3Dose ) AND: OR: $InfluenzaVaccine >= 1 day(s) starts after end of $InfluenzaVaccine OR: Union of: "Diagnosis: Anaphylactic Reaction to Influenza Vaccine" "Diagnosis: Malignant Neoplasm of Lymphatic and Hematopoietic Tissue" "Diagnosis: Anaphylactic Reaction to Neomycin" "Diagnosis: HIV" "Diagnosis: Disorders of the Immune System" <= 730 day(s) starts after or concurrent with start of "Birthdate : Patient Characteristic Birthdate"Numerator Exclusions (Performance Not Met)NoneDSRIP Specific ModificationsNoneAdditional InformationData Criteria (QDM Data Elements):? "Diagnosis: Anaphylactic Reaction to Common Baker's Yeast" using "Anaphylactic Reaction to Common Baker's Yeast Grouping Value Set (2.16.840.1.113883.3.464.1003.199.12.1032)"? "Diagnosis: Anaphylactic Reaction to DTaP Vaccine" using "Anaphylactic Reaction to DTaP Vaccine Grouping Value Set (2.16.840.1.113883.3.464.1003.199.12.1031)"? "Diagnosis: Anaphylactic Reaction to Hemophilus Influenza B (HiB) Vaccine" using "Anaphylactic Reaction to Hemophilus Influenza B (HiB) Vaccine Grouping Value Set (2.16.840.1.113883.3.464.1003.199.12.1030)"? "Diagnosis: Anaphylactic Reaction to Hepatitis A Vaccine" using "Anaphylactic Reaction to Hepatitis A Vaccine Grouping Value Set (2.16.840.1.113883.3.464.1003.199.12.1026)"? "Diagnosis: Anaphylactic Reaction to Hepatitis B Vaccine" using "Anaphylactic Reaction to Hepatitis B Vaccine Grouping Value Set (2.16.840.1.113883.3.464.1003.199.12.1029)"? "Diagnosis: Anaphylactic Reaction to Inactivated Polio Vaccine (IPV)" using "Anaphylactic Reaction to Inactivated Polio Vaccine (IPV) Grouping Value Set (2.16.840.1.113883.3.464.1003.199.12.1023)"? "Diagnosis: Anaphylactic Reaction to Influenza Vaccine" using "Anaphylactic Reaction to Influenza Vaccine Grouping Value Set (2.16.840.1.113883.3.464.1003.199.12.1022)"? "Diagnosis: Anaphylactic Reaction to Neomycin" using "Anaphylactic Reaction to Neomycin Grouping Value Set (2.16.840.1.113883.3.464.1003.199.12.1024)"? "Diagnosis: Anaphylactic Reaction to Pneumococcal Conjugate Vaccine" using "Anaphylactic Reaction to Pneumococcal Conjugate Vaccine Grouping Value Set (2.16.840.1.113883.3.464.1003.199.12.1027)"? "Diagnosis: Anaphylactic Reaction to Polymyxin" using "Anaphylactic Reaction to Polymyxin Grouping Value Set (2.16.840.1.113883.3.464.1003.199.12.1025)"? "Diagnosis: Anaphylactic Reaction to Rotavirus Vaccine" using "Anaphylactic Reaction to Rotavirus Vaccine Grouping Value Set (2.16.840.1.113883.3.464.1003.199.12.1021)"? "Diagnosis: Anaphylactic Reaction to Streptomycin" using "Anaphylactic Reaction to Streptomycin Grouping Value Set (2.16.840.1.113883.3.464.1003.199.12.1028)"? "Diagnosis: Disorders of the Immune System" using "Disorders of the Immune System Grouping Value Set (2.16.840.1.113883.3.464.1003.120.12.1001)"? "Diagnosis: Encephalopathy due to Childhood Vaccination" using "Encephalopathy due to Childhood Vaccination Grouping Value Set (2.16.840.1.113883.3.464.1003.114.12.1007)"? "Diagnosis: Hepatitis A" using "Hepatitis A Grouping Value Set (2.16.840.1.113883.3.464.1003.110.12.1024)"? "Diagnosis: Hepatitis B" using "Hepatitis B Grouping Value Set (2.16.840.1.113883.3.464.1003.110.12.1025)"? "Diagnosis: HIV" using "HIV Grouping Value Set (2.16.840.1.113883.3.464.1003.120.12.1003)"? "Diagnosis: Intussusception" using "Intussusception Grouping Value Set (2.16.840.1.113883.3.464.1003.199.12.1056)"? "Diagnosis: Malignant Neoplasm of Lymphatic and Hematopoietic Tissue" using "Malignant Neoplasm of Lymphatic and Hematopoietic Tissue Grouping Value Set (2.16.840.1.113883.3.464.1003.108.12.1009)"? "Diagnosis: Measles" using "Measles Grouping Value Set (2.16.840.1.113883.3.464.1003.110.12.1053)"? "Diagnosis: Mumps" using "Mumps Grouping Value Set (2.16.840.1.113883.3.464.1003.110.12.1032)"? "Diagnosis: Rubella" using "Rubella Grouping Value Set (2.16.840.1.113883.3.464.1003.110.12.1037)"? "Diagnosis: Severe Combined Immunodeficiency" using "Severe Combined Immunodeficiency Grouping Value Set (2.16.840.1.113883.3.464.1003.120.12.1007)"? "Diagnosis: Varicella Zoster" using "Varicella Zoster Grouping Value Set (2.16.840.1.113883.3.464.1003.110.12.1039)"? "Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient SNOMEDCT Value Set (2.16.840.1.113883.3.666.5.307)"? "Encounter, Performed: Face-to-Face Interaction" using "Face-to-Face Interaction Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1048)"? "Encounter, Performed: Home Healthcare Services" using "Home Healthcare Services Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1016)"? "Encounter, Performed: Office Visit" using "Office Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1001)"? "Encounter, Performed: Preventive Care - Established Office Visit, 0 to 17" using "Preventive Care - Established Office Visit, 0 to 17 Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1024)"? "Encounter, Performed: Preventive Care- Initial Office Visit, 0 to 17" using "Preventive Care- Initial Office Visit, 0 to 17 Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1022)"? "Immunization, Administered: DTaP Vaccine" using "DTaP Vaccine Grouping Value Set (2.16.840.1.113883.3.464.1003.196.12.1214)"? "Immunization, Administered: Haemophilus Influenzae Type B (HiB) Vaccine" using "Haemophilus Influenzae Type B (HiB) Vaccine Grouping Value Set (2.16.840.1.113883.3.464.1003.196.12.1217)"? "Immunization, Administered: Hepatitis A Vaccine" using "Hepatitis A Vaccine Grouping Value Set (2.16.840.1.113883.3.464.1003.196.12.1215)"? "Immunization, Administered: Hepatitis B Vaccine" using "Hepatitis B Vaccine Grouping Value Set (2.16.840.1.113883.3.464.1003.196.12.1216)"? "Immunization, Administered: Inactivated Polio Vaccine (IPV)" using "Inactivated Polio Vaccine (IPV) Grouping Value Set (2.16.840.1.113883.3.464.1003.196.12.1219)"? "Immunization, Administered: Influenza Vaccine" using "Influenza Vaccine Grouping Value Set (2.16.840.1.113883.3.464.1003.196.12.1218)"? "Immunization, Administered: Measles, Mumps and Rubella (MMR) Vaccine" using "Measles, Mumps and Rubella (MMR) Vaccine Grouping Value Set (2.16.840.1.113883.3.464.1003.196.12.1224)"? "Immunization, Administered: Pneumococcal Conjugate Vaccine" using "Pneumococcal Conjugate Vaccine Grouping Value Set (2.16.840.1.113883.3.464.1003.196.12.1221)"? "Immunization, Administered: Rotavirus Vaccine (2 dose schedule)" using "Rotavirus Vaccine (2 dose schedule) Grouping Value Set (2.16.840.1.113883.3.464.1003.196.12.1222)"? "Immunization, Administered: Rotavirus Vaccine (3 dose schedule)" using "Rotavirus Vaccine (3 dose schedule) Grouping Value Set (2.16.840.1.113883.3.464.1003.196.12.1223)"? "Immunization, Administered: Varicella Zoster Vaccine (VZV)" using "Varicella Zoster Vaccine (VZV) Grouping Value Set (2.16.840.1.113883.3.464.1003.196.12.1170)"? "Intervention, Order: Hospice care ambulatory" using "Hospice care ambulatory SNOMEDCT Value Set (2.16.840.1.113762.1.4.1108.15)"? "Intervention, Performed: Hospice care ambulatory" using "Hospice care ambulatory SNOMEDCT Value Set (2.16.840.1.113762.1.4.1108.15)"? "Laboratory Test, Performed: Anti Hepatitis A IgG Antigen Test" using "Anti Hepatitis A IgG Antigen Test Grouping Value Set (2.16.840.1.113883.3.464.1003.198.12.1033)"? "Laboratory Test, Performed: Anti Hepatitis B Virus Surface Ab" using "Anti Hepatitis B Virus Surface Ab Grouping Value Set (2.16.840.1.113883.3.464.1003.198.12.1073)"? "Laboratory Test, Performed: Measles Antibody Test (IgG Antibody presence)" using "Measles Antibody Test (IgG Antibody presence) Grouping Value Set (2.16.840.1.113883.3.464.1003.198.12.1060)"? "Laboratory Test, Performed: Measles Antibody Test (IgG Antibody Titer)" using "Measles Antibody Test (IgG Antibody Titer) Grouping Value Set (2.16.840.1.113883.3.464.1003.198.12.1059)"? "Laboratory Test, Performed: Mumps Antibody Test (IgG Antibody presence)" using "Mumps Antibody Test (IgG Antibody presence) Grouping Value Set (2.16.840.1.113883.3.464.1003.198.12.1062)"? "Laboratory Test, Performed: Mumps Antibody Test (IgG Antibody Titer)" using "Mumps Antibody Test (IgG Antibody Titer) Grouping Value Set (2.16.840.1.113883.3.464.1003.198.12.1061)"? "Laboratory Test, Performed: Rubella Antibody Test (IgG Antibody presence)" using "Rubella Antibody Test (IgG Antibody presence) Grouping Value Set (2.16.840.1.113883.3.464.1003.198.12.1064)"? "Laboratory Test, Performed: Rubella Antibody Test (IgG Antibody Titer)" using "Rubella Antibody Test (IgG Antibody Titer) Grouping Value Set (2.16.840.1.113883.3.464.1003.198.12.1063)"? "Laboratory Test, Performed: Varicella Zoster Antibody Test (IgG Antibody Presence)" using "Varicella Zoster Antibody Test (IgG Antibody Presence) Grouping Value Set (2.16.840.1.113883.3.464.1003.198.12.1067)"? "Laboratory Test, Performed: Varicella Zoster Antibody Test (IgG Antibody Titer)" using "Varicella Zoster Antibody Test (IgG Antibody Titer) Grouping Value Set (2.16.840.1.113883.3.464.1003.198.12.1066)"? "Procedure, Performed: DTaP Vaccine Administered" using "DTaP Vaccine Administered Grouping Value Set (2.16.840.1.113883.3.464.1003.110.12.1022)"? "Procedure, Performed: Haemophilus Influenzae Type B (HiB) Vaccine Administered" using "Haemophilus Influenzae Type B (HiB) Vaccine Administered Grouping Value Set (2.16.840.1.113883.3.464.1003.110.12.1043)"? "Procedure, Performed: Hepatitis A Vaccine Administered" using "Hepatitis A Vaccine Administered Grouping Value Set (2.16.840.1.113883.3.464.1003.110.12.1041)"? "Procedure, Performed: Hepatitis B Vaccine Administered" using "Hepatitis B Vaccine Administered Grouping Value Set (2.16.840.1.113883.3.464.1003.110.12.1042)"? "Procedure, Performed: Inactivated Polio Vaccine (IPV) Administered" using "Inactivated Polio Vaccine (IPV) Administered Grouping Value Set (2.16.840.1.113883.3.464.1003.110.12.1045)"? "Procedure, Performed: Influenza Vaccine Administered" using "Influenza Vaccine Administered Grouping Value Set (2.16.840.1.113883.3.464.1003.110.12.1044)"? "Procedure, Performed: Measles, Mumps and Rubella (MMR) Vaccine Administered" using "Measles, Mumps and Rubella (MMR) Vaccine Administered Grouping Value Set (2.16.840.1.113883.3.464.1003.110.12.1031)"? "Procedure, Performed: Pneumococcal Conjugate Vaccine Administered" using "Pneumococcal Conjugate Vaccine Administered Grouping Value Set (2.16.840.1.113883.3.464.1003.110.12.1046)"? "Procedure, Performed: Rotavirus Vaccine (2 dose schedule) Administered" using "Rotavirus Vaccine (2 dose schedule) Administered Grouping Value Set (2.16.840.1.113883.3.464.1003.110.12.1048)"? "Procedure, Performed: Rotavirus Vaccine (3 dose schedule) Administered" using "Rotavirus Vaccine (3 dose schedule) Administered Grouping Value Set (2.16.840.1.113883.3.464.1003.110.12.1047)"? "Procedure, Performed: Varicella Zoster Vaccine (VZV) Administered" using "Varicella Zoster Vaccine (VZV) Administered Grouping Value Set (2.16.840.1.113883.3.464.1003.110.12.1040)"? Attribute: "Discharge status: Discharged to Health Care Facility for Hospice Care" using "Discharged to Health Care Facility for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.207)"? Attribute: "Result: Positive Finding" using "Positive Finding Grouping Value Set (2.16.840.1.113883.3.464.1003.121.12.1016)"? Attribute: "Discharge status: Discharged to Home for Hospice Care" using "Discharged to Home for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.209)"L1-115: Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%)Measure Description:Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.L1-115: Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%)DY7/DY8 Program IDL1-115Measure DetailsSteward: NCQANQF #: 0059Source: CMS MIPS #1 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusOptionalMeasure ClassificationType: Clinical OutcomeMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: QISMCHPL: 0.2936MPL: 0.522National Quality Compass 2016 - All LOBs: Average (90th and 25th percentiles)Directionality: NegativeUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionPatients 18-75 years of age with diabetes with a visit during the measurement period Exclusions: Exclude patients who were in hospice care during the measurement yearDenominator InclusionsCLAIMS/REGISTRY:Patients aged 18 years to 75 years on date of encounterANDDiagnosis for diabetes (ICD-10-CM): E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, E10.319, E10.3211, E10.3212, E10.3213, E10.3219, E10.3291, E10.3292, E10.3293, E10.3299, E10.3311, E10.3312, E10.3313, E10.3319, E10.3391, E10.3392, E10.3393, E10.3399, E10.3411, E10.3412, E10.3413, E10.3419, E10.3491, E10.3492, E10.3493, E10.3499, E10.3511, E10.3512, E10.3513, E10.3519, E10.3521, E10.3522, E10.3523, E10.3529, E10.3531, E10.3532, E10.3533, E10.3539, E10.3541, E10.3542, E10.3543, E10.3549, E10.3551, E10.3552, E10.3553, E10.3559, E10.3591, E10.3592, E10.3593, E10.3599, E10.36, E10.37X1, E10.37X2, E10.37X3, E10.37X9, E10.39, E10.40, E10.41, E10.42, E10.43, E10.44, E10.49, E10.51, E10.52, E10.59, E10.610, E10.618, E10.620, E10.621, E10.622, E10.628, E10.630, E10.638, E10.641, E10.649, E10.65, E10.69, E10.8, E10.9, E11.00, E11.01, E11.21, E11.22, E11.29, E11.311, E11.319, E11.3211, E11.3212, E11.3213, E11.3219, E11.3291, E11.3292, E11.3293, E11.3299, E11.3311, E11.3312, E11.3313, E11.3319, E11.3391, E11.3392, E11.3393, E11.3399, E11.3411, E11.3412, E11.3413, E11.3419, E11.3491, E11.3492, E11.3493, E11.3499, E11.3511, E11.3512, E11.3513, E11.3519, E11.3521, E11.3522, E11.3523, E11.3529, E11.3531, E11.3532, E11.3533, E11.3539, E11.3541, E11.3542, E11.3543, E11.3549, E11.3551, E11.3552, E11.3553, E11.3559, E11.3591, E11.3592, E11.3593, E11.3599, E11.36, E11.37X1, E11.37X2, E11.37X3, E11.37X9, E11.39, E11.40, E11.41, E11.42, E11.43, E11.44, E11.49, E11.51, E11.52, E11.59, E11.610, E11.618, E11.620, E11.621, E11.622, E11.628, E11.630, E11.638, E11.641, E11.649, E11.65, E11.69, E11.8, E11.9, E13.00, E13.01, E13.10, E13.11, E13.21, E13.22, E13.29, E13.311, E13.319, E13.3211, E13.3212, E13.3213, E13.3219, E13.3291, E13.3292, E13.3293, E13.3299, E13.3311, E13.3312, E13.3313, E13.3319 E13.3391, E13.3392, E13.3393, E13.3399, E13.3411, E13.3412, E13.3413, E13.3419, E13.3491, E13.3492, E13.3493, E13.3499, E13.3511, E13.3512, E13.3513, E13.3519, E13.3521, E13.3522, E13.3523, E13.3529, E13.3531, E13.3532, E13.3533, E13.3539, E13.3541, E13.3542, E13.3543, E13.3549, E13.3551, E13.3552, E13.3553, E13.3559, E13.3591, E13.3592, E13.3593, E13.3599, E13.36, E13.37X1, E13.37X2, E13.37X3, E13.37X9, E13.39, E13.40, E13.41, E13.42, E13.43, E13.44, E13.49, E13.51, E13.52, E13.59, E13.610, E13.618, E13.620, E13.621, E13.622, E13.628, E13.630, E13.638, E13.641, E13.649, E13.65, E13.69, E13.8, E13.9, O24.011, O24.012, O24.013, O24.019, O24.02, O24.03, O24.111, O24.112, O24.113, O24.119, O24.12, O24.13, O24.311, O24.312, O24.313, O24.319, O24.32, O24.33, O24.811, O24.812, O24.813, O24.819, O24.82, O24.83ANDPatient encounter during performance period (CPT or HCPCS): 97802, 97803, 97804, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99281, 99282, 99283, 99284, 99285, 99291, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0270, G0271, G0402, G0438, G0439 E.H.R.: AND: "Diagnosis: Diabetes" overlaps "Measurement Period" AND: Age>= 18 year(s) at: "Measurement Period" AND: Age< 75 year(s) at: "Measurement Period" AND: Union of: "Encounter, Performed: Office Visit" "Encounter, Performed: Face-to-Face Interaction" "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" "Encounter, Performed: Home Healthcare Services" "Encounter, Performed: Annual Wellness Visit" during "Measurement Period"For both the Claims and E.H.R. specifications, providers should limit office visit/E&M CPT codes 99201 - 99205 and 99211 - 99219 to primary care, outpatient specialty care where primary care is managed, and speciaty care related to diabetes management. Encounters may be limited by clinic, place of service, or physician but not by visit specific services.Denominator ExclusionsCLAIMS/REGISTRY:Hospice services provided to patient any time during the measurement period: G9687 E.H.R.: OR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Home for Hospice Care)" ends during "Measurement Period" OR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Health Care Facility for Hospice Care)" ends during "Measurement Period" OR: Union of: "Intervention, Order: Hospice care ambulatory" "Intervention, Performed: Hospice care ambulatory" overlaps "Measurement Period"Numerator DescriptionPatients whose most recent HbA1c level (performed during the measurement period) is >9.0%Numerator Inclusions (Performance Met)CLAIMS/REGISTRY:Most recent hemoglobin A1c level > 9.0% (3046F)ORHemoglobin A1c level was not performed during the measurement period (12 months) (3046F with 8P) E.H.R.: AND: OR: "Laboratory Test, Performed: HbA1c Laboratory Test" satisfies all: Most Recent: (result) during "Measurement Period" (result > 9 %) OR: AND: Most Recent: "Occurrence A of Laboratory Test, Performed: HbA1c Laboratory Test" during "Measurement Period" AND NOT: "Occurrence A of Laboratory Test, Performed: HbA1c Laboratory Test (result)" OR NOT: "Laboratory Test, Performed: HbA1c Laboratory Test" during "Measurement Period"Numerator Exclusions (Performance Not Met)CLAIMS/REGISTRY:Most recent hemoglobin A1c (HbA1c) level < 7.0% (3044F)ORMost recent hemoglobin A1c (HbA1c) level 7.0 to 9.0% (3045F) E.H.R.:NoneDSRIP Specific ModificationsNoneAdditional InformationData Criteria (QDM Data Elements)? "Diagnosis: Diabetes" using "Diabetes Grouping Value Set (2.16.840.1.113883.3.464.1003.103.12.1001)"? "Encounter, Performed: Annual Wellness Visit" using "Annual Wellness Visit Grouping Value Set (2.16.840.1.113883.3.526.3.1240)"? "Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient SNOMEDCT Value Set (2.16.840.1.113883.3.666.5.307)"? "Encounter, Performed: Face-to-Face Interaction" using "Face-to-Face Interaction Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1048)"? "Encounter, Performed: Home Healthcare Services" using "Home Healthcare Services Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1016)"? "Encounter, Performed: Office Visit" using "Office Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1001)"? "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" using "Preventive Care Services - Established Office Visit, 18 and Up Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1025)"? "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" using "Preventive Care Services-Initial Office Visit, 18 and Up Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1023)"? "Intervention, Order: Hospice care ambulatory" using "Hospice care ambulatory SNOMEDCT Value Set (2.16.840.1.113762.1.4.1108.15)"? "Intervention, Performed: Hospice care ambulatory" using "Hospice care ambulatory SNOMEDCT Value Set (2.16.840.1.113762.1.4.1108.15)"? "Laboratory Test, Performed: HbA1c Laboratory Test" using "HbA1c Laboratory Test Grouping Value Set (2.16.840.1.113883.3.464.1003.198.12.1013)"? Attribute: "Discharge status: Discharged to Health Care Facility for Hospice Care" using "Discharged to Health Care Facility for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.207)"? Attribute: "Discharge status: Discharged to Home for Hospice Care" using "Discharged to Home for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.209)"L1-147: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-UpMeasure Description:Percentage of patients aged 18 years and older 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 encounterNormal Parameters: Age 65 years and older BMI >= 23 and < 30 Age 18 – 64 years BMI >= 18.5 and < 25L1-147: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-UpDY7/DY8 Program IDL1-147Measure DetailsSteward: CMSNQF #: 0421 / 2828 eMeasureSource: CMS MIPS #128 (Claims V2.0 12/11/2017) eMeasure: 10/25/17Data SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: QISMCHPL: 0.9254MPL: 0.7651National Quality Compass 2016 - All LOBs: Average (90th and 25th percentiles)Directionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is eligible for a baseline numerator of 0 per PFM Section VI.22.b.i (page 24). If approved for a baseline of zero, the DY7 goal will be 89.35% and DY8 goal of 89.67%.Denominator DescriptionAll patients aged 18 years and older on the date of the encounter with at least one eligible encounter during the measurement periodDenominator InclusionsCLAIMS/REGISTRY:Patients aged ≥18 years on date of encounterANDPatient encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 96150, 96151, 96152, 97161, 97162, 97163, 97165, 97166, 97167, 97802, 97803, 98960, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, , 99385, 99386, 99387, 99395, 99396, 99397, D7140, D7210, G0101, G0108, G0270, G0271, G0402, G0438, G0439, G0447WITHOUTTelehealth Modifier: GQ, GT, 95, POS 02 E.H.R.: AND: Age>= 18 year(s) at: "Occurrence A of Encounter, Performed: BMI Encounter Code Set" AND: "Occurrence A of Encounter, Performed: BMI Encounter Code Set" during "Measurement Period"Denominator ExclusionsCLAIMS/REGISTRY:BMI not documented, documentation the patient is not eligible for BMI calculation: G8422ORBMI is documented as being outside of normal limits, follow-up plan is not documented, documentation the patient is not eligible: G8938ORBMI is documented as being outside of normal limits, follow-up plan is not completed for documented reason: G9716 Not Eligible for BMI Calculation or Follow-Up Plan (Denominator Exclusion) – A patient is not eligible if one or more of the following reasons are documented:? Patients receiving palliative care? Patients who are pregnant? Patients who refuse measurement of height and/or weight or refuse follow-upPatients with a documented BMI outside normal limits and a documented reason for not completing BMI follow-up plan (Denominator Exception) –? The Medical Reason exception could include, but is not limited to, the following patients as deemed appropriate by the health care provider? Elderly Patients (65 or older) for whom weight reduction/weight gain would complicate other underlying health conditions such as the following examples:? Illness or physical disability? Mental illness, dementia, confusion? Nutritional deficiency, such as Vitamin/mineral deficiency? 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 E.H.R.:Denominator Exclusions: OR: Union of: "Encounter, Performed: Palliative care encounter" starts before or concurrent with end of "Occurrence A of Encounter, Performed: BMI Encounter Code Set" "Intervention, Order: Palliative Care" starts before or concurrent with end of "Occurrence A of Encounter, Performed: BMI Encounter Code Set" "Physical Exam, Performed not done: Patient Reason refused" for "BMI LOINC Value" during "Occurrence A of Encounter, Performed: BMI Encounter Code Set" "Diagnosis: Pregnancy Dx" overlaps "Measurement Period"Denominator Exceptions: OR: Union of: - "Intervention, Order not done: Medical or Other reason not done" for "Above Normal Follow-up" - "Intervention, Order not done: Medical or Other reason not done" for "Referrals where weight assessment may occur" - "Medication, Order not done: Medical or Other reason not done" for "Above Normal Medications" - "Intervention, Order not done: Medical or Other reason not done" for "Below Normal Follow up" - "Medication, Order not done: Medical or Other reason not done" for "Below Normal Medications" - <= 12 month(s) starts before or concurrent with end of "Occurrence A of Encounter, Performed: BMI Encounter Code Set" Numerator DescriptionPatients 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 encounterNumerator Instructions:? Height and Weight - An eligible professional or their staff is required to measure both height and weight. Both height and weight must be measured within twelve months of the current encounter and may be obtained from separate encounters. Self-reported values cannot be used.? Follow-Up Plan – If the most recent documented BMI is outside of normal parameters, then a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter. The documented follow-up plan must be based on the most recent documented BMI, outside of normal parameters, example: “Patient referred to nutrition counseling for BMI above or below normal parameters”. (See Definitions for examples of follow-up plan treatments).? Performance Met for G8417 & G8418? If the provider documents a BMI and a follow-up plan at the current visit OR? If the patient has a documented BMI within the previous twelve months of the current encounter, the provider documents a follow-up plan at the current visit OR? If the patient has a documented BMI within the previous twelve months of the current encounter AND the patient has a documented follow-up plan for a BMI outside normal parameters within the previous twelve months of the current visit Definitions:BMI – Body mass index (BMI), is a number calculated using the Quetelet index: weight divided byheight squared (W/H2) and is commonly used to classify weight categories. BMI can be calculated using:Metric Units: BMI = Weight (kg) / (Height (m) x Height (m))OREnglish Units: BMI = Weight (lbs) / (Height (in) x Height (in)) x 703Follow-Up Plan – Proposed outline of treatment to be conducted as a result of a BMI out of normal parameters. A follow-up plan may include, but is not limited to:? Documentation of education? Referral (for example a registered dietitian, nutritionist, occupational therapist, physical therapist, primary care provider, exercise physiologist, mental health professional, or surgeon)? Pharmacological interventions? Dietary supplements? Exercise counseling? Nutrition counselingNumerator Inclusions (Performance Met)CLAIMS/REGISTRY:BMI is documented within normal parameters and no follow-up plan is required (G8420)ORPerformance Met: BMI is documented above normal parameters and a follow-up plan is documented (G8417)ORPerformance Met: BMI is documented below normal parameters and a follow-up plan is documented (G8418) E.H.R.: AND: OR: "Physical Exam, Performed: BMI LOINC Value" satisfies all: Most Recent: (result) <= 12 month(s) starts before or concurrent with end of "Occurrence A of Encounter, Performed: BMI Encounter Code Set" (result >= 18.5 kg/m2) (result < 25 kg/m2) OR: AND: Union of: "Intervention, Order: Above Normal Follow-up" "Intervention, Order: Referrals where weight assessment may occur (reason: Overweight)" "Medication, Order: Above Normal Medications" <= 12 month(s) starts before or concurrent with end of "Occurrence A of Encounter, Performed: BMI Encounter Code Set" AND: "Physical Exam, Performed: BMI LOINC Value" satisfies all: Most Recent: (result) <= 12 month(s) starts before or concurrent with end of "Occurrence A of Encounter, Performed: BMI Encounter Code Set" (result >= 25 kg/m2) OR: AND: Union of: "Intervention, Order: Below Normal Follow up" "Intervention, Order: Referrals where weight assessment may occur (reason: Underweight)" "Medication, Order: Below Normal Medications" <= 12 month(s) starts before or concurrent with end of "Occurrence A of Encounter, Performed: BMI Encounter Code Set" AND: "Physical Exam, Performed: BMI LOINC Value" satisfies all: Most Recent: (result) <= 12 month(s) starts before or concurrent with end of "Occurrence A of Encounter, Performed: BMI Encounter Code Set" (result < 18.5 kg/m2)Numerator Exclusions (Performance Not Met)CLAIMS/REGISTRY:BMI not documented and no reason is given (G8421)ORBMI documented outside normal parameters, no follow-up plan documented, no reason given (G8419) E.H.R.:NoneDSRIP Specific ModificationsNoneAdditional InformationData Criteria (QDM Data Elements):? "Diagnosis: Pregnancy Dx" using "Pregnancy Dx Grouping Value Set (2.16.840.1.113883.3.600.1.1623)"? "Encounter, Performed: BMI Encounter Code Set" using "BMI Encounter Code Set Grouping Value Set (2.16.840.1.113883.3.600.1.1751)"? "Encounter, Performed: Palliative care encounter" using "Palliative care encounter ICD10CM Value Set (2.16.840.1.113883.3.600.1.1575)"? "Intervention, Order: Above Normal Follow-up" using "Above Normal Follow-up Grouping Value Set (2.16.840.1.113883.3.600.1.1525)"? "Intervention, Order: Below Normal Follow up" using "Below Normal Follow up Grouping Value Set (2.16.840.1.113883.3.600.1.1528)"? "Intervention, Order: Palliative Care" using "Palliative Care Grouping Value Set (2.16.840.1.113883.3.600.1.1579)"? "Intervention, Order: Referrals where weight assessment may occur" using "Referrals where weight assessment may occur Grouping Value Set (2.16.840.1.113883.3.600.1.1527)"? "Intervention, Order not done: Medical or Other reason not done" using "Medical or Other reason not done SNOMEDCT Value Set (2.16.840.1.113883.3.600.1.1502)"? "Medication, Order: Above Normal Medications" using "Above Normal Medications RXNORM Value Set (2.16.840.1.113883.3.600.1.1498)"? "Medication, Order: Below Normal Medications" using "Below Normal Medications RXNORM Value Set (2.16.840.1.113883.3.600.1.1499)"? "Medication, Order not done: Medical or Other reason not done" using "Medical or Other reason not done SNOMEDCT Value Set (2.16.840.1.113883.3.600.1.1502)"? "Physical Exam, Performed: BMI LOINC Value" using "BMI LOINC Value LOINC Value Set (2.16.840.1.113883.3.600.1.681)"? "Physical Exam, Performed not done: Patient Reason refused" using "Patient Reason refused SNOMEDCT Value Set (2.16.840.1.113883.3.600.791)"? Attribute: "Reason: Overweight" using "Overweight SNOMEDCT Value Set (2.16.840.1.113883.3.600.2387)"? Attribute: "Reason: Underweight" using "Underweight SNOMEDCT Value Set (2.16.840.1.113883.3.600.2388)"L1-160: Follow-Up After Hospitalization for Mental IllnessMeasure Description:The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported: - The percentage of discharges for which the patient received follow-up within 30 days of discharge - The percentage of discharges for which the patient received follow-up within 7 days of discharge.L1-160: Follow-Up After Hospitalization for Mental IllnessDY7/DY8 Program IDL1-160Measure DetailsSteward: NCQANQF #: 0576Source: CMS MIPS #391 (Claims/Registry)Data SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusOptionalMeasure ClassificationType: Clinical OutcomeMeasure Parts: 2Achievement CalculationsCategory: P4PGoal Calculation: QISMCHPL: 30 Days: 0.78527 Days: 0.6423MPL: 30 Days: 0.54087 Days: 0.342National Quality Compass 2016 - All LOBs: Average (90th and 25th percentiles)Directionality: PositiveUnit of Measurement for Payer TypeUnit: EncountersMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionRate 1 & 2: Patients 6 years of age and older who were discharged from an acute inpatient setting (including acutecare psychiatric facilities) with a principal diagnosis of mental illness on or between January 1 and December 1 of the measurement periodDenominator InclusionsRate 1 & 2: Patients aged 6 years and older as of the date of dischargeANDDiagnosis for mental illness (ICD-10-CM): F20.0, F20.1, F20.2, F20.3, F20.5, F20.81, F20.89, F20.9, F21, F22, F23, F24, F25.0, F25.1, F25.8, F25.9, F28, F29, F30.10, F30.11, F30.12, F30.13, F30.2,F30.3, F30.4, F30.8, F30.9, F31.0, F31.10, F31.11, F31.12, F31.13, F31.2, F31.30, F31.31, F31.32, F31.4,F31.5, F31.60, F31.61, F31.62, F31.63, F31.64, F31.70, F31.71, F31.72, F31.73, F31.74, F31.75, F31.76,F31.77, F31.78, F31.81, F31.89, F31.9, F32.0, F32.1, F32.2, F32.3, F32.4, F32.5, F32.81, F32.89, F32.9, F33.0,F33.1, F33.2, F33.3, F33.40, F33.41, F33.42, F33.8, F33.9, F34.0, F34.1, F34.81, F34.89, F34.9, F39, F42.2, F42.3, F42.8, F42.9, F43.0, F43.10, F43.11, F43.12, F43.20, F43.21, F43.22, F43.23, F43.24, F43.25, F43.29, F43.8, F43.9, F44.89, F53, F60.0, F60.1, F60.2, F60.3, F60.4, F60.5, F60.6, F60.7, F60.81, F60.89, F60.9, F63.0, F63.1, F63.2, F63.3, F63.81, F63.89, F63.9, F68.10, F68.11, F68.12, F68.13, F68.8, F84.0, F84.2, F84.3, F84.5, F84.8,F84.9, F90.0, F90.1, F90.2, F90.8, F90.9, F91.0, F91.1, F91.2, F91.3, F91.8, F91.9, F93.0, F93.8, F93.9,F94.0, F94.1, F94.2, F94.8, F94.9ANDPatient encounter during the performance period (CPT): 99221, 99222, 99223, 99231, 99232,99233,99238, 99239, 99291ANDPatient alive at time of acute inpatient setting dischargeANDPatient is discharged from an acute inpatient setting on or between January 1 and December 1 of the measurement periodANDExclude discharges followed by readmission or direct transfer to a Non-acute facility within the 30- day follow-up period, regardless of principal diagnosis for the readmission.ANDExclude discharges followed by readmission or direct transfer to an acute facility within the 30-day follow-up period if the principal diagnosis was for non-mental healthNOTE: These discharges are excluded from the measure because readmission or transfer may preventan outpatient follow-up visit from taking place.Denominator ExclusionsRate 1: Patients who use hospice services any time during the measurement period: G9760ORClinician documented reason patient was not able to complete 30 day follow-up from acute inpatient setting discharge (e.g., patient death prior to follow-up visit, patient non-compliant for visit follow-up) (G9403) Rate 2: Patients who use hospice services any time during the measurement period: G9760OR Clinician documented reason patient was not able to complete 7 day follow-up from acute inpatient setting discharge (i.e., patient death prior to follow-up visit, patient non-compliance for visit follow-up) (G9406)Numerator DescriptionRate 1: An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 30 days after acute inpatient discharge. Include outpatient visits, intensive outpatient visits or partial hospitalizationsthat occur on the date of discharge Rate 2: Patient received follow-up within 7 days fromdischarge (G9405)Numerator Inclusions (Performance Met)Rate 1: Patient received follow-up on the date of discharge or within 30 days after discharge (G9402) Rate 2: Patient received follow-up within 7 days from discharge (G9405)Numerator Exclusions (Performance Not Met)Rate 1: Patient did not receive follow-up on the date of discharge or within 30 days after discharge (G9404)Rate 2:Patient did not receive follow-up on or within 7 days after discharge (G9407)DSRIP Specific ModificationsNoneAdditional InformationNoneL1-186: Breast Cancer ScreeningMeasure Description:The percentage of women 50-74 years of age who had a mammogram to screen for breast cancer.L1-186: Breast Cancer ScreeningDY7/DY8 Program IDL1-186Measure DetailsSteward: NCQANQF #: 2372Source: CMS MIPS #112 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusOptionalMeasure ClassificationType: Cancer ScreeningMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: QISMCHPL: 0.7144MPL: 0.5228National Quality Compass 2016 - All LOBs: Average (90th and 25th percentiles)Directionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionWomen 51 - 74 years of age with a visit during the measurement period DENOMINATOR NOTE: The intent of the measure is that starting at age 50 women should have one or more mammograms every 24 months with a 3 month grace period.Denominator InclusionsCLAIMS/REGISTRY: Patients 51 to 74 years of age on date of encounterANDPatient encounter during the performance period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0402, G0438, G0439, 99386, 99387, 99396, 99397 E.H.R.: AND: Age>= 51 year(s) at: "Measurement Period" AND: Age< 74 year(s) at: "Measurement Period" AND: "Patient Characteristic Sex: Female" AND: Union of: "Encounter, Performed: Office Visit" "Encounter, Performed: Face-to-Face Interaction" "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" "Encounter, Performed: Home Healthcare Services" "Encounter, Performed: Annual Wellness Visit" during "Measurement Period"Denominator ExclusionsCLAIMS/REGISTRY: Women who had a bilateral mastectomy or who have a history of a bilateral mastectomy or for whom there is evidence of a right and a left unilateral mastectomy: G9708ORHospice services used by patient any time during the measurement period: G9709 E.H.R.: OR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Home for Hospice Care)" ends during "Measurement Period" OR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Health Care Facility for Hospice Care)" ends during "Measurement Period" OR: Union of: "Intervention, Order: Hospice care ambulatory" "Intervention, Performed: Hospice care ambulatory" overlaps "Measurement Period" OR: "Procedure, Performed: Bilateral Mastectomy" ends before end of "Measurement Period" OR: Count= 2 : "Procedure, Performed: Unilateral Mastectomy" ends before end of "Measurement Period" OR: AND: Union of: "Diagnosis: Status Post Right Mastectomy" "Diagnosis: Unilateral Mastectomy, Unspecified Laterality (anatomical location site: Right)" starts before end of "Measurement Period" AND: Union of: "Diagnosis: Status Post Left Mastectomy" "Diagnosis: Unilateral Mastectomy, Unspecified Laterality (anatomical location site: Left)" starts before end of "Measurement Period" OR: "Diagnosis: History of bilateral mastectomy" starts before end of "Measurement Period"Numerator DescriptionWomen with one or more mammograms during the measurement period or the 15 months prior to the measurement periodNumerator Inclusions (Performance Met)CLAIMS/REGISTRY: Screening mammography results documented andreviewed (3014F) E.H.R.: AND: "Diagnostic Study, Performed: Mammography" < 27 month(s) ends before or concurrent with end of "Measurement Period"Numerator Exclusions (Performance Not Met)CLAIMS/REGISTRY: Screening mammography results were not documented and reviewed, reason not otherwise specified (3014F with 8P) E.H.R.:NoneDSRIP Specific ModificationsFor DSRIP reporting purpose, HHSC has added CPT values 99386 (Prev visit new age 40 - 64), 99387 (Prev visit new age 65+), 99396 (Prev visit est age 40 - 64), and 99397 (Prev visit est age 65+) to the denominator inclusions for the Claims version of the specifications.Additional InformationData Criteria (QDM Data Elements):? "Diagnosis: History of bilateral mastectomy" using "History of bilateral mastectomy Grouping Value Set (2.16.840.1.113883.3.464.1003.198.12.1068)"? "Diagnosis: Status Post Left Mastectomy" using "Status Post Left Mastectomy Grouping Value Set (2.16.840.1.113883.3.464.1003.198.12.1069)"? "Diagnosis: Status Post Right Mastectomy" using "Status Post Right Mastectomy Grouping Value Set (2.16.840.1.113883.3.464.1003.198.12.1070)"? "Diagnosis: Unilateral Mastectomy, Unspecified Laterality" using "Unilateral Mastectomy, Unspecified Laterality Grouping Value Set (2.16.840.1.113883.3.464.1003.198.12.1071)"? "Diagnostic Study, Performed: Mammography" using "Mammography Grouping Value Set (2.16.840.1.113883.3.464.1003.108.12.1018)"? "Encounter, Performed: Annual Wellness Visit" using "Annual Wellness Visit Grouping Value Set (2.16.840.1.113883.3.526.3.1240)"? "Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient SNOMEDCT Value Set (2.16.840.1.113883.3.666.5.307)"? "Encounter, Performed: Face-to-Face Interaction" using "Face-to-Face Interaction Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1048)"? "Encounter, Performed: Home Healthcare Services" using "Home Healthcare Services Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1016)"? "Encounter, Performed: Office Visit" using "Office Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1001)"? "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" using "Preventive Care Services - Established Office Visit, 18 and Up Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1025)"? "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" using "Preventive Care Services-Initial Office Visit, 18 and Up Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1023)"? "Intervention, Order: Hospice care ambulatory" using "Hospice care ambulatory SNOMEDCT Value Set (2.16.840.1.113762.1.4.1108.15)"? "Intervention, Performed: Hospice care ambulatory" using "Hospice care ambulatory SNOMEDCT Value Set (2.16.840.1.113762.1.4.1108.15)"? "Patient Characteristic Sex: Female" using "Female AdministrativeGender Value Set (2.16.840.1.113883.3.560.100.2)"? "Procedure, Performed: Bilateral Mastectomy" using "Bilateral Mastectomy Grouping Value Set (2.16.840.1.113883.3.464.1003.198.12.1005)"? "Procedure, Performed: Unilateral Mastectomy" using "Unilateral Mastectomy Grouping Value Set (2.16.840.1.113883.3.464.1003.198.12.1020)"? Attribute: "Anatomical location site: Left" using "Left Grouping Value Set (2.16.840.1.113883.3.464.1003.122.12.1036)"? Attribute: "Anatomical location site: Right" using "Right Grouping Value Set (2.16.840.1.113883.3.464.1003.122.12.1035)"? Attribute: "Discharge status: Discharged to Health Care Facility for Hospice Care" using "Discharged to Health Care Facility for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.207)"? Attribute: "Discharge status: Discharged to Home for Hospice Care" using "Discharged to Home for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.209)"L1-205: Third next available appointmentMeasure Description:This measure is used to assess the average number of days to the third next available appointment for an office visit* for each clinic and/or department. This measure does not differentiate between "new" and "established" patients.*Office Visit: A patient encounter with a health care provider in an office, clinic, or ambulatory care facility as an outpatient.L1-205: Third next available appointmentDY7/DY8 Program IDL1-205Measure DetailsSteward: Wisconsin Collaborative for Healthcare QualityNQF #: NASource: SourceAnyRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: NegativeUnit of Measurement for Payer TypeUnit: NAMeasure will be reported as an all-payer rate only.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionThe denominator for this measure should be reported as 1.Denominator InclusionsNot ApplicableDenominator ExclusionsNot applicable.Numerator DescriptionContinuous variable statement: Average number of days to third next available appointment for an office visit for each clinic and/or department The measure will take into account calendar days, including weekends, holidays and clinician days off.Numerator Inclusions (Performance Met)Not ApplicableNumerator Exclusions (Performance Not Met)Not ApplicableDSRIP Specific ModificationsFor DSRIP reporting Purposes, the denominator for this measure is 1 so that the resulting rate is days to third next available appointment. Measure stewards denominator description is included in the measure description.Additional InformationA. All providers are included. Full-time and part-time providers are included, regardless of the number of hours s/he practices per week.- Providers who truly job share are counted as one provider (i.e., they share one schedule, and/or they work separate day and share coverage of one practice).- When measuring a care team, each member of the care team is counted separately (i.e., MD, NP, PA).- If a provider is practicing in a specialty other than the one which s/he is board certified, the provider should be included in the specialty in which s/he is practicing.- For providers practicing at more than 1 location, measure days to third next available for only the provider's primary location as long as the provider is at that location 51%+ of their time.- New providers who started seeing patients during the reporting period and have an active schedule should be included. 2. Locums are included in the measure only if they are assigned to a specific site for an extended period of time (greater than 4 weeks) and provide continuity care to a panel of patients. B. Mid-Level providers are included in the measure (NP, PA, CNM).- Mid-Level providers should have continuity practice and their own schedule available to see patients. C. Resident Providers are to be included if they have an active schedule AND are considered a Primary Care Provider within the organization. D. Providers with closed practices should be included. They still have to schedule their current patients. In addition, it may not be clear when they start seeing new patients again. Exclusions: Exclude clinicians who do not practice for an extended period of time (greater than 4 weeks) due to maternity leave, sabbatical, family medical leave.Mid-Level providers who function only as an "extender," overflow to another practice, or urgent care should not be included.Exclude Resident Providers if they are not considered a Primary Care Provider, have an inconsistent schedule, and a restricted patient panel. Time to third next available appointment is a nationally accepted measure of access and is endorsed by the Institute for Healthcare Improvement. This measure is used across the country at most major healthcare institutions. In addition, the members of the Wisconsin Collaborative for Healthcare Quality have undergone a data audit and validation by MetaStar, Inc, an independent third party. The purpose of this process was to audit the systems used to produce the data and to conduct measure determination. Measure determination consists of a series of steps to assure that the denominator is accurate, the sampling process is accurate, the numerator is appropriate, the entity has complied with the algorithm and documentation is appropriate.L1-207: Diabetes care: BP control (<140/90mm Hg)Measure Description:The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) whose most recent blood pressure level taken during the measurement year is <140/90 mm Hg.L1-207: Diabetes care: BP control (<140/90mm Hg)DY7/DY8 Program IDL1-207Measure DetailsSteward: NCQANQF #: 0061Source: See notesData SourceClaimsRequired StatusOptionalMeasure ClassificationType: Clinical OutcomeMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: QISMCHPL: 0.7564MPL: 0.5229National Quality Compass 2016 - All LOBs: Average (90th and 25th percentiles)Directionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionPatients 18 - 75 years of age with diabetes with a visit during the measurement periodDenominator InclusionsCLAIMS:Patients aged 18 years to 75 years on date of encounterANDDiagnosis for diabetes (ICD-10-CM): E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, E10.319, E10.3211, E10.3212, E10.3213, E10.3219, E10.3291, E10.3292, E10.3293, E10.3299, E10.3311, E10.3312, E10.3313, E10.3319, E10.3391, E10.3392, E10.3393, E10.3399, E10.3411, E10.3412, E10.3413, E10.3419, E10.3491, E10.3492, E10.3493, E10.3499, E10.3511, E10.3512, E10.3513, E10.3519, E10.3521, E10.3522, E10.3523, E10.3529, E10.3531, E10.3532, E10.3533, E10.3539, E10.3541, E10.3542, E10.3543, E10.3549, E10.3551, E10.3552, E10.3553, E10.3559, E10.3591, E10.3592, E10.3593, E10.3599, E10.36, E10.37X1, E10.37X2, E10.37X3, E10.37X9, E10.39, E10.40, E10.41, E10.42, E10.43, E10.44, E10.49, E10.51, E10.52, E10.59, E10.610, E10.618, E10.620, E10.621, E10.622, E10.628, E10.630, E10.638, E10.641, E10.649, E10.65, E10.69, E10.8, E10.9, E11.00, E11.01, E11.21, E11.22, E11.29, E11.311, E11.319, E11.3211, E11.3212, E11.3213, E11.3219, E11.3291, E11.3292, E11.3293, E11.3299, E11.3311, E11.3312, E11.3313, E11.3319, E11.3391, E11.3392, E11.3393, E11.3399, E11.3411, E11.3412, E11.3413, E11.3419, E11.3491, E11.3492, E11.3493, E11.3499, E11.3511, E11.3512, E11.3513, E11.3519, E11.3521, E11.3522, E11.3523, E11.3529, E11.3531, E11.3532, E11.3533, E11.3539, E11.3541, E11.3542, E11.3543, E11.3549, E11.3551, E11.3552, E11.3553, E11.3559, E11.3591, E11.3592, E11.3593, E11.3599, E11.36, E11.37X1, E11.37X2, E11.37X3, E11.37X9, E11.39, E11.40, E11.41, E11.42, E11.43, E11.44, E11.49, E11.51, E11.52, E11.59, E11.610, E11.618, E11.620, E11.621, E11.622, E11.628, E11.630, E11.638, E11.641, E11.649, E11.65, E11.69, E11.8, E11.9, E13.00, E13.01, E13.10, E13.11, E13.21, E13.22, E13.29, E13.311, E13.319, E13.3211, E13.3212, E13.3213, E13.3219, E13.3291, E13.3292, E13.3293, E13.3299, E13.3311, E13.3312, E13.3313, E13.3319 E13.3391, E13.3392, E13.3393, E13.3399, E13.3411, E13.3412, E13.3413, E13.3419, E13.3491, E13.3492, E13.3493, E13.3499, E13.3511, E13.3512, E13.3513, E13.3519, E13.3521, E13.3522, E13.3523, E13.3529, E13.3531, E13.3532, E13.3533, E13.3539, E13.3541, E13.3542, E13.3543, E13.3549, E13.3551, E13.3552, E13.3553, E13.3559, E13.3591, E13.3592, E13.3593, E13.3599, E13.36, E13.37X1, E13.37X2, E13.37X3, E13.37X9, E13.39, E13.40, E13.41, E13.42, E13.43, E13.44, E13.49, E13.51, E13.52, E13.59, E13.610, E13.618, E13.620, E13.621, E13.622, E13.628, E13.630, E13.638, E13.641, E13.649, E13.65, E13.69, E13.8, E13.9, O24.011, O24.012, O24.013, O24.019, O24.02, O24.03, O24.111, O24.112, O24.113, O24.119, O24.12, O24.13, O24.311, O24.312, O24.313, O24.319, O24.32, O24.33, O24.811, O24.812, O24.813, O24.819, O24.82, O24.83ANDPatient encounter during performance period (CPT or HCPCS): 97802, 97803, 97804, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99281, 99282, 99283, 99284, 99285, 99291, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0270, G0271, G0402, G0438, G0439E.H.R: AND: "Diagnosis: Diabetes" overlaps "Measurement Period" AND: Age>= 18 year(s) at: "Measurement Period" AND: Age< 75 year(s) at: "Measurement Period" AND: Union of: "Encounter, Performed: Office Visit" "Encounter, Performed: Face-to-Face Interaction" "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" "Encounter, Performed: Home Healthcare Services" "Encounter, Performed: Annual Wellness Visit" during "Measurement Period"For both the Claims and E.H.R. specifications, providers should limit office visit/E&M CPT codes 99201 - 99205 and 99211 - 99219 to primary care, outpatient specialty care where primary care is managed, and speciaty care related to diabetes management. Encounters may be limited by clinic, place of service, or physician but not by visit specific services.Denominator ExclusionsCLAIMS:Hospice services provided to patient any time during the measurement period: G9687E.H.R.: OR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Home for Hospice Care)" ends during "Measurement Period" OR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Health Care Facility for Hospice Care)" ends during "Measurement Period" OR: Union of: "Intervention, Order: Hospice care ambulatory" "Intervention, Performed: Hospice care ambulatory" overlaps "Measurement Period"Numerator DescriptionPatients whose blood pressure at the most recent visit is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement period Numerator Instructions: To describe both systolic and diastolic blood pressure values, each must be reported separately. If there are multiple blood pressures on the same date of service, use the lowest systolic and lowest diastolic blood pressure on that date as the representative blood pressure. NUMERATOR NOTE: In reference to the numerator element, only blood pressure readings performed by an eligible clinician in the provider office are acceptable for numerator compliance with this measure. Blood pressure readings from the patient's home (including readings directly from monitoring devices) are not acceptable.If no blood pressure is recorded during the measurement period, the patient's blood pressure is assumed "not controlled."If there are multiple blood pressure readings on the same day, use the lowest systolic and the lowest diastolic reading as the most recent blood pressure reading.Numerator Inclusions (Performance Met)CLAIMS:Most recent systolic blood pressure < 140 mmHg (G8752)ANDMost recent diastolic blood pressure < 90 mmHg (G8754)E.H.R.: AND: Most Recent: "Occurrence A of Encounter, Performed: Adult Outpatient Visit" satisfies all: during "Measurement Period" overlaps "Physical Exam, Performed: Diastolic Blood Pressure (result)" overlaps "Physical Exam, Performed: Systolic Blood Pressure (result)" overlaps "Occurrence A of Diagnosis: Essential Hypertension" AND: "Physical Exam, Performed: Diastolic Blood Pressure" satisfies all: Most Recent: during "Occurrence A of Encounter, Performed: Adult Outpatient Visit" (result < 90 mmHg) AND: "Physical Exam, Performed: Systolic Blood Pressure" satisfies all: Most Recent: during "Occurrence A of Encounter, Performed: Adult Outpatient Visit" (result < 140 mmHg)Numerator Exclusions (Performance Not Met)Most recent systolic blood pressure ≥ 140 mmHg (G8753)ORMost recent diastolic blood pressure ≥ 90 mmHg (G8755)ORNo documentation of blood pressure measurement, reason not given (G8756)DSRIP Specific ModificationsDenominator has been modified to follow the specifications of measure A1-115 Comprehensive Diabetes Care: HbA1c Poor Control (>9%). Numerator values were specified to follow the specifications of measure A2-103 Controlling High Blood Pressure (excluding the E.H.R. numerator inclusion elements requiring a hypertension diagnosis). Additional InformationNoneL1-210: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up DocumentedMeasure 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 indicatedL1-210: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up DocumentedDY7/DY8 Program IDL1-210Measure DetailsSteward: CMSNQF #: NASource: CMS MIPS #317 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionAll patients aged 18 years and olderDenominator InclusionsCLAIMS/REGISTRY:Patients aged ≥ 18 yearsANDPatient encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90839, 90845, 90880, 92002, 92004, 92012, 92014, 96118, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99281, 99282, 99283, 99284, 99285, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, D7140, D7210, G0101, G0402, G0438, G0439WITHOUTTelehealth Modifier: GQ, GT E.H.R.: AND: Age>= 18 year(s) at: "Measurement Period" AND: "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" during "Measurement Period"Denominator ExclusionsCLAIMS/REGISTRY:Patient not eligible due to active diagnosis of hypertension: G9744ORDocumented reason for not screening or recommending a follow-up for high blood pressure (G9745) Not Eligible for High Blood Pressure Screening (Denominator Exclusion)-? Patient has an active diagnosis of hypertension Patients with a Documented Reason for not Screening or Follow-Up Plan for High Blood Pressure (Denominator Exception)-? Patient refuses to participate (either BP measurement or follow-up)? 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. This may include but is not limited to severely elevated BP when immediate medical treatment is indicated E.H.R.: OR: "Diagnosis: Diagnosis of hypertension" starts before start of "Occurrence A of Encounter, Performed: BP Screening Encounter Codes"Numerator DescriptionPatients 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 NOTE: Although the recommended screening interval for a normal BP reading is every 2 years, to meet the intent of this measure, BP screening and follow-up must be performed once per measurement period. For patients with Normal blood pressure a follow-up plan is not required. If the blood pressure is pre-hypertensive (SBP > 120 and <139 OR DBP >80 and <89) at a PCP encounter no additional follow-up would be needed, this would meet the intent of the measure (G8783). Definitions:Blood Pressure (BP) Classification - BP is defined by four (4) BP reading classifications: Normal, Pre- Hypertensive, First Hypertensive, and Second Hypertensive ReadingsRecommended BP Follow-Up - The Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) recommends BP screening intervals, lifestyle modifications and interventions based on the current BP reading as listed in the “Recommended Blood Pressure Follow- Up Interventions” listed belowRecommended Lifestyle Modifications - The JNC 7 report outlines lifestyle modifications which must include one or more of the following as indicated:? Weight Reduction? Dietary Approaches to Stop Hypertension (DASH) Eating Plan? Dietary Sodium Restriction? Increased Physical Activity? Moderation in alcohol (ETOH) ConsumptionSecond Hypertensive Reading - Requires a BP reading of Systolic BP ≥ 140 mmHg OR Diastolic BP ≥ 90 mmHg during the current encounter AND a most recent BP reading within the last 12 months Systolic BP ≥ 140 mmHg OR Diastolic BP ≥ 90 mmHgSecond Hypertensive BP Reading Interventions - The JNC 7 report outlines BP follow-up interventions for a second hypertensive BP reading and must include one or more of the following as indicated:? Anti-Hypertensive Pharmacologic Therapy? Laboratory Tests? Electrocardiogram (ECG)Recommended Blood Pressure Follow-up Interventions -? Normal BP: No follow-up required for Systolic BP <120 mmHg AND Diastolic BP < 80 mmHg? Pre-Hypertensive BP: Follow-up with rescreen every year with systolic BP of 120 – 139 mmHg OR diastolic BP of 80 – 89 mmHg AND recommended lifestyle modifications OR referral to Alternate/Primary Care Provider? First Hypertensive BP Reading: Patients with one elevated reading of systolic BP >= 140 mmHg OR diastolic BP >= 90 mmHg:? Follow-up with rescreen > 1 day and < 4 weeks AND recommend lifestyle modifications OR referral to Alternative/Primary Care Provider? Second Hypertensive BP Reading: Patients with second elevated reading of systolic BP >= 140 mmHg OR diastolic BP >= 90 mmHg:? Follow-up with Recommended lifestyle modifications AND one or more of the Second Hypertensive Reading Interventions OR referral to Alternative/Primary Care Provider Recommended Blood Pressure Follow-Up (must include all indicated actions for each BP Classification): A. Normal BP Readiing (Systolic <120 AND Diastolic <80): No follow up required B. Pre-Hypertensive BP Reading (Systolic greater than or equal to 120 and less than or equal to 139, or Diastolic greater than or equal to 80 and less than or equal to 89):Rescreen BP within a minimum of 1 year AND recomemended Lifestyle Modifications OR Referal to Alternative/Primary Care Provider C. First Hypertensive BP Reading (Systolic greater than or equal to 140 or Diastolic greater than or equal to 90): Rescreen BP within a minimum of >1 day and <4 weeks AND recommend Lifestyle ModificationsORReferal to Alternative/Primary Care Provider D. Second Hypertensive BP Reading (Systolic greater than or equal to 140 or Diastolic greater than or equal to 90): Recommend Lifestyle Modifications AND 1 or more of the Second Hypertensive Reading Interventions (see definitions) ORReferral to Alternative/Primary Care ProviderNumerator Inclusions (Performance Met)CLAIMS/REGISTRY:Normal blood pressure reading documented, follow-up not required (G8783)ORPre-Hypertensive or Hypertensive blood pressure reading documented, AND the indicated follow-up is documented (G8950) E.H.R.: AND: Most Recent: "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" satisfies all: overlaps "Physical Exam, Performed: Diastolic Blood Pressure (result)" overlaps "Physical Exam, Performed: Systolic Blood Pressure (result)" AND: OR: AND: "Physical Exam, Performed: Systolic Blood Pressure" satisfies all: Most Recent: during "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" (result < 120 mmHg) AND: "Physical Exam, Performed: Diastolic Blood Pressure" satisfies all: Most Recent: during "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" (result < 80 mmHg) OR: AND: OR: AND: "Physical Exam, Performed: Systolic Blood Pressure" satisfies all: Most Recent: during "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" (result >= 120 mmHg) (result < 140 mmHg) AND: "Physical Exam, Performed: Diastolic Blood Pressure" satisfies all: Most Recent: during "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" (result < 90 mmHg) OR: AND: "Physical Exam, Performed: Diastolic Blood Pressure" satisfies all: Most Recent: during "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" (result >= 80 mmHg) (result < 90 mmHg) AND: "Physical Exam, Performed: Systolic Blood Pressure" satisfies all: Most Recent: during "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" (result < 140 mmHg) AND: OR: "Intervention, Order: Referral to Alternative Provider / Primary Care Provider (reason: Finding of Hypertension)" <= 1 day(s) starts after or concurrent with start of "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" OR: AND: $HypertensionRecommendations <= 1 day(s) starts after or concurrent with start of "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" AND: "Intervention, Order: Followup within one year (reason: Finding of Hypertension)" <= 1 day(s) starts after or concurrent with start of "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" OR: AND: OR: AND NOT: "Physical Exam, Performed: Systolic Blood Pressure (result)" < 1 year(s) starts before start of "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" AND NOT: "Physical Exam, Performed: Diastolic Blood Pressure (result)" < 1 year(s) starts before start of "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" OR: AND: "Physical Exam, Performed: Systolic Blood Pressure" satisfies all: Most Recent: < 1 year(s) starts before start of "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" (result < 140 mmHg) AND: "Physical Exam, Performed: Diastolic Blood Pressure" satisfies all: Most Recent: < 1 year(s) starts before start of "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" (result < 90 mmHg) AND: OR: "Physical Exam, Performed: Systolic Blood Pressure" satisfies all: Most Recent: during "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" (result >= 140 mmHg) OR: "Physical Exam, Performed: Diastolic Blood Pressure" satisfies all: Most Recent: during "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" (result >= 90 mmHg) AND: OR: "Intervention, Order: Referral to Alternative Provider / Primary Care Provider (reason: Finding of Hypertension)" <= 1 day(s) starts after or concurrent with start of "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" OR: AND: $HypertensionRecommendations <= 1 day(s) starts after or concurrent with start of "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" AND: "Intervention, Order: Followup within 4 weeks (reason: Finding of Hypertension)" <= 1 day(s) starts after or concurrent with start of "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" OR: AND: OR: "Physical Exam, Performed: Systolic Blood Pressure" satisfies all: Most Recent: < 1 year(s) starts before start of "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" (result >= 140 mmHg) OR: "Physical Exam, Performed: Diastolic Blood Pressure" satisfies all: Most Recent: < 1 year(s) starts before start of "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" (result >= 90 mmHg) AND: OR: "Physical Exam, Performed: Systolic Blood Pressure" satisfies all: Most Recent: during "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" (result >= 140 mmHg) OR: "Physical Exam, Performed: Diastolic Blood Pressure" satisfies all: Most Recent: during "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" (result >= 90 mmHg) AND: OR: "Intervention, Order: Referral to Alternative Provider / Primary Care Provider (reason: Finding of Hypertension)" <= 1 day(s) starts after or concurrent with start of "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" OR: AND: $HypertensionRecommendations <= 1 day(s) starts after or concurrent with start of "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" AND: Union of: "Medication, Order: Anti-Hypertensive Pharmacologic Therapy" "Laboratory Test, Order: Laboratory Tests for Hypertension" "Diagnostic Study, Order: ECG 12 lead or study order" <= 1 day(s) starts after or concurrent with start of "Occurrence A of Encounter, Performed: BP Screening Encounter Codes"Numerator Exclusions (Performance Not Met)CLAIMS/REGISTRY:Blood pressure reading not documented, reason not given (G8785)ORPre-Hypertensive or Hypertensive blood pressure reading documented, indicated follow-up not documented, reason not given (G8952) E.H.R.:NoneDSRIP Specific ModificationsNoneAdditional InformationE.H.R.:Data Criteria (QDM Variables):? $HypertensionRecommendations = o Union of: "Intervention, Order: Lifestyle Recommendation" "Intervention, Order: Weight Reduction Recommended" "Intervention, Order: Dietary Recommendations" "Intervention, Order: Physical Activity Recommendation" "Intervention, Order: Moderation of ETOH Consumption Recommendation" Data Criteria (QDM Data Elements):? "Diagnosis: Diagnosis of hypertension" using "Diagnosis of hypertension Grouping Value Set (2.16.840.1.113883.3.600.263)"? "Diagnostic Study, Order: ECG 12 lead or study order" using "ECG 12 lead or study order Grouping Value Set (2.16.840.1.113883.3.600.2448)"? "Diagnostic Study, Order not done: Patient Reason refused" using "Patient Reason refused SNOMEDCT Value Set (2.16.840.1.113883.3.600.791)"? "Encounter, Performed: BP Screening Encounter Codes" using "BP Screening Encounter Codes Grouping Value Set (2.16.840.1.113883.3.600.1920)"? "Intervention, Order: Dietary Recommendations" using "Dietary Recommendations Grouping Value Set (2.16.840.1.113883.3.600.1515)"? "Intervention, Order: Followup within 4 weeks" using "Followup within 4 weeks SNOMEDCT Value Set (2.16.840.1.113883.3.600.1537)"? "Intervention, Order: Followup within one year" using "Followup within one year SNOMEDCT Value Set (2.16.840.1.113883.3.600.1474)"? "Intervention, Order: Lifestyle Recommendation" using "Lifestyle Recommendation SNOMEDCT Value Set (2.16.840.1.113883.3.600.1508)"? "Intervention, Order: Moderation of ETOH Consumption Recommendation" using "Moderation of ETOH Consumption Recommendation SNOMEDCT Value Set (2.16.840.1.113883.3.600.823)"? "Intervention, Order: Physical Activity Recommendation" using "Physical Activity Recommendation Grouping Value Set (2.16.840.1.113883.3.600.1518)"? "Intervention, Order: Referral to Alternative Provider / Primary Care Provider" using "Referral to Alternative Provider / Primary Care Provider SNOMEDCT Value Set (2.16.840.1.113883.3.600.1475)"? "Intervention, Order: Weight Reduction Recommended" using "Weight Reduction Recommended Grouping Value Set (2.16.840.1.113883.3.600.1510)"? "Intervention, Order not done: Patient Reason refused" using "Patient Reason refused SNOMEDCT Value Set (2.16.840.1.113883.3.600.791)"? "Laboratory Test, Order: Laboratory Tests for Hypertension" using "Laboratory Tests for Hypertension Grouping Value Set (2.16.840.1.113883.3.600.1482)"? "Laboratory Test, Order not done: Patient Reason refused" using "Patient Reason refused SNOMEDCT Value Set (2.16.840.1.113883.3.600.791)"? "Medication, Order: Anti-Hypertensive Pharmacologic Therapy" using "Anti-Hypertensive Pharmacologic Therapy RXNORM Value Set (2.16.840.1.113883.3.600.1476)"? "Medication, Order not done: Patient Reason refused" using "Patient Reason refused SNOMEDCT Value Set (2.16.840.1.113883.3.600.791)"? "Physical Exam, Performed: Diastolic Blood Pressure" using "Diastolic Blood Pressure Grouping Value Set (2.16.840.1.113883.3.526.3.1033)"? "Physical Exam, Performed: Systolic Blood Pressure" using "Systolic Blood Pressure Grouping Value Set (2.16.840.1.113883.3.526.3.1032)"? "Physical Exam, Performed not done: Medical or Other reason not done" using "Medical or Other reason not done SNOMEDCT Value Set (2.16.840.1.113883.3.600.1.1502)"? "Physical Exam, Performed not done: Patient Reason refused" using "Patient Reason refused SNOMEDCT Value Set (2.16.840.1.113883.3.600.791)"? Attribute: "Reason: Finding of Hypertension" using "Finding of Hypertension SNOMEDCT Value Set (2.16.840.1.113883.3.600.2395)"L1-211: Weight Assessment and Counseling for Nutrition and Physical Activity for Children/ AdolescentsMeasure Description:Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported. - Percentage of patients with height, weight, and body mass index (BMI) percentile documentation- Percentage of patients with counseling for nutrition- Percentage of patients with counseling for physical activityL1-211: Weight Assessment and Counseling for Nutrition and Physical Activity for Children/ AdolescentsDY7/DY8 Program IDL1-211Measure DetailsSteward: NCQANQF #: 0024Source: eMeasure: SourceE.H.R.Required StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 3Achievement CalculationsCategory: P4PGoal Calculation: QISMCHPL: BMI Percentile: 0.8637Counseling for Nutrition: 0.7952 Counseling for Physical Activity: 0.7158MPL: BMI Percentile: 0.545Counseling for Nutrition: 0.5184Counseling for Physical Activity: 0.4509National Quality Compass 2016 - All LOBs: Average (90th and 25th percentiles)Directionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is eligible for a baseline numerator of 0 per PFM Section VI.22.b.i (page 24). If approved for a baseline of zero, the goals for DY7 and DY8 will be as follows for each measure part: - BMI Percentile: DY7 goal is 77.78% and DY8 goal of 78.64%- CDenominator DescriptionPatients 3-17 years of age with at least one outpatient visit with a primary care physician (PCP) or an obstetrician/gynecologist (OB/GYN) during the measurement period. Exclusions: Patients who have a diagnosis of pregnancy during the measurement period. Exclude patients who were in hospice care during the measurement year.Denominator InclusionsAND: Age >= 3 year(s) at: "Measurement Period" AND: Age < 17 year(s) at: "Measurement Period" AND: $OutpatientVisitsDenominator ExclusionsOR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Home for Hospice Care)" ends during "Measurement Period" OR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Health Care Facility for Hospice Care)" ends during "Measurement Period" OR: Union of: "Intervention, Order: Hospice care ambulatory" "Intervention, Performed: Hospice care ambulatory" overlaps "Measurement Period" OR: "Diagnosis: Pregnancy" overlaps "Measurement Period"Numerator DescriptionRate 1: Patients who had a height, weight and body mass index (BMI) percentile recorded during the measurement periodRate 2: Patients who had counseling for nutrition during a visit that occurs during the measurement periodRate 3: Patients who had counseling for physical activity during a visit that occurs during the measurement periodNumerator Inclusions (Performance Met)Population Criteria 1: AND: "Physical Exam, Performed: BMI percentile (result)" during "Measurement Period" AND: "Physical Exam, Performed: Height (result)" during "Measurement Period" AND: "Physical Exam, Performed: Weight (result)" during "Measurement Period" Population Criteria 2: AND: "Intervention, Performed: Counseling for Nutrition" during $OutpatientVisits Population Criteria 3: AND: "Intervention, Performed: Counseling for Physical Activity" during $OutpatientVisitsNumerator Exclusions (Performance Not Met)NoneDSRIP Specific ModificationsNoneAdditional InformationData Criteria (QDM Variables):? $OutpatientVisits = o Union of: "Encounter, Performed: Face-to-Face Interaction" "Encounter, Performed: Office Visit" "Encounter, Performed: Preventive Care Services-Individual Counseling" "Encounter, Performed: Preventive Care- Initial Office Visit, 0 to 17" "Encounter, Performed: Preventive Care - Established Office Visit, 0 to 17" "Encounter, Performed: Preventive Care Services - Group Counseling" "Encounter, Performed: Home Healthcare Services" during "Measurement Period"Data Criteria (QDM Data Elements):? "Diagnosis: Pregnancy" using "Pregnancy Grouping Value Set (2.16.840.1.113883.3.526.3.378)"? "Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient SNOMEDCT Value Set (2.16.840.1.113883.3.666.5.307)"? "Encounter, Performed: Face-to-Face Interaction" using "Face-to-Face Interaction Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1048)"? "Encounter, Performed: Home Healthcare Services" using "Home Healthcare Services Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1016)"? "Encounter, Performed: Office Visit" using "Office Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1001)"? "Encounter, Performed: Preventive Care - Established Office Visit, 0 to 17" using "Preventive Care - Established Office Visit, 0 to 17 Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1024)"? "Encounter, Performed: Preventive Care Services - Group Counseling" using "Preventive Care Services - Group Counseling Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1027)"? "Encounter, Performed: Preventive Care Services-Individual Counseling" using "Preventive Care Services-Individual Counseling Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1026)"? "Encounter, Performed: Preventive Care- Initial Office Visit, 0 to 17" using "Preventive Care- Initial Office Visit, 0 to 17 Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1022)"? "Intervention, Order: Hospice care ambulatory" using "Hospice care ambulatory SNOMEDCT Value Set (2.16.840.1.113762.1.4.1108.15)"? "Intervention, Performed: Counseling for Nutrition" using "Counseling for Nutrition Grouping Value Set (2.16.840.1.113883.3.464.1003.195.12.1003)"? "Intervention, Performed: Counseling for Physical Activity" using "Counseling for Physical Activity Grouping Value Set (2.16.840.1.113883.3.464.1003.118.12.1035)"? "Intervention, Performed: Hospice care ambulatory" using "Hospice care ambulatory SNOMEDCT Value Set (2.16.840.1.113762.1.4.1108.15)"? "Physical Exam, Performed: BMI percentile" using "BMI percentile Grouping Value Set (2.16.840.1.113883.3.464.1003.121.12.1012)"? "Physical Exam, Performed: Height" using "Height Grouping Value Set (2.16.840.1.113883.3.464.1003.121.12.1014)"? "Physical Exam, Performed: Weight" using "Weight Grouping Value Set (2.16.840.1.113883.3.464.1003.121.12.1015)"? Attribute: "Discharge status: Discharged to Health Care Facility for Hospice Care" using "Discharged to Health Care Facility for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.207)"? Attribute: "Discharge status: Discharged to Home for Hospice Care" using "Discharged to Home for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.209)"L1-224: Dental Sealant: ChildrenMeasure Description:Increase the proportion of children aged 6 to 9 years who have received dental sealants on one or more of their permanent first molar teethL1-224: Dental Sealant: ChildrenDY7/DY8 Program IDL1-224Measure DetailsSteward: Healthy People 2020NQF #: NASource: SourceAnyRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionNumber of children aged 6 to 9 with at least one permanent first molar present and valid sealant codes for at least one permanent first molarDenominator InclusionsNone listed by measure steward.Denominator ExclusionsNone listed by measure steward.Numerator DescriptionNumber of children aged 6 to 9 with a clinical confirmation of dental sealants applied to one or more first permanent molarsNumerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationNoneL1-225: Dental Caries: ChildrenMeasure Description:Percentage of children with untreated dental cariesL1-225: Dental Caries: ChildrenDY7/DY8 Program IDL1-225Measure DetailsSteward: Healthy People 2020NQF #: NASource: NAData SourceAnyRequired StatusOptionalMeasure ClassificationType: Clinical OutcomeMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: NegativeUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionTotal number of children that have seen a dental provider within the measurement periodDenominator InclusionsNoneDenominator ExclusionsNoneNumerator DescriptionNumber of children with untreated dental cariesNumerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationNoneL1-227: Dental Caries: AdultsMeasure Description:Percentage of adults aged 18 or more years with untreated dental decayL1-227: Dental Caries: AdultsDY7/DY8 Program IDL1-227Measure DetailsSteward: Healthy People 2020NQF #: NASource: NAData SourceAnyRequired StatusOptionalMeasure ClassificationType: Clinical OutcomeMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: NegativeUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionNumber of adults aged 18 or more years with at least one permanent tooth present and valid coronal caries codes for at least one permanent toothDenominator InclusionsNoneDenominator ExclusionsNoneNumerator DescriptionNumber of adults aged 18 years or more with coronal caries that has not been restored in at least one permanent toothNumerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationNoneL1-231: Preventive Services for Children at Elevated Caries RiskMeasure Description:Percentage of children who are at “elevated” risk (i.e., “moderate” or “high”) who received a topical fluoride application and/or sealants within the reporting yearL1-231: Preventive Services for Children at Elevated Caries RiskDY7/DY8 Program IDL1-231Measure DetailsSteward: American Dental AssociationNQF #: NASource: SourceClaimsRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionUnduplicated number of enrolled children at “elevated” risk (i.e., “moderate” or “high”)Denominator InclusionsNADenominator ExclusionsNANumerator DescriptionUnduplicated number of children at “elevated” risk (i.e., “moderate” or “high”) who received a topical fluoride application and/or sealants as a dental serviceNumerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsMeasure is specified for plan/program use. For DSRIP reporting purposes, references to continuous plan enrollment have been removed.NOTE: For DSRIP reporting purposes, providers can include children 18 and under to align with measure bundle F1, or children age 21 and under to align with measure steward recommendations.Additional InformationStep 1. Check if the enrollee meets age criterion at the last day of the reporting year: a. If age criterion is met, then proceed to next step. b. If age criterion is not met or there are missing or invalid field codes (e.g., birth date), then STOP processing. This enrollee does not get counted. Step 2. (Removed for DSRIP reporting purposes) Step 3. Check if subject is at “elevated risk”: a. If subject meets ANY of the following criteria, then include in denominator: i. the subject has a CDT Code among those in Table 1 in the reporting year, OR ii. the subject has a CDT Code among those in Table 1 in any of the three years prior to the reporting year, (NOTE: The subject does not need to be enrolled in any of the prior three years for the denominator enrollment criteria; this is a “look back” for enrollees who do have claims experience in any of the prior three years.) OR iii. the subject has a visit with a CDT code = (D0602 or D0603) in the reporting year. b. If the subject does not meet any of the above criteria for elevated risk, then STOP processing. This enrollee will not be included in the measure denominator. Step 4. Check if subject received topical fluoride or a sealant as dental service during the reporting year: a. If [CDT CODE] = D1206 or D12085 or D1351, AND b. If [RENDERING PROVIDER TAXONOMY] code = any of the NUCC maintained Provider Taxonomy Codes in Table 2 below, then include in numerator; proceed to next step.6 c. If both a AND b are not met, then the service was not a “dental service”; STOP processing. This enrollee is already included in the denominator but will not be included in the numerator. Note: In this step, all claims with missing or invalid CDT CODE, missing or invalid NUCC maintained Provider Taxonomy Codes, or NUCC maintained Provider Taxonomy Codes that do not appear in Table 2 should not be included in the numerator. Numerator: Step 4Denominator: Step 3 Tabe 1: CDT Codes to identify "elevated risk"D1354, D2140, D2150, D2160, D2161, D2330, D2331, D2332, D2335, D2390, D2391, D2392, D2393, D2394, D2410, D2420, D2430, D2510, D2520, D2530, D2542, D2543, D2544, D2610, D2620, D2630, D2642, D2643, D2644, D2650, D2651, D2652, D2662, D2663, D2664, D2710, D2712, D2720, D2721, D2722, D2740, D2750, D2751, D2752, D2780, D2781, D2782, D2783, D2790, D2791, D2792, D2794, D2799, D2930, D2931, D2932, D2933, D2934, D2940, D2941, D2950, D3110, D3120, D3220, D3221, D3222, D3230, D3240, D3310, D3320, D3330, Table 2: NUCC maintained Provider Taxonomy Codes classified as “Dental Service”*122300000X, 1223D0001X, 1223D0004X, 1223E0200X, 1223G0001X, 1223P0106X, 1223P0221X, 1223P0300X, 1223P0700X, 1223S0112X, 1223X0008X, 1223X0400X, 124Q00000X**, 125J00000X, 125K00000X, 125Q00000X, 261QF0400X, 261QR1300X* Services provided by County Health Department dental clinics may also be included as “dental” services.** Only dental hygienists who provide services under the supervision of a dentist should be classified as “dental” services. Services provided by independently practicing dental hygienists should be classified as “oral health” services and are not applicable to this measure.NOTE: Programs that do not use standard NUCC maintained provider taxonomy codes should use a valid mapping to identify providers whose services would be categorized as “dental” services. Stand-alone dental plans that reimburse ONLY for services rendered by or under the supervision of the dentist can consider all claims as “dental” services.L1-235: Post-Partum Follow-Up and Care CoordinationMeasure Description:Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for post-partum care within 8 weeks of giving birth who received a breast feeding evaluation and education, post-partum depression screening, post-partum glucose screening for gestational diabetes patients, and family and contraceptive planningL1-235: Post-Partum Follow-Up and Care CoordinationDY7/DY8 Program IDL1-235Measure DetailsSteward: CMSNQF #: NASource: PQRS #336Data SourceAnyRequired StatusOptionalMeasure ClassificationType: Clinical OutcomeMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionAll patients, regardless of age, who gave birth during a 12-month period seen for post-partum care visit before or at 8 weeks of giving birthDenominator InclusionsDenominator: All patients, regardless of ageANDPatient encounter during reporting period (CPT): 59400, 59410, 59430, 59510, 59515, 59610, 59614, 59618, 59622ANDPost-partum Care Visit before or at 8 weeks post-deliveryDenominator ExclusionsNANumerator DescriptionPatients receiving the following at a post-partum visit:- Breast feeding evaluation and education, including patient-reported breast feeding- Post-partum depression screening- Post-partum glucose screening for gestational diabetes patients and- Family and contraceptive planningNumerator Inclusions (Performance Met)Performance Met: Post-partum screenings, evaluations and education performed (G9357)Numerator Exclusions (Performance Not Met)Performance Not Met: Post-partum screenings, evaluations and education not performed (G9358)DSRIP Specific ModificationsFor DSRIP Reporting purposes providers may include all <=8 week postpartum visits in a 12 month period regardless of date of birth. Additional InformationDefinitions:Breast Feeding Evaluation and Education – Patients who were evaluated for breast feeding before or at 8 weeks post-partum.Post-Partum Depression Screening – Patients who were screened for post-partum depression before or at 8 weeks post-partum. Questions may be asked either directly by a health care provider or in the form of self-completed paper- or computer administered questionnaires and results should be documented in the medical record. Depression screening may include a self-reported validated depression screening tool (e.g., PHQ-2, Beck Depression Inventory, Beck Depression Inventory for Primary Care, Edinburgh Postnatal Depression Scale (EPDS).Post-Partum Glucose Screening for Gestational Diabetes – Patients who were diagnosed with gestational diabetes during pregnancy who were screened with a glucose screen before or at 8 weeks post-partum.Family and Contraceptive Planning – Patients who were provided family and contraceptive planning and education (including contraception, if necessary) before or at 8 weeks post-partum.Numerator Instruction: To satisfactorily meet the numerator ALL components (breast feeding evaluation and education, post-partum depression screening, family and contraceptive planning and post-partum glucose screening for patients with gestational diabetes) must be performed.L1-237: Well-Child Visits in the First 15 Months of Life (6 or more visits)Measure Description:The percentage of children 15 months old who had six or more well-child visits with a PCP during their first 15 months of life.L1-237: Well-Child Visits in the First 15 Months of Life (6 or more visits)DY7/DY8 Program IDL1-237Measure DetailsSteward: NCQANQF #: 1392Source: CMS Child Core SetData SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: QISMCHPL: 0.7388MPL: 0.5349National Quality Compass 2016 - All LOBs: Average (90th and 25th percentiles)Directionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is eligible for a baseline numerator of 0 per PFM Section VI.22.b.i (page 24). If approved for a baseline of zero, the DY7 goal will be 67.76% and DY8 goal of 68.37%.Denominator DescriptionChildren 15 months old during the measurement year.Denominator InclusionsNone listed by measure steward.Denominator ExclusionsNone listed by measure steward.Numerator DescriptionChildren who received six or more well-child visits with a PCP during their first 15 months of life.Numerator Inclusions (Performance Met)Children who received 6 or more well-child visits (Well-Care Value Set), on different dates of service, with a PCP during their first 15 months of life.The well-child visit must occur with a PCP, but the PCP does not have to be the practitioner assigned to the child. A Primary Care Practitionher (PCP) is a physician or nonphysician (e.g., nurse practitioner, physician assistant) who offers primary care medical services. Licensed practical nurses and registered nurses are not considered PCPs. Well-Care Value Set:CPT: 99381, 99382, 99383, 99384, 99385, 99391, 99392, 99393, 99394, 99395, 99461HCPS: G0438, G0439ICD-10-CM: Z00.00, Z00.01, Z00.110, Z00.111, Z00.121, Z00.129, Z00.5, Z00.8, Z02.0, Z02.1, Z02.2, Z02.3, Z02.4, Z02.5, Z02.6, Z02.71, Z02.79, Z02.81, Z02.82, Z02.83, Z02.89, Z02.9Numerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsThis measure was specified at the health plan level, and has been respecified from the CMS 2017 Child Core Set to remove requirements for continuous enrollment. For DSRIP reporting purposes, providers will report only children who received six or more visAdditional InformationInclude all paid, suspended, pending, and denied claims. Medical Record Review:- Documentation from the medical record must include a note indicating a visit with a PCP, the date when the well-child visit occurred and evidence of all of the following: ? A health history ? A physical developmental history ? A mental developmental history ? A physical exam ? Health education/anticipatory guidance- Do not include services rendered during an inpatient or emergency department (ED) visit.- Preventive services may be rendered on visits other than well-child visits. Well-child preventive services count toward the measure, regardless of the primary intent of the visit, but services that are specific to the assessment or treatment of an acute or chronic condition do not count toward the measure.- Services that occur over multiple visits may be counted, as long as all services occur in the time frame specified by the measure. L1-241: Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisonsMeasure Description:The percentage of individuals receiving the project intervention(s) who had a potentially preventable admission/readmission to a criminal justice setting (e.g. jail, prison, etc.) within the measurement periodL1-241: Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisonsDY7/DY8 Program IDL1-241Measure DetailsSteward: NoneNQF #: NASource: NAData SourceAnyRequired StatusOptionalMeasure ClassificationType: Clinical OutcomeMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: NegativeUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionNumber of individuals receiving project intervention(s)Denominator InclusionsDenominator:Number of individuals receiving project intervention(s)Numerator:If an individual has more than one jail booking occurrence within the measurement period, that individual would only be counted once in the numeratorDenominator ExclusionsNone listed by measure steward.Numerator DescriptionThe number of individuals receiving project intervention(s) who had a potentially preventable admission/readmission to a criminal justice setting (e.g. jail, prison, etc.) within the measurement period.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationNoneL1-242: Reduce Emergency Department visits for Chronic Ambulatory Care Sensitive Conditions (ACSC)Measure Description:Rate of Emergency Department (ED) utilization for ACSC:- Grand mal status and other epileptic convulsions- Chronic obstructive pulmonary diseases- Asthma- Heart failure and pulmonary edema- Hypertension- Angina, or- DiabetesL1-242: Reduce Emergency Department visits for Chronic Ambulatory Care Sensitive Conditions (ACSC)DY7/DY8 Program IDL1-242Measure DetailsSteward: NANQF #: NASource: SourceClaims, E.H.R.Required StatusOptionalMeasure ClassificationType: Clinical OutcomeMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: NegativeUnit of Measurement for Payer TypeUnit: EncountersMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionTotal number of ED visits for individuals 18 years or older during the measurement periodDenominator InclusionsNADenominator ExclusionsNANumerator DescriptionTotal number of ED Visits with a primary chronic ACSC diagnosis for any individual 18 years and older during the measurement periodNumerator Inclusions (Performance Met)Grand mal status and other epileptic convulsions: G40Chronic obstructive pulmonary diseases: J20, J40, J41, J42, J43, J44, J47, Acute bronchitis [J209] only with secondary diagnosis of J41, J42, J43, J44, J47Asthma: J45Heart failure and pulmonary edema: I50, I110, J810, Exclude cases with a surgical procedure starting with 02Hypertension: I10, I119, Exclude cases with a surgical procedure starting with 02Angina: I20, I240, I248, I249, Exclude cases with a surgical procedure starting with 0 or 1Diabetes: E101, E131, E110, E130, E10641, E11641, E106, E116, E108, E118, E109, E119Numerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationWhere only two digits are listed, all diagnoses at the 3rd, 4th, and 5th digit should be included (e.g., asthma is listed as J45, but you should include J45.20, J45.21, J45.22…J45.991, J45.998). Where only three digits are listed, all diagnoses at the 4th, and 5th digit should also be included etc., etc. All diagnoses refer to principal diagnosis, unless otherwise specified (e.g., dehydration, iron deficiency, nutritional deficiency, etc.). Where exclusions of surgical patients are specified (e.g., hypertension), search all procedure fields for excluded procedures.L1-268: Pneumonia vaccination status for older adultsMeasure Description:Percentage of patients 65 years of age and older who ever received a pneumococcal vaccination.L1-268: Pneumonia vaccination status for older adultsDY7/DY8 Program IDL1-268Measure DetailsSteward: CMSNQF #: 0043Source: CMS MIPS #111 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusOptionalMeasure ClassificationType: ImmunizationMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionPatients 65 years of age and older with a visit during the measurement period DENOMINATOR NOTE: This measure assesses whether patients 65 years of age or older have received one or more pneumococcal vaccinationsDenominator InclusionsCLAIMS/REGISTRY:Patients aged ≥ 65 years on date of encounterANDPatient encounter during the performance period (CPT or HCPCS): 99201, 99202, 99203, 99204,99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0402, G0438, G0439, 99387, 99397 E.H.R.: AND: Age>= 65 year(s) at: "Measurement Period" AND: Union of: "Encounter, Performed: Office Visit" "Encounter, Performed: Face-to-Face Interaction" "Encounter, Performed: Annual Wellness Visit" "Encounter, Performed: Home Healthcare Services" "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" during "Measurement Period"NOTE: Providers should limit office visit value set, and face-to-face-interaction value sets to primary care, outpatient specialty care where primary care is managed, and specialty care related to diabetes management. Encounters may be limited by clinic, place of service, or physician but not by visit specific services.Denominator ExclusionsCLAIMS/REGISTRY:Patient received hospice services any time during the measurement period: G9707 E.H.R.: OR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Home for Hospice Care)" ends during "Measurement Period" OR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Health Care Facility for Hospice Care)" ends during "Measurement Period" OR: Union of: "Intervention, Order: Hospice care ambulatory" "Intervention, Performed: Hospice care ambulatory" overlaps "Measurement Period"Numerator DescriptionPatients who have ever received a pneumococcal vaccination NUMERATOR NOTE: While the measure provides credit for adults 65 years of age and older who have ever received either the PCV13 or PPSV23 vaccine (or both), according to ACIP recommendations, patients should receive both vaccines. The order and timing of the vaccinations depends on certain patient characteristics, and are described in more detail in the ACIP recommendations.Numerator Inclusions (Performance Met)CLAIMS/REGISTRY:Pneumococcal vaccine administered or previously received (4040F) E.H.R.: AND: Union of: "Immunization, Administered: Pneumococcal Vaccine" "Procedure, Performed: Pneumococcal Vaccine Administered" "Assessment, Performed: History of Pneumococcal Vaccine" starts before or concurrent with end of "Measurement Period"Numerator Exclusions (Performance Not Met)CLAIMS/REGISTRY:Pneumococcal vaccine was not administered or previously received, reason not otherwise specified (4040F with 8P) E.H.R.:NoneDSRIP Specific ModificationsFor DSRIP reporting purpose, HHSC has added CPT values 99387 (Prev visit new age 65+), and 99397 (Prev visit est age 65+) to the denominator inclusions for the Claims version of the specifications.Additional InformationData Criteria (QDM Data Elements):? "Assessment, Performed: History of Pneumococcal Vaccine" using "History of Pneumococcal Vaccine Grouping Value Set (2.16.840.1.113883.3.464.1003.110.12.1028)"? "Encounter, Performed: Annual Wellness Visit" using "Annual Wellness Visit Grouping Value Set (2.16.840.1.113883.3.526.3.1240)"? "Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient SNOMEDCT Value Set (2.16.840.1.113883.3.666.5.307)"? "Encounter, Performed: Face-to-Face Interaction" using "Face-to-Face Interaction Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1048)"? "Encounter, Performed: Home Healthcare Services" using "Home Healthcare Services Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1016)"? "Encounter, Performed: Office Visit" using "Office Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1001)"? "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" using "Preventive Care Services - Established Office Visit, 18 and Up Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1025)"? "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" using "Preventive Care Services-Initial Office Visit, 18 and Up Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1023)"? "Immunization, Administered: Pneumococcal Vaccine" using "Pneumococcal Vaccine Grouping Value Set (2.16.840.1.113883.3.464.1003.110.12.1027)"? "Intervention, Order: Hospice care ambulatory" using "Hospice care ambulatory SNOMEDCT Value Set (2.16.840.1.113762.1.4.1108.15)"? "Intervention, Performed: Hospice care ambulatory" using "Hospice care ambulatory SNOMEDCT Value Set (2.16.840.1.113762.1.4.1108.15)"? "Procedure, Performed: Pneumococcal Vaccine Administered" using "Pneumococcal Vaccine Administered Grouping Value Set (2.16.840.1.113883.3.464.1003.110.12.1034)"? Attribute: "Discharge status: Discharged to Health Care Facility for Hospice Care" using "Discharged to Health Care Facility for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.207)"? Attribute: "Discharge status: Discharged to Home for Hospice Care" using "Discharged to Home for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.209)"L1-269: Preventive Care and Screening: Influenza ImmunizationMeasure Description:Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunizationL1-269: Preventive Care and Screening: Influenza ImmunizationDY7/DY8 Program IDL1-269Measure DetailsSteward: AMA / PCPINQF #: 0041 / 3070 eMeasureSource: CMS MIPS #110 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusOptionalMeasure ClassificationType: ImmunizationMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsMeasure is NOT eligible for a shortened baseline measurement period.Measure is not eligible for a baseline of 0.Denominator DescriptionAll patients aged 6 months and older seen for at least two visits or at least one preventive visit during the measurement periodDenominator InclusionsCLAIMS/REGISTRY:Patients aged ≥ 6 months seen for a visit between October 1 and March 31ANDAt least two patient encounters with at least one encounter during January thru March and/or October thru December (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241*, 99242*, 99243*, 99244*, 99245*, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350WITHOUT:Telehealth Modifier: GQ, GTORAt least one encounter - January thru March and/or October thru December (CPT or HCPCS): 90945, 90947, 90951, 90952, 90953, 90954, 90955, 90956, 90957, 90958, 90959, 90960, 90961, 90962, 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 96160, 96161, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99381*, 99382*, 99383*, 99384*, 99385*, 99386*, 99387*, 99391*, 99392*, 99393*, 99394*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99429*, 99512*, G0438, G0439WITHOUT:Telehealth Modifier: GQ, GT E.H.R.:Initial Population = AND: Age>= 6 month(s) at: "Measurement Period" AND: OR: Count>= 2 : Union of: "Encounter, Performed: Office Visit" "Encounter, Performed: Outpatient Consultation" "Encounter, Performed: Care Services in Long-Term Residential Facility" "Encounter, Performed: Home Healthcare Services" "Encounter, Performed: Patient Provider Interaction" during "Measurement Period" OR: Count>= 1 : Union of: "Encounter, Performed: Preventive Care- Initial Office Visit, 0 to 17" "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" "Encounter, Performed: Preventive Care Services-Individual Counseling" "Encounter, Performed: Preventive Care Services - Group Counseling" "Encounter, Performed: Preventive Care Services - Other" "Encounter, Performed: Discharge Services - Nursing Facility" "Encounter, Performed: Nursing Facility Visit" "Encounter, Performed: Annual Wellness Visit" "Procedure, Performed: Peritoneal Dialysis" "Procedure, Performed: Hemodialysis" "Encounter, Performed: Preventive Care - Established Office Visit, 0 to 17" "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" "Encounter, Performed: Face-to-Face Interaction" during "Measurement Period"Denominator = AND: Initial Population AND: OR: "Encounter, Performed: Encounter-Influenza" satisfies any: <= 92 day(s) starts before or concurrent with start of "Measurement Period" <= 89 day(s) starts after or concurrent with start of "Measurement Period" OR: "Procedure, Performed: Hemodialysis" satisfies any: <= 92 day(s) starts before or concurrent with start of "Measurement Period" <= 89 day(s) starts after or concurrent with start of "Measurement Period" OR: "Procedure, Performed: Peritoneal Dialysis" satisfies any: <= 92 day(s) starts before or concurrent with start of "Measurement Period" <= 89 day(s) starts after or concurrent with start of "Measurement Period"Denominator ExclusionsCLAIMS/REGISTRY:Influenza immunization was not administered for reasons documented by clinician (e.g., patient allergy or other medical reasons, patient declined or other patient reasons, vaccine not available or other system reasons) (G8483) E.H.R.:Denominator Exceptions =OR: Union of: - "Communication: From Patient to Provider: Influenza Vaccination Declined" - "Procedure, Performed not done: Medical Reason" for "Influenza Vaccination" - "Procedure, Performed not done: Patient Reason" for "Influenza Vaccination" - "Procedure, Performed not done: System Reason" for "Influenza Vaccination" - "Immunization, Administered not done: Medical Reason" for "Influenza Vaccine" - "Immunization, Administered not done: Patient Reason" for "Influenza Vaccine" - "Immunization, Administered not done: System Reason" for "Influenza Vaccine" - <= 153 day(s) starts before or concurrent with start of "Measurement Period"OR: Union of: - "Communication: From Patient to Provider: Influenza Vaccination Declined" - "Procedure, Performed not done: Medical Reason" for "Influenza Vaccination" - "Procedure, Performed not done: Patient Reason" for "Influenza Vaccination" - "Procedure, Performed not done: System Reason" for "Influenza Vaccination" - "Immunization, Administered not done: Medical Reason" for "Influenza Vaccine" - "Immunization, Administered not done: Patient Reason" for "Influenza Vaccine" - "Immunization, Administered not done: System Reason" for "Influenza Vaccine" - <= 89 day(s) starts after or concurrent with start of "Measurement Period"OR: - AND: "Occurrence A of Diagnosis: Allergy to Eggs" overlaps "Measurement Period" - AND NOT: "Occurrence A of Diagnosis: Allergy to Eggs" > 89 day(s) starts after start of "Measurement Period" - AND NOT: "Occurrence A of Diagnosis: Allergy to Eggs" <= 89 day(s) ends after start of "Measurement Period"OR: - AND: "Occurrence A of Diagnosis: Allergy to Influenza Vaccine" overlaps "Measurement Period" - AND NOT: "Occurrence A of Diagnosis: Allergy to Influenza Vaccine" > 89 day(s) starts after start of "Measurement Period" - AND NOT: "Occurrence A of Diagnosis: Allergy to Influenza Vaccine" <= 89 day(s) ends after start of "Measurement Period"OR: - AND: "Occurrence A of Diagnosis: Intolerance to Influenza Vaccine" overlaps "Measurement Period" - AND NOT: "Occurrence A of Diagnosis: Intolerance to Influenza Vaccine" > 89 day(s) starts after start of "Measurement Period" - AND NOT: "Occurrence A of Diagnosis: Intolerance to Influenza Vaccine" <= 89 day(s) ends after start of "Measurement Period"OR: - AND: "Occurrence A of Procedure, Intolerance: Influenza Vaccination" overlaps "Measurement Period" - AND NOT: "Occurrence A of Procedure, Intolerance: Influenza Vaccination" > 89 day(s) starts after start of "Measurement Period" - AND NOT: "Occurrence A of Procedure, Intolerance: Influenza Vaccination" <= 89 day(s) ends after start of "Measurement Period"OR: - AND: "Occurrence A of Immunization, Intolerance: Influenza Vaccine" overlaps "Measurement Period" - AND NOT: "Occurrence A of Immunization, Intolerance: Influenza Vaccine" > 89 day(s) starts after start of "Measurement Period" - AND NOT: "Occurrence A of Immunization, Intolerance: Influenza Vaccine" <= 89 day(s) ends after start of "Measurement Period"OR: - AND: "Occurrence A of Immunization, Allergy: Influenza Vaccine" overlaps "Measurement Period" - AND NOT: "Occurrence A of Immunization, Allergy: Influenza Vaccine" > 89 day(s) starts after start of "Measurement Period" - AND NOT: "Occurrence A of Immunization, Allergy: Influenza Vaccine" <= 89 day(s) ends after start of "Measurement Period"Numerator DescriptionPatients who received an influenza immunization OR who reported previous receipt of an influenza immunization Numerator Instructions:The numerator for this measure can be met by reporting either administration of an influenza vaccination or that the patient reported previous receipt of the current season’s influenza immunization. If the performance of the numerator is not met, an eligible clinician can report a valid denominator exception for having not administered an influenza vaccination. For eligible clinicians reporting a denominator exception for this measure, there should be a clear rationale and documented reason for not administering an influenza immunization if the patient did not indicate previous receipt, which could include a medical reason (e.g., patient allergy), patient reason (e.g., patient declined), or system reason (e.g., vaccination not available). The system reason should be indicated only for cases of disruption or shortage of influenza vaccination supply. Definition:Previous Receipt – Receipt of the current season’s influenza immunization from another provider OR from same provider prior to the visit to which the measure is applied (typically, prior vaccination would include influenza vaccine given since August 1st).Numerator Inclusions (Performance Met)CLAIMS/REGISTRY:Influenza immunization administered or previously received (G8482) E.H.R.: AND: OR: "Procedure, Performed: Influenza Vaccination" satisfies any: <= 153 day(s) starts before or concurrent with start of "Measurement Period" <= 89 day(s) starts after or concurrent with start of "Measurement Period" OR: "Immunization, Administered: Influenza Vaccine" satisfies any: <= 153 day(s) starts before or concurrent with start of "Measurement Period" <= 89 day(s) starts after or concurrent with start of "Measurement Period" OR: "Communication: From Patient to Provider: Previous Receipt of Influenza Vaccine" satisfies any: <= 153 day(s) starts before or concurrent with start of "Measurement Period" <= 89 day(s) starts after or concurrent with start of "Measurement Period"Numerator Exclusions (Performance Not Met)CLAIMS/REGISTRY:Influenza immunization was not administered, reason not given (G8484) E.H.R.:NoneDSRIP Specific ModificationsNoneAdditional InformationData Criteria (QDM Data Elements):? "Communication: From Patient to Provider: Influenza Vaccination Declined" using "Influenza Vaccination Declined Grouping Value Set (2.16.840.1.113883.3.526.3.1255)"? "Communication: From Patient to Provider: Previous Receipt of Influenza Vaccine" using "Previous Receipt of Influenza Vaccine Grouping Value Set (2.16.840.1.113883.3.526.3.1185)"? "Diagnosis: Allergy to Eggs" using "Allergy to Eggs Grouping Value Set (2.16.840.1.113883.3.526.3.1253)"? "Diagnosis: Allergy to Influenza Vaccine" using "Allergy to Influenza Vaccine Grouping Value Set (2.16.840.1.113883.3.526.3.1256)"? "Diagnosis: Intolerance to Influenza Vaccine" using "Intolerance to Influenza Vaccine Grouping Value Set (2.16.840.1.113883.3.526.3.1257)"? "Encounter, Performed: Annual Wellness Visit" using "Annual Wellness Visit Grouping Value Set (2.16.840.1.113883.3.526.3.1240)"? "Encounter, Performed: Care Services in Long-Term Residential Facility" using "Care Services in Long-Term Residential Facility Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1014)"? "Encounter, Performed: Discharge Services - Nursing Facility" using "Discharge Services - Nursing Facility Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1013)"? "Encounter, Performed: Encounter-Influenza" using "Encounter-Influenza Grouping Value Set (2.16.840.1.113883.3.526.3.1252)"? "Encounter, Performed: Face-to-Face Interaction" using "Face-to-Face Interaction Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1048)"? "Encounter, Performed: Home Healthcare Services" using "Home Healthcare Services Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1016)"? "Encounter, Performed: Nursing Facility Visit" using "Nursing Facility Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1012)"? "Encounter, Performed: Office Visit" using "Office Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1001)"? "Encounter, Performed: Outpatient Consultation" using "Outpatient Consultation Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1008)"? "Encounter, Performed: Patient Provider Interaction" using "Patient Provider Interaction Grouping Value Set (2.16.840.1.113883.3.526.3.1012)"? "Encounter, Performed: Preventive Care - Established Office Visit, 0 to 17" using "Preventive Care - Established Office Visit, 0 to 17 Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1024)"? "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" using "Preventive Care Services - Established Office Visit, 18 and Up Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1025)"? "Encounter, Performed: Preventive Care Services - Group Counseling" using "Preventive Care Services - Group Counseling Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1027)"? "Encounter, Performed: Preventive Care Services - Other" using "Preventive Care Services - Other Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1030)"? "Encounter, Performed: Preventive Care Services-Individual Counseling" using "Preventive Care Services-Individual Counseling Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1026)"? "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" using "Preventive Care Services-Initial Office Visit, 18 and Up Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1023)"? "Encounter, Performed: Preventive Care- Initial Office Visit, 0 to 17" using "Preventive Care- Initial Office Visit, 0 to 17 Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1022)"? "Immunization, Administered: Influenza Vaccine" using "Influenza Vaccine Grouping Value Set (2.16.840.1.113883.3.526.3.1254)"? "Immunization, Administered not done: Medical Reason" using "Medical Reason Grouping Value Set (2.16.840.1.113883.3.526.3.1007)"? "Immunization, Administered not done: Patient Reason" using "Patient Reason Grouping Value Set (2.16.840.1.113883.3.526.3.1008)"? "Immunization, Administered not done: System Reason" using "System Reason Grouping Value Set (2.16.840.1.113883.3.526.3.1009)"? "Immunization, Allergy: Influenza Vaccine" using "Influenza Vaccine Grouping Value Set (2.16.840.1.113883.3.526.3.1254)"? "Immunization, Intolerance: Influenza Vaccine" using "Influenza Vaccine Grouping Value Set (2.16.840.1.113883.3.526.3.1254)"? "Procedure, Intolerance: Influenza Vaccination" using "Influenza Vaccination Grouping Value Set (2.16.840.1.113883.3.526.3.402)"? "Procedure, Performed: Hemodialysis" using "Hemodialysis Grouping Value Set (2.16.840.1.113883.3.526.3.1083)"? "Procedure, Performed: Influenza Vaccination" using "Influenza Vaccination Grouping Value Set (2.16.840.1.113883.3.526.3.402)"? "Procedure, Performed: Peritoneal Dialysis" using "Peritoneal Dialysis Grouping Value Set (2.16.840.1.113883.3.526.3.1084)"? "Procedure, Performed not done: Medical Reason" using "Medical Reason Grouping Value Set (2.16.840.1.113883.3.526.3.1007)"? "Procedure, Performed not done: Patient Reason" using "Patient Reason Grouping Value Set (2.16.840.1.113883.3.526.3.1008)"? "Procedure, Performed not done: System Reason" using "System Reason Grouping Value Set (2.16.840.1.113883.3.526.3.1009)"L1-271: Immunization for AdolescentsMeasure Description:The percentage of adolescents 13 years of age who had the recommended immunizations by their 13th birthdayL1-271: Immunization for AdolescentsDY7/DY8 Program IDL1-271Measure DetailsSteward: NCQANQF #: 1407Source: CMS MIPS #394 (Claims/Registry)Data SourceClaims, E.H.R.Required StatusOptionalMeasure ClassificationType: ImmunizationMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: QISMCHPL: 0.3039MPL: 0.1587National Quality Compass 2017 - All LOBs: Average (90th and 25th percentiles)Directionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is eligible for a baseline numerator of 0 per PFM Section VI.22.b.i (page 24). If approved for a baseline of zero, the DY7 goal will be 82.09% and DY8 goal of 82.54%.Denominator DescriptionAdolescents who turn 13 years of age during the measurement periodDenominator InclusionsPatients who turn 13 years of age during the measurement periodANDPatient encounter during the performance period (CPT or HCPCS): 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, G0402, 99384, 99394Denominator ExclusionsMeningococcal, Tdap and/or HPV vaccine contraindicated OR patient allergic to the meningococcal, Tdap, and/or HPV vaccineORPatients who use hospice services any time during the measurement period: G9761Numerator DescriptionAdolescents who had one dose of meningococcal vaccine on or between the patient’s 11th and 13th birthdays AND one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) on or between the patient’s 10th and 13th birthdays AND at least TWO HPV vaccines on or between the patient’s 9th and 13th birthdaysNumerator Inclusions (Performance Met)Patient had one dose of meningococcal vaccine on or between the patient’s 11th and 13th birthdays (G9414)ANDPatient had one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) on or between the patient’s 10th and 13th birthdays (G9416)ANDPatient had at least TWO HPV vaccines on or between the patient’s 9th and 13th birthdays (G9762)Numerator Exclusions (Performance Not Met)Patient did not have one dose of meningococcal vaccine on or between the patient’s 11th and 13th birthdays (G9415)ORPatient did not have one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) on or between the patient’s 10th and 13th birthdays (G9417)ORPatient did not have at least TWO HPV vaccines on or between the patient’s 9th and 13th birthdays (G9763)DSRIP Specific ModificationsFor DSRIP reporting purposes, HHSC has added CPT values 99384 (Prev visit new age 12-17) and 99394 (Prev visit est age 12-17) to the denominator inclusions.Under CMS MIPS specifications, measure is reported as 4 rates. HHSC combined specifications for rates 1 - 3 so that provider reports one rate for DSRIP purposes that is equivalent to rate 4 of the QPP specifications. As of December 2016, CDC recommends a two dose schedule for girls and boys who initiate the vaccine series at ages 9 - 14. Measure specifications have been updated to reflect this two dose schedule, rather than a three does schedule. Meites E, Kempe A, Markowitz LE. Use of a 2-Dose Schedule for Human Papillomavirus Vaccination — Updated Recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep 2016;65:1405–1408. DOI: InformationNoneL1-272: Adults (18+ years) Immunization statusMeasure Description:Percentage of adult patients 18 years and older who are up-to-date with the following immunizations at their most recent visit:- One tetanus and diphtheria toxoids (Td) vaccine in the last 10 years- Varicella – two doses or history of disease up to year 1995- Pneumococcal polysaccharide vaccine (PPSV23 or PCV13) for patients 65 and older- One influenza within last year- Herpes zoster/shingles (patients 60 years and older)L1-272: Adults (18+ years) Immunization statusDY7/DY8 Program IDL1-272Measure DetailsSteward: Institute for Clinical Systems ImprovementNQF #: NASource: CDC Recommended immunization schedule for adults aged 19 years and older, United States, 2017 SourceE.H.R.Required StatusOptionalMeasure ClassificationType: ImmunizationMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionNumber of patients 18 years and older at the beginning of the measurement period.Denominator InclusionsA visit during the measurement yearDenominator ExclusionsDenominator Exclusions: Patients with immunization contraindications listed in the medical record should be excludedNumerator DescriptionNumber of patients who are up-to-date with following immunizations:-One tetanus and diphtheria toxoids (Td) vaccine in the last 10 years-Varicella – two doses or evidence of immunity-Pneumococcal polysaccharide vaccine (PPSV23 or PCV13) for patients 65 and older at the beginning of the measurement period-One influenza dose within the last year-One dose Herpes zoster/shingles (patients 60 years and older at the beginning of the measurement period)NOTE: To align with measure L1-268 Pneumonia Vaccination Status for Older Adults, providers may include adults 65 years of age and older who have ever received either the PCV13 or PPSV23 vaccine (or both). According to ACIP recommendations, patients should receive both vaccines. The order and timing of the vaccinations depends on certain patient characteristics, and are described in more detail in the ACIP recommendations.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationPer the CDC immunization schedule for adults age 19 years and older US 2017, evidence of immunity to varicella in adults is: - US born before 1980; - documentation of 2 doses of VAR at least 4 weeks apart; - history of varicella or herpes zoster diagnosis or verification of herpes of varicella or herpes zoster disease by a healthcare provider; - or laboratory evidence of immunity or disease.L1-280: Chlamydia Screening in Women (CHL)Measure Description:The percentage of women 16–24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year.L1-280: Chlamydia Screening in Women (CHL)DY7/DY8 Program IDL1-280Measure DetailsSteward: NCQANQF #: 0033Source: eMeasure: SourceE.H.R.Required StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: QISMCHPL: 0.6892MPL: 0.4881National Quality Compass 2016 - All LOBs: Average (90th and 25th percentiles)Directionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is eligible for a baseline numerator of 0 per PFM Section VI.22.b.i (page 24). If approved for a baseline of zero, the DY7 goal will be 61.69% and DY8 goal of 62.41%.Denominator DescriptionWomen 16 to 24 years of age who are sexually active and who had a visit in the measurement period Exclusions: Women who are only eligible for the initial population due to a pregnancy test and who had an x-ray or an order for a specified medication within 7 days of the pregnancy test. Exclude patients who were in hospice care during the measurement year.Denominator InclusionsAND: Age>= 16 year(s) at: "Measurement Period" AND: Age< 24 year(s) at: "Measurement Period" AND: "Patient Characteristic Sex: Female" AND: Union of: "Encounter, Performed: Office Visit" "Encounter, Performed: Face-to-Face Interaction" "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" "Encounter, Performed: Preventive Care - Established Office Visit, 0 to 17" "Encounter, Performed: Preventive Care- Initial Office Visit, 0 to 17" "Encounter, Performed: Home Healthcare Services" during "Measurement Period" AND: OR: "Assessment, Performed: Sexually Active (result: Yes Response)" starts before end of "Measurement Period" OR: Union of: "Diagnosis: Other Female Reproductive Conditions" "Diagnosis: Genital Herpes" "Diagnosis: Gonococcal Infections and Venereal Diseases" "Medication, Active: Contraceptive Medications" "Diagnosis: Inflammatory Diseases of Female Reproductive Organs" "Diagnosis: Chlamydia" "Diagnosis: HIV" "Diagnosis: Syphilis" "Diagnosis: Complications of Pregnancy, Childbirth and the Puerperium" overlaps "Measurement Period" OR: Union of: "Laboratory Test, Order: Pregnancy Test" "Laboratory Test, Order: Pap Test" "Procedure, Performed: Delivery Live Births" "Laboratory Test, Order: Lab Tests During Pregnancy" "Laboratory Test, Order: Lab Tests for Sexually Transmitted Infections" "Medication, Order: Contraceptive Medications" "Diagnostic Study, Order: Diagnostic Studies During Pregnancy" "Procedure, Performed: Procedures During Pregnancy" "Procedure, Performed: Procedures Involving Contraceptive Devices" during "Measurement Period"Denominator ExclusionsOR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Home for Hospice Care)" ends during "Measurement Period" OR: "Encounter, Performed: Encounter Inpatient (discharge status: Discharged to Health Care Facility for Hospice Care)" ends during "Measurement Period" OR: Union of: "Intervention, Order: Hospice care ambulatory" "Intervention, Performed: Hospice care ambulatory" overlaps "Measurement Period" OR: AND: Union of: "Medication, Order: Isotretinoin" "Diagnostic Study, Order: X-Ray Study (all inclusive)" <= 7 day(s) starts after end of ("Laboratory Test, Order: Pregnancy Test" during "Measurement Period" ) AND NOT: Union of: Union of: "Diagnosis: Other Female Reproductive Conditions" "Diagnosis: Genital Herpes" "Diagnosis: Gonococcal Infections and Venereal Diseases" "Medication, Active: Contraceptive Medications" "Diagnosis: Inflammatory Diseases of Female Reproductive Organs" "Diagnosis: Chlamydia" "Diagnosis: HIV" "Diagnosis: Syphilis" "Diagnosis: Complications of Pregnancy, Childbirth and the Puerperium" overlaps "Measurement Period" Union of: "Laboratory Test, Order: Pap Test" "Procedure, Performed: Delivery Live Births" "Laboratory Test, Order: Lab Tests During Pregnancy" "Laboratory Test, Order: Lab Tests for Sexually Transmitted Infections" "Medication, Order: Contraceptive Medications" "Diagnostic Study, Order: Diagnostic Studies During Pregnancy" "Procedure, Performed: Procedures During Pregnancy" "Procedure, Performed: Procedures Involving Contraceptive Devices" during "Measurement Period"Numerator DescriptionWomen with at least one chlamydia test during the measurement periodNumerator Inclusions (Performance Met)AND: "Laboratory Test, Performed: Chlamydia Screening (result)" during "Measurement Period"Numerator Exclusions (Performance Not Met)NoneDSRIP Specific ModificationsNoneAdditional InformationGuidance:- Codes to identify sexually active women include codes for: pregnancy, sexually transmitted infections, contraceptives or contraceptive devices, and infertility treatments.- The denominator exclusion does not apply to patients who qualify for the initial population (IP) based on services other than the pregnancy test alone. These other services include services for sexually transmitted infections, contraceptives or contraceptive devices and infertility treatments. For example, a patient who has both a pregnancy test and a chlamydia diagnosis, either of which would qualify them for the IP, would not be eligible for this denominator exclusion.- Patient self-report for procedures as well as diagnostic studies should be recorded in 'Procedure, Performed' template or 'Diagnostic Study, Performed' template in QRDA-1. Patient self-report is not allowed for laboratory tests. Data Criteria (QDM Data Elements):? "Assessment, Performed: Sexually Active" using "Sexually Active Grouping Value Set (2.16.840.1.113883.3.464.1003.121.12.1040)"? "Diagnosis: Chlamydia" using "Chlamydia Grouping Value Set (2.16.840.1.113883.3.464.1003.112.12.1003)"? "Diagnosis: Complications of Pregnancy, Childbirth and the Puerperium" using "Complications of Pregnancy, Childbirth and the Puerperium Grouping Value Set (2.16.840.1.113883.3.464.1003.111.12.1012)"? "Diagnosis: Genital Herpes" using "Genital Herpes Grouping Value Set (2.16.840.1.113883.3.464.1003.110.12.1049)"? "Diagnosis: Gonococcal Infections and Venereal Diseases" using "Gonococcal Infections and Venereal Diseases Grouping Value Set (2.16.840.1.113883.3.464.1003.112.12.1001)"? "Diagnosis: HIV" using "HIV Grouping Value Set (2.16.840.1.113883.3.464.1003.120.12.1003)"? "Diagnosis: Inflammatory Diseases of Female Reproductive Organs" using "Inflammatory Diseases of Female Reproductive Organs Grouping Value Set (2.16.840.1.113883.3.464.1003.112.12.1004)"? "Diagnosis: Other Female Reproductive Conditions" using "Other Female Reproductive Conditions Grouping Value Set (2.16.840.1.113883.3.464.1003.111.12.1006)"? "Diagnosis: Syphilis" using "Syphilis Grouping Value Set (2.16.840.1.113883.3.464.1003.112.12.1002)"? "Diagnostic Study, Order: Diagnostic Studies During Pregnancy" using "Diagnostic Studies During Pregnancy Grouping Value Set (2.16.840.1.113883.3.464.1003.111.12.1008)"? "Diagnostic Study, Order: X-Ray Study (all inclusive)" using "X-Ray Study (all inclusive) Grouping Value Set (2.16.840.1.113883.3.464.1003.198.12.1034)"? "Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient SNOMEDCT Value Set (2.16.840.1.113883.3.666.5.307)"? "Encounter, Performed: Face-to-Face Interaction" using "Face-to-Face Interaction Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1048)"? "Encounter, Performed: Home Healthcare Services" using "Home Healthcare Services Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1016)"? "Encounter, Performed: Office Visit" using "Office Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1001)"? "Encounter, Performed: Preventive Care - Established Office Visit, 0 to 17" using "Preventive Care - Established Office Visit, 0 to 17 Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1024)"? "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" using "Preventive Care Services - Established Office Visit, 18 and Up Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1025)"? "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" using "Preventive Care Services-Initial Office Visit, 18 and Up Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1023)"? "Encounter, Performed: Preventive Care- Initial Office Visit, 0 to 17" using "Preventive Care- Initial Office Visit, 0 to 17 Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1022)"? "Intervention, Order: Hospice care ambulatory" using "Hospice care ambulatory SNOMEDCT Value Set (2.16.840.1.113762.1.4.1108.15)"? "Intervention, Performed: Hospice care ambulatory" using "Hospice care ambulatory SNOMEDCT Value Set (2.16.840.1.113762.1.4.1108.15)"? "Laboratory Test, Order: Lab Tests During Pregnancy" using "Lab Tests During Pregnancy Grouping Value Set (2.16.840.1.113883.3.464.1003.111.12.1007)"? "Laboratory Test, Order: Lab Tests for Sexually Transmitted Infections" using "Lab Tests for Sexually Transmitted Infections Grouping Value Set (2.16.840.1.113883.3.464.1003.110.12.1051)"? "Laboratory Test, Order: Pap Test" using "Pap Test Grouping Value Set (2.16.840.1.113883.3.464.1003.108.12.1017)"? "Laboratory Test, Order: Pregnancy Test" using "Pregnancy Test Grouping Value Set (2.16.840.1.113883.3.464.1003.111.12.1011)"? "Laboratory Test, Performed: Chlamydia Screening" using "Chlamydia Screening Grouping Value Set (2.16.840.1.113883.3.464.1003.110.12.1052)"? "Medication, Active: Contraceptive Medications" using "Contraceptive Medications Grouping Value Set (2.16.840.1.113883.3.464.1003.196.12.1080)"? "Medication, Order: Contraceptive Medications" using "Contraceptive Medications Grouping Value Set (2.16.840.1.113883.3.464.1003.196.12.1080)"? "Medication, Order: Isotretinoin" using "Isotretinoin Grouping Value Set (2.16.840.1.113883.3.464.1003.196.12.1143)"? "Patient Characteristic Sex: Female" using "Female AdministrativeGender Value Set (2.16.840.1.113883.3.560.100.2)"? "Procedure, Performed: Delivery Live Births" using "Delivery Live Births Grouping Value Set (2.16.840.1.113883.3.464.1003.111.12.1015)"? "Procedure, Performed: Procedures During Pregnancy" using "Procedures During Pregnancy Grouping Value Set (2.16.840.1.113883.3.464.1003.111.12.1009)"? "Procedure, Performed: Procedures Involving Contraceptive Devices" using "Procedures Involving Contraceptive Devices Grouping Value Set (2.16.840.1.113883.3.464.1003.111.12.1010)"? Attribute: "Result: Yes Response" using "Yes Response Grouping Value Set (2.16.840.1.113883.3.464.1003.122.12.1050)"? Attribute: "Discharge status: Discharged to Health Care Facility for Hospice Care" using "Discharged to Health Care Facility for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.207)"? Attribute: "Discharge status: Discharged to Home for Hospice Care" using "Discharged to Home for Hospice Care SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.209)"L1-343: Syphilis positive screening ratesMeasure Description:The percentage of newly diagnosed primary or secondary syphilis among all individuals (males and females) during the measurement period.L1-343: Syphilis positive screening ratesDY7/DY8 Program IDL1-343Measure DetailsSteward: NANQF #: NASource: NAData SourceAnyRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: NegativeUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionNumber of individuals (i.e. males and females)Denominator InclusionsNADenominator ExclusionsNANumerator DescriptionNumber of new reported cases of primary and secondary syphilis among all individuals (males and females) during the measurement periodNumerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationNote: In DY2-6 measure was specified as three rates (male, female, and a total rate). For DY7-8 measure is specified as a total rate only.L1-344: Follow-up after Treatment for Primary or Secondary SyphilisMeasure Description:Percentage of individuals who undergo follow-up clinical and/or serologic evaluation at 6-months after treatment for primary or secondary syphilisL1-344: Follow-up after Treatment for Primary or Secondary SyphilisDY7/DY8 Program IDL1-344Measure DetailsSteward: CDCNQF #: NASource: SourceAnyRequired StatusOptionalMeasure ClassificationType: Clinical OutcomeMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionTotal number of individuals who have undergone initial treatment for primary or secondary syphilis during the index period.Denominator InclusionsNADenominator ExclusionsIndividuals who are deceasedNumerator DescriptionThe number of individuals from the denominator who have undergone treatment for primary or secondary syphilis and complete clinical and serologic testing at 6 months (+/1 30 days)Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsFor DSRIP reporting purposes, an index period has been defined as starting 150 days prior to the start of the measurement period (to allow for follow up at 6 months -30 days) and ending 210 days prior to the end of the measurement period (to allow for folAdditional InformationMeasurement Periods:Baseline:Index Period: 08/04/2016 - 06/04/2017Measurement Period: 01/01/2017 - 12/31/2017 PY1:Index Period: 08/04/2017 - 06/04/2018Measurement Period: 01/01/2018 - 12/31/2018 PY2Index Period: 08/04/2018 - 06/04/2019Measurement Period: 01/01/2019 - 12/31/2019 PY3Index Period: 08/04/2019 - 06/04/2020Measurement Period: 01/01/2020 - 12/31/2020 CDC Clinical Guidelines 2015:Follow-Up:- Clinical and serologic evaluation should be performed at 6 and 12 months after treatment; more frequent evaluation might be prudent if follow-up is uncertain or if repeat infection is a concern. Serologic response (i.e., titer) should be compared with the titer at the time of treatment. However, assessing serologic response to treatment can be difficult, and definitive criteria for cure or failure have not been well established. In addition, nontreponemal test titers might decline more slowly for persons previously treated for syphilis (408,409).- Persons who have signs or symptoms that persist or recur and those with at least a fourfold increase in nontreponemal test titer persisting for >2 weeks likely experienced treatment failure or were re-infected. These persons should be retreated and reevaluated for HIV infection. Because treatment failure usually cannot be reliably distinguished from reinfection with T. pallidum, a CSF analysis also should be performed; treatment should be guided by CSF findings.- Failure of nontreponemal test titers to decline fourfold within 6–12 months after therapy for primary or secondary syphilis might be indicative of treatment failure. However, clinical trial data have demonstrated that 15%–20% of persons with primary and secondary syphilis treated with the recommended therapy will not achieve the fourfold decline in nontreponemal titer used to define response at 1 year after treatment (406,409). Serologic response to treatment appears to be associated with several factors, including the person’s stage of syphilis (earlier stages are more likely to decline fourfold and become negative) and initial nontreponemal antibody titers (lower titers are less likely to decline fourfold than higher titers) (409). Optimal management of persons who have less than a fourfold decline in titers after treatment of syphilis is unclear. At a minimum, these persons should receive additional clinical and serologic follow-up and be evaluated for HIV infection. If additional follow-up cannot be ensured, retreatment is recommended. Because treatment failure might be the result of unrecognized CNS infection, CSF examination can be considered in such situations.- For retreatment, weekly injections of benzathine penicillin G 2.4 million units IM for 3 weeks is recommended, unless CSF examination indicates that neurosyphilis is present (see Neurosyphilis). Serologic titers might not decline despite a negative CSF examination and a repeated course of therapy (410). In these circumstances, although the need for additional therapy or repeated CSF examinations is unclear, it is not generally recommended.L1-345: Gonorrhea Positive Screening RatesMeasure Description:The percentage of newly diagnosed gonorrhea among all individuals (males and females) during the measurement period.L1-345: Gonorrhea Positive Screening RatesDY7/DY8 Program IDL1-345Measure DetailsSteward: NANQF #: NASource: NAData SourceAnyRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: NegativeUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionNumber of individuals (i.e. total number of females and males)Denominator InclusionsNADenominator ExclusionsNANumerator DescriptionNumber of new reported cases of gonorrhea among all cases (males and females) during the measurement periodNumerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationNote: In DY2-6 measure was specified as three rates (male, female, and a total rate). For DY7-8 measure is specified as a total rate only.L1-346: Follow-up testing for N. gonorrhoeae among recently infected men and womenMeasure Description:The proportion of men and women who undergo follow up testing for uncomplicated Gonorrhea 3-months (+/- 15 days) after treatment during the measurement period.L1-346: Follow-up testing for N. gonorrhoeae among recently infected men and womenDY7/DY8 Program IDL1-346Measure DetailsSteward: CDCNQF #: NASource: SourceAnyRequired StatusOptionalMeasure ClassificationType: Clinical OutcomeMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionTotal number of individuals treated for uncomplicated Gonorrhea during the index period.Denominator InclusionsNADenominator ExclusionsIndividuals who are deceasedNumerator DescriptionThe number of individuals from the denominator who undergo follow-up testing for uncomplicated Gonorrhea 3-months (+/- 15 days) after treatment.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsFor DSRIP reporting purposes, an index period has been defined as starting 75 days prior to the start of the measurement period (to allow for follow up at 3 months -15 days) and ending 95 days prior to the end of the measurement period (to allow for folloAdditional InformationMeasurement Period:Baseline:Index Period: 10/18/2016 - 09/17/2017Measurement Period: 01/01/2017 - 12/31/2017 PY1Index Period: 10/18/2017 - 09/17/2018Measurement Period: 01/01/2018 - 12/31/2018 PY2Index Period: 10/18/2018 - 09/17/2019Measurement Period: 01/01/2019 - 12/31/2019PY3Index Period: 10/18/2019 - 09/17/2020Measurement Period: 01/01/2020 - 12/31/2020 CDC Clinical Guidelines 2015:- A high prevalence of N. gonorrhoeae infection has been observed among men and women previously treated for gonorrhea (86,480,481,577). Rather than signaling treatment failure, most of these infections result from reinfection caused by failure of sex partners to receive treatment or the initiation of sexual activity with a new infected partner, indicating a need for improved patient education and treatment of sex partners. Men or women who have been treated for gonorrhea should be retested 3 months after treatment regardless of whether they believe their sex partners were treated.L1-347: Latent Tuberculosis Infection (LTBI) treatment rateMeasure Description:Percentage of patients with latent tuberculosis infection who complete a course of treatment.L1-347: Latent Tuberculosis Infection (LTBI) treatment rateDY7/DY8 Program IDL1-347Measure DetailsSteward: CDCNQF #: NASource: SourceAnyRequired StatusOptionalMeasure ClassificationType: Clinical OutcomeMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionTotal number of individuals identified with Latent Tuberculosis Infection (LTBI) that initiated (accepted) a LTBI treatment regimen during the index periodDenominator InclusionsNone listed by measure steward.Denominator ExclusionsIndividuals who are deceasedNumerator DescriptionIndividuals from the denominator that completed a LTBI treatment regimen in the time frame specified by selected methodNumerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsFor DSRIP reporting purposes, an index period has been defined for each possible treatment regime based on CDC guidelines. The denominator is the sum of all individuals initiating a treatment regime during the treatment specific index period for a given measurement year. - For Isoniazid (9 month duration) the index period begins 270 days prior the start of the measurement period and ends 270 days after the end of the measurement period- For Isoniazid (6 month duration) the index period begins 182 days prior the start of the measurement period and ends 182 days after the end of the measurement period- For Rifampin (4 month duration) the index period begins 120 days prior the start of the measurement period and ends 120 days after the end of the measurement period- For Isoniazid & Rifapentine (3 month duration) the index period begins 120 days prior the start of the measurement period and ends 120 days after the end of the measurement periodAdditional InformationIsoniazid (9 month duration - 270 daily doses or 76 twice weekly doses)- Baseline Index Period: 04/06/2016 - 04/05/2017 Measurement Period: 01/01/2017 - 12/31/2017- PY1 Index Period: 04/06/2017 - 04/05/2018 Measurement Period: 01/01/2018 - 12/31/2018- PY2 Index Period: 04/06/2018 - 04/05/2019 Measurement Period: 01/01/2019 - 12/31/2019- PY3 Index Period: 04/06/2019 - 04/05/2020 Measurement Period: 01/01/2020 - 12/31/2020 Isoniazid (6 month duration - 180 daily doses or 52 twice weekly doses)- Baseline Index period: 07/03/2016 - 07/02/2017 Measurement Period: 01/01/2017 - 12/31/2017- PY1 Index period: 07/03/2017 - 07/02/2018 Measurement Period: 01/01/2018 - 12/31/2018- PY2 Index period: 07/03/2018 - 07/02/2019 Measurement Period: 01/01/2019 - 12/31/2019- PY3 Index period: 07/03/2019 - 07/02/2020 Measurement Period: 01/01/2020 - 12/31/2020 Rifampin (4 month duration - 12 daily doses)- Baseline Index Period: 09/03/2016 - 09/02/2017 Measurement Period: 01/01/2017 - 12/31/2017- PY1 Index Period: 09/03/2017 - 09/02/2018 Measurement Period: 01/01/2018 - 12/31/2018- PY2 Index Period: 09/03/2018 - 09/02/2019 Measurement Period: 01/01/2019 - 12/31/2019- PY3 Index Period: 09/03/2019 - 09/02/2020 Measurement Period: 01/01/2019 - 12/31/2020 Isoniazid & Rifapentine (3 month duration - 12 weekly doses)- Baseline Index Period: 10/09/2016 - 10/08/2017 Measurement Period: 01/01/2017 - 12/31/2017- PY1 Index Period: 10/09/2017 - 10/08/2018 Measurement Period: 01/01/2018 - 12/31/2018- PY2 Index Period: 10/09/2018 - 10/08/2019 Measurement Period: 01/01/2019 - 12/31/2019- PY3 Index Period: 10/09/2019 - 10/08/2020 Measurement Period: 01/01/2020 - 12/31/2020 Additional CDC Clinical Guidelines (2016):Isoniazid (9 months) Daily interval - Preferred treatment for: - Persons living with HIV - Children aged 2-11 - Pregnant Women (with pyridoxine/vitamin B6 supplements) Twice Weekly (use Directly Observed Therapy) - Prefered Treatment for: - Pregnant Women (with pyridoxine/vitamin B6 supplements) Isoniazid and Rifapentine (3 months) Once Weekly (use Directly Observed Therapy)- Preferred treatment for: - Persons 12 years or older Not recommended for persons who are: - Younger than 2 years old, - Living with HIV/AIDS taking antiretroviral treatment, - Presumed infected with INH or RIF-resistant M. tuberculosis, and - Women who are pregnant or expect to become pregnant within the 12–week regimen. The four treatment regimens for latent TB infection (LTBI) use isoniazid (INH), rifapentine (RPT), or rifampin (RIF). Treatment must be modified if the patient is a contact of an individual with drug-resistant TB disease. Consultation with a TB expert is advised if the known source of TB infection has drug-resistant TB.L1-387: Reduce Emergency Department visits for Behavioral Health and Substance Abuse (Reported as two rates)Measure Description:Rate of ED utilization for behavioral health and substance abuse conditionsL1-387: Reduce Emergency Department visits for Behavioral Health and Substance Abuse (Reported as two rates)DY7/DY8 Program IDL1-387Measure DetailsSteward: NANQF #: NASource: NAData SourceAnyRequired StatusOptionalMeasure ClassificationType: Clinical OutcomeMeasure Parts: 2Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: NegativeUnit of Measurement for Payer TypeUnit: EncountersMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionLHDs may report the denominator as either the total number of ED visits for individuals 18 years or older during the measurement period OR The DSRIP Attributed Target PopulationDenominator InclusionsNADenominator ExclusionsNANumerator DescriptionRate 1: Total number of ED Visits with a primary or secondary diagnosis of behavioral health conditionsRate 2: Total number of ED Visits with a primary or secondary diagnosis of substance abuseNumerator Inclusions (Performance Met)Rate 1:- Behavioral Health (primary and secondary diagnosis): F20-F29 Schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders F30-F39 Mood [affective] disorders F40-F48 Anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders F60-F69 Disorders of adult personality and behavior Rate 2:- Substance Abuse (primary and secondary diagnosis): F10-F16, F18 - F19 Mental and behavioral disorders due to psychoactive substance use, excluding NicotineNumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsLHD may opt to report measure as a percentage of all ED visits, or as ED visits for their DSRIP attributed target population. Providers will need approval from HHSC to define the DSRIP attributedAdditional InformationWhere only two digits are listed, all diagnoses at the 3rd, 4th, and 5th digit should be included (e.g., asthma is listed as J45, but you should include J45.20, J45.21, J45.22…J45.991, J45.998). Where only three digits are listed, all diagnoses at the 4th, and 5th digit should also be included etc., etc.L1-400: Tobacco Use and Help with Quitting Among AdolescentsMeasure Description:The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco userL1-400: Tobacco Use and Help with Quitting Among AdolescentsDY7/DY8 Program IDL1-400Measure DetailsSteward: NCQANQF #: 2803Source: CMS MIPS #402 (Claims/Registry)Data SourceClaimsRequired StatusOptionalMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured unless an exception is requested and approved through the RHP Plan Update.Baseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionAll patients aged 12-20 years with a visit during the measurement periodDenominator InclusionsPatients aged 12-20 years on date of encounter AND Patient encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90839, 90845, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 97165, 97166, 97167, 97168, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99406, 99407, G0438, G0439, 99383, 99384, 99385, 99393, 99394, 99395Denominator ExclusionsNoneNumerator DescriptionPatients who were screened for tobacco use at least once within 18 months (during the measurement period or the six months prior to the measurement period) AND who received tobacco cessation counseling intervention if identified as a tobacco user Definitions:Tobacco Use Status – Any documentation of smoking or tobacco use status, including ‘never’ or ‘non-use’.Tobacco User – Any documentation of active or current use of tobacco products, including smoking. NUMERATOR NOTE: In the event that a patient is screened for tobacco use and identified as a user but did not receive tobacco cessation counseling report G9460.Numerator Inclusions (Performance Met)Patient documented as tobacco user AND received tobacco cessation intervention (must include at least one of the following: advice given to quit smoking or tobacco use, counseling on the benefits of quitting smoking or tobacco use, assistance with or referral to external smoking or tobacco cessation support programs, or current enrollment in smoking or tobacco use cessation program) if identified as a tobacco user (G9458)ORCurrently a tobacco non-user (G9459)Numerator Exclusions (Performance Not Met)Tobacco assessment OR tobacco cessation intervention not performed, reason not given (G9460)DSRIP Specific ModificationsFor DSRIP reporting purpose, HHSC has added CPT values for preventive visits 99383 (Prev visit new age 5 - 11), 99384 (Prev visit new age 12 - 17), 99385 (Prev visit new age 18 - 39), 99393 (Prev visit est age 5 -11), 99394 (Prev visit est age 12 - 17), 99395 (Prev visit est age 18 - 39) to the specifications.Additional InformationNone ................
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